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Intervention

Intervention. Interventions. Conservative observation Dissolution agents Relief of Obstruction Extracorporeal Shockwave Lithotripsy (ESWL) Ureteroscopic stone extraction Percutaneous Nephrolithotomy Open stone surgery Pyelolithotomy Anatrophic Nephrolithotomy Radial Nephrotomy

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Intervention

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  1. Intervention

  2. Interventions • Conservative observation • Dissolution agents • Relief of Obstruction • Extracorporeal Shockwave Lithotripsy (ESWL) • Ureteroscopic stone extraction • Percutaneous Nephrolithotomy • Open stone surgery • Pyelolithotomy • Anatrophic Nephrolithotomy • Radial Nephrotomy • Ureterolithotomy • others

  3. Conservative management • Majority of stones pass out within a 6 week period after the onset of symptoms • depends on the size of the calculi and its location Dissolution agents • Use alkalinizing agents • Given oral, IV or intrarenal Relief of the Obstruction • Emergent drainage in patient with signs of UTI

  4. Extracorporeal Shockwave Lithotripsy (ESWL)

  5. Extracorporeal Shockwave Lithotripsy (ESWL)

  6. Consideration • excessive weight (>300 lb) may severely limit or preclude ESWL. • Pregnant women and patients with large abdominal aortic aneurysms or uncorrectable bleeding disorders should not be treated with ESWL. • Individuals with cardiac pacemakers should be thoroughly evaluated by a cardiologist.

  7. Ureteroscopic stone extraction • Highly effective for lower ureteral calculi • Stone may be extracted using a wire basket • Or lithotrites may be placed through the ureteroscope to fragment the calculi

  8. Percutaneous Nephrolithotomy • the treatment of choice for large (>2.5 cm) calculi; renal and proximal ureteral calculi, those resistant to ESWL, select lower pole calyceal stones with a narrow, long infundibulum and an acute infundibulo- pelvic angle, and instances with evidence of obstruction • Rapid cure

  9. Open stone surgery • Classic way to remove calculi • Mandatory to obtain a radiograph before the incision is made • Not frequently used anymore because of the morbidity of the incision, the possibility of retained stone fragments, and the ease and success of less invasive techniques

  10. Pyelolithotomy • Effective especially with extrarenal pelvis • Transverse pyelotomy - effective and does not require interruption of the renal arterial blood supply • Flexible endoscope – ensures stone-free status • Coagulum – can retrieve multiple, small renal pelvic calculi and difficult- to-access caliceal calculi • Cryoprecipitate • Injected into the renal pelvis, endogenous clotting factors result in a Jelly-like coagulum of the collecting system. • Small stones are entrapped and removed with the coagu- lum.

  11. Anatrophic nephrolithotomy • Used with complex staghorn calculi • Complete staghorn calculus • Partial staghorn calculus • Incision made on the convex surface of the kidney posterior to the line of Brodel • Occlusion of the renal artery followed by renal cooling with slushed ice • Nerve hook is helpful to tease out calculi • Repair of narrowed infundibula helps reduce stone recurrence rates.

  12. Radial nephrotomy • Allows access to limited calyces of the collecting system • Frequently used in blown-out calyces with thin overlying parenchyma • Intraoperative ultrasound to localize the calyx and the calculi • A shallow incision of the renal capsule can be followed by puncture into the collecting system. • Stones may be cut with heavy Mayo scissors, and remaining fragments can be retrieved.

  13. Other renal procedures • Partial nephrectomy – for large stones in a renal pole with marked parenchymal thinning • Caution should be taken even with a normal contralateral kidney as stones are frequently associated with a systemic metabolic defect that may recur in the contralateral kidney • Ileal ureter substitution – to decrease pain with frequent stone passage • Autotransplantation with pyelocystostomy – for patients with rare malignant stone disease

  14. Partial nephrectomy Ileal ureter substitution

  15. Ureterolithotomy • Long standing ureteral calculi • Preoperative radiograph to document stone location • Incision lateral to the sacrospinalis muscles to allow medial retraction of the quadratus lumborum; anterior fascicle of the dorsal lumbar fascia must be incised to gain proper exposure • Vessel loop or Babcock clamp placed proximal to the stone to prevent frustrating stone migration • Longitudinal incision over the stone with a hooked blade to expose the calculus • Nerve hook to tease out the stone

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