Treatment of kidney stones

The diagnosis. The main role for the diagnosis belongs to x-ray examination. General view of the urinary tract allows tentatively set the location of the stone, its shape and size. Oxalates, phosphates, carbonates produce intense shade, urates weak. After the overview snapshot produces excretory urography (see), which reveals not only the anatomical condition of the two kidneys, and their functional ability, but also points to the location of the stone and changes in the kidney. Stones composed of uric acid, as a rule, on the radiograph is not visible. To diagnosis apply tomography (see), retrograde pielografia liquid by contrast agent or oxygen. If chromolithography (see Cystoscopy) you can see a stone at the mouth of the ureter; solution of Indigo Carmine, entered intravenously, is not allocated from the defeat or highlighting it is delayed. When calculous janefrose or hydronephrosis sometimes be palpated enlarged kidney.
The differential diagnosis should take into account that pain, for example in the right part of the stomach, can be not only in renal colic, but also in acute appendicitis, cholecystitis, stones, gall bladder, intestinal obstruction, perforated stomach ulcer. Typical restless behavior of the patient, the radiation of pain in the right iliac region and genitals, problems with urination, Peoria (see), microhematuria, lack of allocation of Indigo Carmine from the mouth of the ureter allow for proper diagnosis.
The prognosis depends on the number of stones, their location, the presence of infection.
Treatment may be conservative and surgical. Renal colic is recommended to drink plenty of water, warm bath. To relax the muscles of the ureter assign extract of belladonna or atropine (0.1% solution 0.5 ml) orally or subcutaneously. The strong pain prescribed drugs in combination with inflammatory means. Good effect gives the blockade of the spermatic cord in men or round ligament in women 0.25% solution novokaina in the amount of 80-100 ml If colic continues shown catheterization of the ureter to address the stagnation of urine in the renal pelvis.
When uric acid stones recommend alkaline water - Borjomi, Essentuki, Izhevsk water. It is necessary to monitor the response of the urine and not to bring it to alkalization, as this may lead to increased selection of phosphates. When oxalates and phosphates appoint indifferent or carbonated mineral water Narzan, Truskavets water), decoctions horsetail, Valerian, chamomile hot.
Treatment in the resorts of Truskavets, Zheleznovodsk, Isti-su, Krainka, Sairme shows patients urolithiasis, complicated pyelonephritis and cystitis. The resorts should be sent only to those patients with urolithiasis, in which the size and shape of the stones, and the condition of the urinary tract are not preventing urination and spontaneous discharge of concrements. It is also advisable to refer to the resorts of patients with stones removed operative and conservative way, after 1.5-2 months. after the operation. One should not direct to resort treatment of patients with stones can be removed only through surgery.
Surgical treatment is indicated in cases when the stone causes frequent pain, with frequent exacerbations of chronic pyelonephritis, developing hydronephrosis, repetitive macrohematuria. When the stones are located in the pelvis of the kidney, perform surgery - pallidotomy, if the stone is in the ureter - ureterolithotomy.
Patients suffering from urolithiasis, must comply with the diet. To limit the use of products such as liver, kidney, brain, fried meat, salted fish, contributing to the increase in the education of uric acid. Recommend vegetables and fruits, drink plenty of water (tea, milk tea, cranberry juice, water). When phosphaturia appoint meat products with the aim of acidification of urine, is not recommended eggs, milk, potatoes, alkaline water. When salt diathesis or small stones prescribed drugs: enatin, tistedal, avian, extract madder; if there is an infection, antibiotics are used, as well as derivative nitrofurana.

Treatment. Apply conservative and surgical treatment of kidney stones.
An important task of conservative treatment of kidney stones is the dissolution of stones, creating opportunities spontaneous their discharge and control of urinary infection. Oral used Marena spray booth, Rogatin, tistedal, Artemisa. The action of these drugs is based on the fact that they improve the blood circulation in the kidney, cause blood of renal papillae, enhance diuresis, having simultaneously spasmolytic, analgesic, and bacteriostatic properties. As a consequence, the observed discharge small kidney stones, and some authors admit the possibility of dissolution of small stones. Prescribe these drugs 4-5 drops on sugar for 1/2-1 hours before meals 3 times a day for 1-2 months and more. Artemsol appoint 3-18 drops on sugar before eating, holding under the tongue or cheek.
Noteworthy is the extract madder of dyeing, appointed in the form of tablets to 0.5 g 3 times a day for 20 to 30 days. The tablet is dissolved in 1/2 glass of warm water. At colouring of urine brown treatment dye marinoy temporarily cease. Madder of dyeing has diuretic and antispasmodic effect, helps in loosening stones containing phosphates and magnesia. To enhance excretion of urine salts and small uratov use of the drug by uredan. Prescribe it inside one teaspoon on 1 / 2 Cup water 3-4 times a day before meals for 30-40 days. The course of treatment can be repeated. Bibus (Century Bibus, 1959) proposed for the dissolution of urate stones of kidneys lemon juice (2 lemon daily in the continuation of 6-12 months). The success he received in 50% of cases. Patients calculous hydronephrosis and pyonephrosis this therapy is contraindicated.
Introduction to the body of acids and alkalis changes the pH of the blood serum and urine, which helps dissolve salts. If phosphaturia (calcularii), phosphate and carbonate rocks to get acidic urine get diluted hydrochloric acid by 10-15 drops 1/3 Cup water during meals 3 times a day, 5% solution of phosphoric acid 20 drops during meals 3 times a day, sodium benzoate 0.5 g 4 times a day (this drug also has bacteriostatic action in urinary infections), 5-10 days 2 times a month, ammonium chloride 0.3 g 3 times a day, boric acid 0.3 g with hexamethylenetetramine 0.5, When phosphaturia and phosphates recommended intake of phosphate monobasic sodium 5-8 g daily. If oxaluria and oratorio, oxalate and urate stones for oschelacivania urine use the baking soda (a teaspoon per glass of water), alkaline mineral water, sodium citrate (8 to 10 g / day of fractional doses). When aseptic phosphaturia and phosphate rock with the aim of acidification of urine useful application of penicillin.
There is a direct method of dissolution of stones renal pelvis and cups, in which solvent with a special two-way ureteric catheter is introduced into the renal pelvis, where he come into direct contact with the stone. For direct dissolution of kidney stones used lemon, ethylenediaminetetraacetic (EDTA, Trilon-B) and gluconic acid, enzymes (trypsin in 1-3-5%solutions, pepsin, hyaluronidase), piperazine in combination with glycocoll and other substances. The success of attempts on direct dissolution of stones was insignificant and mainly in respect of phosphates and carbonates. Oxalate and Ratna stone, as a rule, direct dissolution is not amenable.
Still not studied the question of the effect of long-term administration of various solvents stones on kidney function and the patient. Therefore, the method of direct dissolution of stones is not widely spread. Developed the method of destruction of kidney stones by electrolysis.
A significant place among conservative measures is the elimination of pains, renal colic. To do this, assign a warm bath, hot water bottles, injection pain medications in combination with spasmolytic (omnopon 1%-1 ml, promedol 2%-1 ml together with atropine 0.1% to 1 ml), inside papaverine 0.02 g 3 times a day, platifillin 0.003 g 3 times a day, kellin to 0.02 g 2-3 times a day, avian 0.05 g 3 times, and tistedal, Rogatin, Artemisa 20-30 drops to receive only once. When persistent colic shown procaine lumbar blockade 0.25% novokaina solution of 100 ml each of perirenal region, as well as the blockade of the spermatic cord or round uterine ligament (60-80 ml of 0.25% solution novokaina). Treatment for kidney stones timely measures to combat urinary infection, especially in the case of the development of pyelonephritis. With this purpose used antibiotics, drugs nitrofuranovye series, sulfanilamida.
When kidney stones for relapse prevention, slowing down the development of nephrolithiasis and effects on kidney stone diathesis designate an appropriate diet. When urates, when the acidity of urine increased significantly, shows a dairy-vegetarian food, as this alkalify urine. Meat eating limit. Liver, kidney, brain, jellies from power patients urate stones and uraturia exclude, as these products contain large amounts of purine bases, which is the main source of education urinary and oxalic acids. At the same time appoint mineral water (Essentuki № 17, Borjomi, Naftusia, etc.). When phosphate rock and phosphaturia when the urine is alkaline reaction, it is necessary to oxidize the urine, which is prescribed mainly meat. From the diet of the patient exclude milk, egg yolk, containing a lot of calcium salts, limit the consumption of vegetables, potatoes. Allow cereals, flour dishes, sugar, honey, fats (animal and vegetable), carrots, green onions, rose, fruit, watermelon, melon. Mineral waters can be assigned Naftusya, dolomite Narzan. When oxalate stones and oxaluria urine is acidic. At the same time it is necessary to take into account the endogenous formation in an organism of the patient of oxalic acid and exogenous receipt her and calcium from food. Therefore, from the power of the patient should be deleted sorrel, lettuce, spinach, rhubarb, pepper, and all kinds of meat food that contain a lot of nucleic acid substances and purine. Limit the consumption of potatoes, tomatoes, carrots, milk. Allow meat and fish, flour, cereal meals, animal and vegetable fats, sugar, honey, fruit, vegetables - cabbage, beets, asparagus, cucumbers, watermelons, melons. Given that the content of magnesium in the urine helps dissolve calcium should not be excluded from the diet of the patient beans, cocoa, chocolate, because along with the content of oxalic acid, these products contain a lot of magnesia. Of the mineral water is recommended Essentuki № 20, Naftusia, Sairme. In all cases of kidney stones prohibit alcoholic beverages, limit the reception of hot and spicy food. When cystine stones and cystinuria special diet is not required. Described diet should only be considered as a model and strictly tailored.
Mineral water treatment indicated for kidney stone diathesis, aseptic and infected stones of kidneys, ureters, when the shape and size of the stone, the state of pelvis and ureter give grounds to expect spontaneous discharge of the rock under the impact of the increased diuresis, in the postoperative period, with chronic pyelonephritis. Contraindications to treatment for drinking resorts are significant defeat parenhima kidney dysfunction of the kidneys, the dynamics of the pelvis and ureter and PIO - and hydronephrosis. Treatment allocation to drinking resorts (Truskavets, Essentuki, Zheleznovodsk) should be considered beneficial effect of mineral water on the increase diureza, which promotes discharge of salts, small stones, mucus, pus, having a salutary effect on the inflammatory process in the urinary tract.

Surgical treatment. Indications for operations on the occasion of kidney stones are divided into absolute and relative. Absolutely shown operation with anuria, long profuse hematuria, pyelonephritis with frequent exacerbations, PIO and hydronephrosis, introducing paranemia.
The presence of multiple and Staghorn calculi stones of kidneys in the absence of infection and expressed pain relief is a relative indication for surgery. You should not take action when a small aseptic parenchymal (checkover) stones, when the disease occurs without obvious symptoms, as well as in cases of presence of small smooth aseptic pelvis stones that do not cause pain relief and a significant impairment of urine outflow, as such stones can move spontaneously. When bilateral Staghorn calculi stones of kidneys operation is carried out only in absolute condition; it should be conserving: nephrostomy, removing stones, preventing the outflow of urine. When bilateral unbranched stones renal pelvis should be taken dvuhmestnoe operation, first remove the stone to more diseased kidney to prevent its complete destruction, and in 2-3 months - less modified. But the resolution of this issue requires an individual approach. For two-sided stone, as with only one kidney, the delete operation of the stone should be made possible before, to prevent the death of renal tissue.
Of great practical importance is the question of the indications for surgery about kidney stones in pregnant women and for termination of their pregnancy. If kidney function is preserved and there is no phenomena nephropathy, having filled flowing stone is not an indication for abortion. If kidney stones pregnant complicated by the attacks of pyelonephritis and conservative treatment success does not, then with the proper attitude women need to try to save the fetus, causing the operation to remove the stone, and in severe cases of pyelonephritis - nephrectomy. Tactics urologist and obstetrician at a combination of pregnancy and kidney stones should be aimed at preserving pregnancy. Absolute indication for abortion is a kidney stone disease, complicated clearly expressed nephropathy (A. I. Pytel and N. A. Lopatkin).
Contra-indications to surgical treatment of patients with urolithiasis are organic diseases of the cardiovascular system events decompensation, tuberculosis of lungs in the phase of deterioration, a breach of cerebral circulation, severe diabetes, cachexia.
Removal of stones renal pelvis shows pelotonia. Back pelotonia gives the best and most secure access to the pelvis and stone. A big advantage is back pelotonia in situ (S. P. Fedorov), which are not violated due kidney surrounding tissues of the kidney is not dislocate in the wound remains the neuro-muscular system. When vnutripuzarnom location pelvis is contraindicated typical rear pelotonia and pelotonia in situ (danger of injury major renal vascular, difficulties of access to the pelvis). In such cases illustrates a lower pelotonia and calicotome [Babich (A. Babies)] or modification of this operation - subcortical pelotonia (I. P. Pogorelko). For secondary operations in the pelvis to remove recurrent stones used subcapsular Palotai (A. P. Frumkin)to avoid injuries large vessels, pleura, peritoneum and intestines in the presence of extensive scarring and postoperative adhesions around the kidney after previously completed transactions. Not all of kidney stones can be removed with the help of pielokamie. When large Staghorn calculi stones, and stones in the kidney cups sometimes have to resort to nefrologii. If nephrotomy need to avoid sectional cut the kidneys, which leads to a large bleeding (when there is enough preserved renal parenchyma) and the subsequent loss of renal parenchymal with the development of it common scar-sclerotic changes. In some cases stones calices have to combine nephrotomy with pelotonia, promoting stone finger entered through the pelvis in a Cup, to the periphery of the kidneys. An important place among the activities when kidney stones saves nephrectomy. It is indicated in cases hard place of pyelonephritis, when you don't succeed from the use of antibiotic therapy and threatens the development of sepsis, when Pioneros. Nephrectomy valid only in the presence of the second satisfactory functioning kidneys. Great attention should be paid in cases of extensive adhesions buds with the surrounding organs and tissues subcapsular nephrectomy (S. P. Fedorov). Operations nephrostomy and pyelostomy are of a forced nature, and are used for temporary or permanent drain urine from the kidneys, with significant lesions of the renal parenchyma, in cases of Pioneros, purulent pyelonephritis, when radical surgery is impossible, in obstructive anuria, to prevent secondary renal post-operative bleeding. When morphologic changes in the kidneys, pelvis and ureter, in violation of normal topographic anatomic relationships and outflow of urine from the kidneys simultaneously with the removal of the kidney stone can be shown various reconstructive and plastic operations on the kidneys, pelvis and ureter (see the Ureter, operations, Kidneys, surgery).
After the removal of stones from kidneys, ureters may experience a recurrence of kidney stones. Distinguish between true and false relapses. Under the latest understand remaining undetected and undeleted during the operation of small stones, pieces of stone. True recurrences operated in the kidney on the various statistical data observed in 5-20%, and often they occur after nephrolithotomy and if infected, alkaline urine.
Prevention. For prevention of kidney stones and its recurrence, carry out the following activities: increase diureza patient (excessive drinking, appropriate mineral water); diet, given the nature of urolithic diathesis; medications that influence reaction in the urine, reducing the concentration of salts in it, enhance diuresis and facilitate leaching of salts, small stones; measures to combat urinary infection.