Surgery 6th year, Tutorial (Dr. Sarwar Noori)

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Nov. 29th, 2011

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Surgery 6th year, Tutorial (Dr. Sarwar Noori)

  1. 1. Renal stones endoscopic management Dr sarwar noori mahmood F.I.C.MS(urology), F.E.B.U
  2. 2. Indications for treatment <ul><li>Presence of symptoms and /or obstruction </li></ul><ul><li>in a functioning kidney </li></ul>
  3. 3. Treatment of Renal Stones <ul><li>Four Options 1) conservative , </li></ul><ul><li> 2) non-invasive: ESWL </li></ul><ul><li>3) minimal invasive : PCNL, URS </li></ul><ul><li>4) open surgery </li></ul><ul><li>New technology :  morbidity,  hospital stay, </li></ul><ul><li>  invasiveness </li></ul>
  4. 4. Natural history of renal stones
  5. 6. Spontaneous clearance of stones takes place ONLY WHEN— 1.There is good flow of urine/function on the affected side & 2.There is no distal obstruction
  6. 7. MANAGEMENT OF RENAL CALCULI by ESWL <ul><li>< 2cm in diameter and/or surface area < 500 mm 2 </li></ul><ul><li> Treatment : ESWL mono-therapy </li></ul><ul><li> > 2cm in diameter and/or surface area > 500 mm 2 </li></ul><ul><li> Treatment : PCNL +/- ESWL </li></ul><ul><li> Combination therapy </li></ul>
  7. 8. Treatment of Renal Stones
  8. 9. ESWL
  9. 10. Generation of shock wave
  10. 11. T H E M A G I C W O R D--- LITHOTRIPSY EXTRA CORPOREAL SHOCK WAVE LITHOTRIPSY WHAT ARE SHOCK WAVES?
  11. 14. There should be a limited amount of gravel , which is expected to be passed out spontaneously within reasonable time limit , without causing much discomfort/colics .
  12. 15. IDEAL SITUATION FOR SUCCESSFUL E.S.W.L. Renal calculus of less than 2 cm having hetrogenous calcification/ architecture In X- ray , in a well functioning renal unit with no distal obstruction
  13. 19. Percutaneous nephrolithomy PCNL The key-hole surgery
  14. 20. <ul><li>Indication of PCNL: </li></ul><ul><li>>2.5-3.0 cm </li></ul><ul><li>failure of ESWL (matrix,cystine,ca oxalate monohydrate) </li></ul><ul><li>cystine stone >1.5 cm </li></ul><ul><li>lower calyx stone ≥ 2.0cm(narrow, long, acute angel infuldibulopelvic angel) </li></ul><ul><li>caliceal diverticulum </li></ul><ul><li>UU stone >1cm not respond to ESWL or difficult with URS. </li></ul>
  15. 21. FUCTIONAL ANATOMY OF KIDNEY FOR PERCUTANEOUS TECHNIQUE   1.              VASCULAR   2.              CALYCEAL   3.              ANATOMIC RELATION  
  16. 23. PERCUTANEOUS RENAL SURGERY   PRE – OP WORK UP   Urine culture Renal function test Haematological profile Caogulation profile KUB and IVU US .                               
  17. 24. Steps for PCNL <ul><li>Retrograde ureteric catheterization </li></ul><ul><li>Fluoroscopy-guided percutaneous puncture(B-ultrasound for simple case) </li></ul><ul><li>Tract dilation </li></ul><ul><li>Lithotripsy </li></ul><ul><li>Double-J stent and nephrostomy tube placement </li></ul>
  18. 25. ANAESTHESIA <ul><li>Epidural anesthesia (Most cases) </li></ul><ul><li>G eneral anesthesia (Obesity and lung dysfunction) </li></ul><ul><li>Local anesthesia ( for second-look ) </li></ul>
  19. 26. Body position <ul><li>prone position (most cases) </li></ul><ul><li>side-lying position ( obesity 、 cardiorespiratory dysfunction ) </li></ul><ul><li>supine position ( transplanted kidney ) </li></ul>
  20. 28. Retrograde ureteric catheterization <ul><li>6Fr ureteric catheter open end </li></ul><ul><li>Wash out small stones </li></ul><ul><li>Prevent small stones moving from pelvis into ureter </li></ul>
  21. 30. <ul><li>AMPLATZ SHEATH </li></ul><ul><li>Metallic </li></ul><ul><li>Teflon </li></ul>
  22. 35. <ul><li>X-ray </li></ul><ul><li>Ultrasonography </li></ul>Which one is better ? 2 methods combination better.why?
  23. 49. <ul><li>Air pneumatic lithotripter </li></ul><ul><li>Ho:YAG laser </li></ul><ul><li>3th generation EMS </li></ul><ul><li>Which one is better? </li></ul>
  24. 50. Double-J stent and nephrostomy tube placement,Tubeless PCNL NOT common
  25. 53. PERCUTANEOUS RENAL SURGERY COMPLICATIONS     1.                         RENAL PELVIC PERFORATION   2.                         HAEMORRHAGE   3.                         INJURY ADJACENT ORGANS   4.                         UROSEPSIS   5.                         FLUID ABSORPTION   6.                         AV MALFORMATION    
  26. 55. Ureteric stone
  27. 56. <ul><li>INDICATIONS FOR INTERVENTION: </li></ul><ul><li>The classical indications for intervention are well known & include the following: </li></ul><ul><li>* Presence of infection </li></ul><ul><li>* Presence of obstruction </li></ul><ul><li>* Persistent colic with no advancement of the stone </li></ul><ul><li>* A stone more than 0.5 cm in diameter </li></ul><ul><li>The classical indications have recently been modified because of the advent of new technology & the high expectations of today's patients. </li></ul><ul><li>THERAPEUTIC OPTIONS: These include: </li></ul><ul><li>* Surgery </li></ul><ul><li>* Percutaneous surgery </li></ul><ul><li>* Ureteroscopy with Electrohydraulic lithotripsy(EHL), Ultrasound lithotripsy, </li></ul><ul><li>Laserlithotripsy, Electro-mechanical Impactor lithotripsy, & Lithoclast lithotripsy. </li></ul><ul><li>* ESWL </li></ul><ul><li>* Spontaneous passage </li></ul>
  28. 57. MANAGEMENT OF URETERIC STONES <ul><li>-Stones < 0.5 cm in diameter doesn’t pass </li></ul><ul><li>spontaneously 4 to 6 weeks and /or causing symptoms : ESWL monotherapy </li></ul><ul><li> -Stones > 0.5 cm in diameter & < 1 cm in </li></ul><ul><li>diameter : ESWL monotherapy </li></ul>
  29. 58. MANAGEMENT OF URETERIC STONES <ul><li>Stones > 1 cm in diameter : trial of ESWL monotherapy </li></ul><ul><li>Patient counselled: </li></ul><ul><li>1. Repeat session may be necessary </li></ul><ul><li>2. URS/PCNL/ureterolithotomy </li></ul>
  30. 59. RESULTS OF URETROSCOPIC LITHOTRIPSY (URS) <ul><li>Achieved stone free status = 85% to 90% </li></ul><ul><li>Failures: </li></ul><ul><li>1. Access problems </li></ul><ul><li>2. Stone migration </li></ul><ul><li>Flexible URS for upper third ureteric calculi </li></ul><ul><li>especially in the male </li></ul>
  31. 60. <ul><li>URS complications: </li></ul><ul><li>pain ,sepsis ,damage to ureteral mucosa and wall, failure </li></ul>
  32. 61. RENAL STONES
  33. 62. Nephrolithotomy
  34. 63. PREVENTION OF STONES <ul><li>1. Treatment of causes </li></ul><ul><li>2. Dietary manipulations </li></ul><ul><li>3. Medications - indication duration </li></ul>
  35. 64. DIETARY ADVICE <ul><li>1. Hydration </li></ul><ul><li>2. Avoid oxalate-rich food </li></ul><ul><li>3. Avoid calcium-rich food ? </li></ul><ul><li>4. Avoid refined carbohydrates </li></ul><ul><li>5. Increase crude fibres </li></ul>
  36. 65. MEDICATIONS <ul><li>1. Thiazides </li></ul><ul><li>2. Allopurinol </li></ul><ul><li>3. Antibiotics </li></ul><ul><li>4. Sodium bicarbonate </li></ul><ul><li>5. Potassium citrate </li></ul><ul><li>6. Magnesium salts </li></ul><ul><li>7. Pyridoxine </li></ul>

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