尿路结石的规范治疗知识在广西试点基层医院培训效果评价

目的探讨在广西基层医院推广"尿路结石治疗的规范诊疗技术"的必要性及推广效果,制定适合我区基层医院使用的尿路结石诊疗规范。方法选择马山县为试点,对县、镇、乡村等各级医院的相关医务人员进行集中培训,并对培训前后医生的泌尿系结石诊疗水平进行考核,评估培训效果和意义。结果前期调查发现马山县各级医院的医生对泌尿系结石的诊疗知识存在明显缺陷。经过培训,受训医生对"泌尿系结石"知识的知晓率由44.8%提高到82.3%,成绩从培训前(44.27±17.21)分提高到(80.07±5.77)分,培训后的各级医院成绩均有所提高(P0.01),培训效果良好。结论广西基层医院医生的尿路结石诊疗知识存在明显缺陷,急需专业培训。通过培训,受训医生尿路结石的诊疗水平得到显著提高,值得在广西各基层医院推广。     

Hypercalciuria associated with pediatric prostatic calculi

Prostatic calculi, though common in adult men, are rare in children. We report three cases of pediatric prostatic calculi seen at our clinic that were associated with hypercalciuria and elevated urinary calcium/creatinine ratios. The patients had no symptoms from their prostatic calcification, but one patient had recurrent symptomatic renal calculi. In patients with prostatic calculi, determination of spot urine calcium/creatinine ratios is recommended. If significant hypercalciuria is found, treatment to prevent upper urinary tract calculi may be considered.     

Urinary Calculi and Risk of Cancer: A Nationwide Population-Based Study

Previous studies have shown that urinary calculi are associated with increased risks of urinary tract cancers. However, the association between urinary calculi and overall cancers is a largely undefined body of knowledge.We conducted a nationwide population-based cohort study using Taiwan''s National Health Insurance Research Database from 2000 and 2009. Patients were excluded if they had antecedent cancers or urinary calculi before the enrollment. All study subjects were followed until the occurrence of cancer, dropout from the NHI program, death, or the end of 2010. Patterns of cancer incidence in patients with urinary calculi were compared with those of the general population using standardized incidence ratio (SIR).A total of 43,516 patients with urinary calculi were included. After a median follow-up of 5.3 years, 1891 patients developed cancer. The risk of overall cancers was significantly increased (SIR, 1.75; 95% confidence interval [CI], 1.68–1.83). We observed that urinary calculi was associated with higher risk of cancers of kidney (4.24; 95% CI, 3.47–5.13), bladder (3.30; 95% CI, 2.69–4.00), thyroid (2.50; 95% CI, 1.78–3.40), hematologic origin (2.41; 95% CI, 1.92–2.99), breast (1.84; 95% CI, 1.54–2.20), lung (1.82; 95% CI, 1.59–2.07), digestive tract (1.69; 95% CI, 1.57–1.82), and head and neck (1.54; 95% CI, 1.32–1.79), respectively.Our study shows that urinary calculi are associated with higher risk of systemic cancers in addition to urinary tract cancers. Further study is required to validate this association.     

Managing prostate disorders in middle age and beyond

Diseases of the prostate may be benign or malignant. It is important for the clinician to realize that a complete urinalysis and digital rectal exam are the cornerstones of management in the diagnosis of prostate disease. Surgery for benign disease is indicated if the patient has compromised renal function, hydronephrosis, recurrent urinary tract infections, urinary retention, or bladder calculi. Surgery is also indicated if the obstructive urinary symptoms interfere with the patient's quality of life. Prostate cancer is a common malignancy in elderly men and treatment options must be guided by the stage of the disease and the general medical status of the patient.     

Obstructive uropathy in adults

Urinary tract obstruction is a common clinical problem. The obstruction of the urinary flow may be acute or chronic, partial or complete, unilateral or bilateral, and may occur at any site of the urinary tract. The major causes of urinary tract obstruction vary with the age of the patient. Anatomic abnormalities, e. g. ureteropelvic junction obstruction, account for the majority of cases in children. In comparison, calculi are most common in young adults, while prostatic hyperplasia or carcinoma, retroperitoneal or pelvic neoplasms, and calculi are the primary causes in older patients. Urinary tract obstruction results in different pathophysiological changes causing various symptoms. In addition to the aetiology, pathophysiology and clinical presentation of obstructive uropathy in adults, modern diagnostic and therapeutic options are presented in this review.     

Renal stones. Solutions and solute

In the formation of calculi within the urinary tract, two fundamental factors are critical when crystals precipitate and stones form: They are solute and the solution itself, which must be oversaturated if crystals are to form and to grow. Several elements present in the urine influence solutions and solute and, thus, stone formation. Because all forms of medical therapy influence these elements favorably to prevent stone formation, this update reviews why stones form and how specific medical therapy works to prevent their formation.     

Treatment of unilateral renal tuberculosis with concomitant calculus on the opposite side of the upper urinary tract and hydronephrosis

Nine cases of unilateral renal tuberculosis (functionless) with the concomitant opposite side calculus of the upper urinary tract and hydronephrosis were analysed. We first removed urinary tract obstruction from the side of calculi, and then perform resection of renal tuberculosis within two weeks as soon as possible. The diagnosis and treatment were also discussed.     

Risk factors for urinary tract calculi in Trinidad

OBJECTIVE: To identify risk factors for urinary tract stones in Trinidad and Tobago. METHODS: A consecutive series of patients presenting to institutions in Trinidad for the management of proven urinary tract calculi was interviewed by questionnaires designed to obtain data on age, gender, ethnicity, occupation, stone location, a family history of stone disease, a past history of certain medical diseases and a semiquantitative estimate of the magnesium intake in food, 'over the counter' drugs and drinking water. An equivalent number of patients attending the same institutions for follow-up and verified from hospital records as having a previous radiological diagnosis of urinary tract stones, as well as a group of asymptomatic members of the community working in the same area, underwent the same interview. Chi-square, anova and Kruskal-Wallis tests were used to examine differences between the groups. Multiple logistic regression analysis was used to determine persistence of the significance of these differences after controlling for confounding variables. RESULTS: Data sufficient for analysis were obtained for 122 previous and 102 prospective patients and 102 controls. The mean age of the patients was 32 years. The ratio of males to females was 0.9-1.8:1 for the affected groups, but significantly more males than females had calculi in the lower urinary tract (19%vs. 6%; P = 0.004). More patients (30%) than controls (7%) gave a positive family history of urinary tract stone disease (P < 0.001). Affected persons had a lower dietary magnesium intake (P = 0.003), which accounted for a significantly lower total magnesium intake (P = 0.02). Logistic regression analysis of the variables studied indicated that independent predictors of the disease were a positive family history (P = 0.001), total magnesium intake (P = 0.001) and age (P < 0.001). CONCLUSION: A low magnesium intake and a positive family history are highly predictive of urinary tract calculi in this population.     

Urolithiasis in chronic inflammatory bowel disease

In a selected material of 228 patients with chronic inflammatory bowel disease (CIBD) the incidence of urolithiasis was 15% (95% confidence limit 11-21). The tendency to urolithiasis is significantly correlated to small-bowel resection and its extent and to obstruction in the urinary tract. On the other hand, there is no definite correlation to the duration or extent of the bowel disease. The significant correlation between urolithiasis and ileal resection is in agreement with the hyperabsorption of oxalate as an important cause of stone formation demonstrated by others. That local factors too play an essential role in the formation of urinary calculi is apparent from the increased incidence of urolithiasis in obstruction of the urinary tract. The incidence of urolithiasis was particularly high (22-25%) among patients with ileostomies. The few and negligible symptoms of and sequelae to, urolithiasis in CIBD encourage a conservative attitude.     

单纯螺旋CT平扫在上尿路结石成分判断中的应用

目的观察单纯螺旋CT平扫在上尿路结石化学成分判断中的应用效果。方法 123枚上尿路结石,其中尿酸结石23枚、草酸钙结石41枚、磷酸钙结石10枚、碳酸钙结石8枚、草酸钙磷酸钙混合结石8例、草酸钙尿酸混合结石16例、磷酸钙尿酸结石11例、碳酸钙尿酸结石3例、草酸钙碳酸钙结石3例。采用十六排螺旋CT在患者术前行单纯平扫,参数120 kV/240 mA,螺距0.75∶1,层厚3 mm,测量结石软组织窗平均CT值。结果 82例纯结石平均CT值由高到低依次是磷酸钙（1 276.70±242.40）HU、草酸钙（1 168.71±220.73）HU、碳酸钙（703.38±129.49）HU、尿酸（535.74±172.54）HU。草酸钙与磷酸钙结石CT值相比P〉0.05,其余各类纯结石两两比较P均〈0.05。非纯尿酸结石CT值为（911.50±163.52）HU,与纯尿酸结石相比P〈0.05。CT值〈700 HU者纯尿酸结石21例、非纯尿酸结石4例,CT值≥700 HU者纯尿酸结石2例、非纯尿酸结石96例。CT值〈700 HU诊断纯尿酸结石灵敏度为91.3%、特异度为96.0%、阳性预测值为84.0%、阴性预测值为98.0%。结论单纯螺旋CT平扫用于判断上尿路结石成分效果满意。根据软组织窗CT值不同,可将体内尿酸结石与其它成分结石区分。软组织窗平均CT值〈700 HU的结石可作为纯尿酸结石的诊断标准。     

Obstruktive Nephropathie

Acute upper urinary tract obstruction is a very painful event and is very dangerous in cases involving infection, but it can also be found with no or few symptoms. The most common cause of upper urinary obstruction is a ureteral calculus. Ultrasound is the most frequent used screening tool. However, for a precise diagnosis, computed tomography is necessary and thus has replaced intravenous urography. Further diagnostic tools such as magnetic resonance imaging, diuretic renography, and retrograde pyelography must be used individually. Treatment depends on the situation. Acute obstructive pyelonephritis must be treated as an emergency, with antibiotics and immediate drainage of the upper urinary tract. Acute upper urinary tract obstruction without infection is intensely painful and needs a fast workup to identify the cause of the obstruction, followed by medical treatment. Asymptomatic or oligosymptomatic obstruction of the upper urinary tract is more dangerous than a symptomatic case because a delay in proper diagnosis can lead to total loss of renal function.     

Urinary incontinence, catheters, and urinary tract infections: an overview of CMS tag F 315

The majority of nursing home residents experience some type of urinary incontinence. Other bladder-related disorders (eg, urinary retention and urinary tract infection) also are common in long-term care facilities. Efforts to manage urological conditions such as the use of indwelling catheters and absorbent products, perineal hygiene and care, toileting, and bladder rehabilitation are areas of concern and have become the subject of revised regulations. The intent of recent changes to the Centers for Medicare and Medicaid Services surveyor guidance for incontinence and urinary catheters is to ensure that: 1) incontinent residents are identified, assessed, and provided appropriate treatment, 2) indwelling catheters are not used without medical justification and removed as soon as clinically warranted, and 3) residents receive appropriate care to prevent urinary tract infections. Nursing homes must implement policies, procedures, and programs to help restore bladder function and continence in order to improve quality-of-life for nursing home residents.     

Some unusual features of gouty arthritis in females

Gouty arthritis in females is relatively infrequent, although the sex ratio may be somewhat altered in different races. A positive family history is relatively prevalent among females whose onset of gout is premenopausal. In those patients with a postmenopausal onset, the incidence of diuretic-associated gout is high. The bimodal distribution of serum urate might be related to some variance of genetic transmission in female gout.Hypertension and coronary heart disease are common coexisting conditions, as is true of gouty arthritis in males. Chronic urinary tract infection dating from previous pregnancies is a frequent complication. The relative prevalence of proteinuria and diminished renal function leads to increased hyperuricemia, with a tendency to a low urinary uric acid output. This explains in part the higher incidence of extensive tophaceous deposition but lower incidence of renal calculi. Diuretics are associated with a higher urine pH, likewise, they reduce the urinary uric acid excretion. This also may contribute to the lower incidence of renal calculi.There may be some statistical support for the low fertility rate among the gouty females. Only two females became pregnant after the onset of gouty arthritis. All other pregnancies occurred before the onset of arthritis. Even then, abnormal pregnancies were relatively frequent. Some hormonal malfunction among the gouty females cannot be discounted.Both renal calculi and tophi are frequent in female gout associated with blood dyscrasias. They may manifest early, preceding the first attack of acute gouty arthritis. In both the male and female secondary gout, the primary underlying disease governs the uric acid metabolism and the clinical symptomatology of gout. The predominant role in pathogenesis is the excessive rate of uric acid production, and its disposal is governed by the different stages of the underlying disease and the treatment. Thus, secondary gout in females appears to be somewhat different from primary gout in females, but not different from secondary gout in males.     

Pediatric urolithiasis: causative factors, diagnosis and medical management

Childhood urolithiasis is associated with considerable morbidity and recurrence. Many risk factors--including those metabolic, genetic, anatomic, dietary and environmental in nature--have been identified in children with urinary tract calculi. As pediatric urolithiasis with a metabolic etiology is the most common disease, evaluating the metabolic risk factors in patients is necessary to both effectively treat current stones and prevent recurrence. We discuss causative risk factors of pediatric urolithiasis, as well as the diagnostic and therapeutic approaches.     

Obstructive uropathy in childhood

"Obstructive uropathy" is a generic term which combines different diseases in infants and childhood. Both the upper and lower urinary tract may be affected. Diseases of the urinary tract can cause an intrinsic obstruction. Sometimes tumours may cause a compression and as secondary effect an obstruction (extrinsic). Ultrasound is the key diagnostic tool and shows dilatation of the obstructed urinary tract. But for the functional exploration of babies and toddlers, renal scanning and X-ray examinations are necessary. These examinations lead to an exposure to radiation which necessitates careful indication. Some of the congenital diseases (for example ureteropelvic junction obstruction, megaureter) show a maturation without any intervention. So one has to decide whether to wait and see or to operate. A percutaneous nephrostomy or a DJ-catheter is not often used in the treatment of obstruction in general. These forms of drainage are more often used in the treatment of stones or of extrinsic obstruction. A pyelocutaneostomy or ureterocutaneostomy is a special surgical procedure in pediatric urology for transient drainage of the upper urinary tract (megaureter). The operation of a seriously ill new-born should be done in a centre for pediatric urology and pediatric nephrology. When the upper urinary tract is dilated, patients may need an antibiotic prophylaxis, because the dilatation of the upper urinary tract increases the risk of urinary tract infections (UTI). The indication for antibiotic prophylaxis should by guided by the criteria of the APN-Consensus Paper. Long-term follow-up is necessary and should comprise ultrasound, physical examination, controlling the blood pressure, urine analysis and blood tests. The aims of diagnostics, treatment and long-term follow-up are the preservation of renal function and to protect the children from UTI. This goal must be reached under conditions that are appropriate for children and their parents.     

Efficacy of rasburicase therapy in obstructive renal failure secondary to urolithiasis: a novel therapeutic option

The overall incidence of nephrolithiasis-related acute and chronic renal failure is poorly known and surely underestimated. However, obstructive nephropathy represents a potentially curable form of kidney disease that often requires for managing an instrumentation of urinary tract. Rasburicase is an enzyme that transforms uric acid to allantoin, a compound more water soluble that will be excreted by the kidney more easily. Rasburicase has been proven to be an effective therapy for prevention of tumour lysis syndrome. But it also represents an interesting new option in managing hyperuricemia in patients with severe tophaceous gout. We administered rasburicase intravenously (0.20 mg/kg/day, for 2 days) in 2 adults with acute obstructive nephropathy from renal calculi, which was receiving temporary haemodialysis. Rasburicase produced a sharp polyuria 12-18 hours after its administration accompanied with a fast reduction of serum creatinine levels, that returned to normal range without further dialysis. If we suppose that rasburicase can pass through glomerular filter by its relatively low molecular weight, it could dissolve tubular uric acid crystals in acute renal failure associated to tumour lysis syndrome, providing the restoration of renal function. But we also could postulate that rasburicase can act in urinary tract, fragmentating renal calculi, promoting relief of obstructive uropathy and the resolution of renal failure. We suggest rasburicase should be tried in this new indication to prove its potential efficacy.     

Extracorporeal shock wave lithotripsy for the treatment of urinary calculi in the elderly

Renal calculus in the elderly patient is associated with the same symptoms and risks as in other patient populations. With the recent development of extracorporeal shock wave lithotripsy (ESWL), many older patients can now be treated for renal calculi. The Department of Urology at the University of Iowa Hospitals and Clinics has performed 107 ESWL treatments on a total of 96 patients over 70 years of age. This represents over 12% of all patients treated at our institution. No deaths related to ESWL treatment have occurred in this group, nor has increased morbidity been observed in comparison to all patients treated. In spite of the increased age and associated medical problems of this patient population, ESWL offers a safe and effective means of treating upper tract urinary calculi in the geriatric age group.     

Surgical management of urolithiasis.

The surgical management of urinary calculus disease has changed dramatically in the past two decades. Minimally invasive options have made open stone surgery nearly obsolete. The development of shock wave lithotripsy, percutaneous nephrostolithotomy techniques and intracorporeal lithotripsy devices has conferred unprecedented management tools for upper tract stones. Moreover, transfusion rates, hospital costs, and convalescence periods have been markedly reduced when compared to open surgery. Likewise, the advent of fiberoptic technology has resulted in miniaturization of ureteroscopes making access to the entire collecting system possible from either a retrograde or antegrade approach. With experience, successful stone retrieval has occurred in upwards of 90% of cases, again with minimal complications. The subspecialty of Endourology has emerged over the past 20 years and significantly changed the management of urinary tract calculi within this short period of time. Further advancements in shock wave and laser technology, training modules and the development of more durable endoscopes may prove beneficial in providing even better stone treatments with a reduction in morbidity.     

Foreign body stone in the urinary bladder: a case report

Bladder calculi rarely form spontaneously and are usually a manifestation of an underlying pathologic condition of the lower urinary tract, including voiding dysfunction, urinary infection, obstruction, or foreign body retention. However, a ruptured Foley balloon-induced bladder stone is an unusual complication of an indwelling Foley catheter. We report a case of spinal cord injury with paraplegia and bladder stone induced by a fragment of a ruptured Foley balloon. The bladder stone and the Foley balloon fragment were successfully removed by cystoscopy. The stone was composed of calcium oxalate and calcium phosphate. We report this unusual case to raise awareness that it is important to check the integrity of the Foley catheter after removal of the tube.