The urethra's main job in males and females is to pass urine outside the body. This thin tube also has an important role in ejaculation for men. When a scar from swelling, injury or infection blocks or slows the flow of urine in this tube, it is called a urethral stricture. Some people feel pain with a urethral stricture.
The urethra's main job in males and females is to pass urine outside the body. This thin tube also has an important role in ejaculation for men. When a scar from swelling, injury or infection blocks or slows the flow of urine in this tube, it is called a urethral stricture. Some people feel pain with a urethral stricture.
Please find the power point on Renal and bladder stones. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
URETHRAL INJURY- Trauma Surgery
#surgicaleducator #babysurgeon
Dear viewers,
Greetings from “Surgical Educator”
Today I have uploaded a video on URETHRAL INJURY- one more in Trauma Surgery. I haven’t talked elaborately but have included the essential minimum an undergraduate medical student should know. I have talked about anatomy, classification, etio-pathogenesis, symptoms, signs, investigations, grading, treatment, complications, treatment algorithm and case vignettes of urethral injuries. My aim is, after watching this video all of you should be able to arrive at a correct working diagnosis of the type of urethral injury and should also be able to institute immediate treatment to the patients if there is a need. The definitive urethroplasty should be done by a Urologist. You can watch the video in the following links:
surgicaleducator.blogspot.com
youtube.com/c/surgicaleducator
Thank you for watching the video.
Types of Urethral injury, Mechanism of Urethral injury, Classification of Urethral injury, Symptoms of Urethral injury, Signs of Urethral injury,
Investigations for Urethral injury, Grading of Urethral Injury, Treatment for Urethral injury, Complications of Urethral Injury
Please find the power point on Renal and bladder stones. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
URETHRAL INJURY- Trauma Surgery
#surgicaleducator #babysurgeon
Dear viewers,
Greetings from “Surgical Educator”
Today I have uploaded a video on URETHRAL INJURY- one more in Trauma Surgery. I haven’t talked elaborately but have included the essential minimum an undergraduate medical student should know. I have talked about anatomy, classification, etio-pathogenesis, symptoms, signs, investigations, grading, treatment, complications, treatment algorithm and case vignettes of urethral injuries. My aim is, after watching this video all of you should be able to arrive at a correct working diagnosis of the type of urethral injury and should also be able to institute immediate treatment to the patients if there is a need. The definitive urethroplasty should be done by a Urologist. You can watch the video in the following links:
surgicaleducator.blogspot.com
youtube.com/c/surgicaleducator
Thank you for watching the video.
Types of Urethral injury, Mechanism of Urethral injury, Classification of Urethral injury, Symptoms of Urethral injury, Signs of Urethral injury,
Investigations for Urethral injury, Grading of Urethral Injury, Treatment for Urethral injury, Complications of Urethral Injury
Common disorder with an annual incidence of 0.1% to 0.5%.
The peak age at onset is 20 to 30 years
Men > Women ( until 50s )
Wide geographic variations exist, due to differences in diet and water composition, as well as ambient and sunlight exposure. 5-9% in Europe 20% in Saudi Arabia
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
3. Objective
• To discuss on management of urolithiasis
focusing on surgical managements
10/9/2021 3
by mengistu.K
4. Introduction
• Urinary stones are polycrystalline aggregates
composed of varying amounts of crystalloid
and organic matrix.
• Third most common affliction of the urinary
tract, exceeded only by UTI and pathologic
conditions of the prostate.
• Site of stone formation has migrated from the
lower to the upper urinary tract.
10/9/2021 4
by mengistu.K
5. • Epidemiology
– Prevalence rates for urinary stones vary from 1%
to 20%.
– Rise in stone incidence and prevalence due to rise
in the detection of asymptomatic calculi.
• Risk factors
– Gender, age, geography, climate, occupation, BMI
and water
10/9/2021 5
by mengistu.K
7. • Predictors of stone recurrence
– younger age
– male sex
– family history
– prior stone event
– non obstructing renal stones
– Symptomatic renal pelvis/lower pole stones and
uric acid composition.
10/9/2021 7
by mengistu.K
10. Diagnostic evaluation
• Clinical evaluation
• Investigations
– Base line investigations
– Radiological evaluation
– Metabolic evaluation
10/9/2021 10
by mengistu.K
11. Clinical evaluation
• Pain – commonest
• Hematuria
• Fever, UTI
• Urosepsis
– Pyonephrosis
– Infected hydronephrosis
• Uremia
– Bilateral obstruction
– Obstruction in solitary
kidney
• Asymptomatic
• Immediate evaluation in
patients with
– Solitary kidney
– Fever or when there is
doubt regarding a
diagnosis of renal colic
10/9/2021 11
by mengistu.K
12. Radiological evaluation
• Cornerstone in the evaluation of stone
disease
• Includes
– Plain X ray KUB + USG of KUB region
– NCCT ( Non Contrast CT)
– IVU ( Intravenous Urogram)
10/9/2021 12
by mengistu.K
14. Analysis of stone composition
• Should be performed in all first-time stone
formers
• Repeat stone analysis is needed in the case of:
– Recurrence under pharmacological prevention
– Early recurrence after interventional therapy with
complete stone clearance
– Late recurrence after a prolonged stone-free
period
10/9/2021 14
by mengistu.K
15. • Diagnosis in special groups and conditions
– Diagnostic imaging during pregnancy
– Diagnostic imaging in children
10/9/2021 15
by mengistu.K
16. Ultrasound (US)
• Primary diagnostic
imaging tool
• Safe ,reproducible and
inexpensive
• Higher potential for
misinterpretation of size
improved with
measuring the acoustic
shadow
• Sensitivity(61%) and
specificity (97%)
10/9/2021 16
by mengistu.K
17. Radiography(KUB and IVP)
• KUB
– Oldest method of
identifying stones
– Sensitivity of 57% and a
specificity of 76%
– Inability to visualize all
stone types
• IVP
– Better delineation of the pelvicalyceal and
ureteral anatomy
– Sensitivity 70% and specificity 95%
– Radiolucent stones detected as filling defects
– Detect Underlying anatomic abnormalities
10/9/2021 17
by mengistu.K
18. Non-contrast-enhanced CT
• The goldstandard imaging with
sensitivity of 98% and
specificity of 97%
• Can determine
– Stone density
– Inner structure of the stone
– Skin-to-stone distance and
surrounding anatomy
• Able to visualize extraurinary
tract abnormalities
• Radiation risk can be reduced
by low-dose CT
10/9/2021 18
by mengistu.K
20. Management
• Acute colic management
– NSAID
– OPIOIDS
• Management of sepsis and/or anuria in
obstructed kidney: two options
– Placement of an indwelling ureteral stent
– Percutaneous placement of a nephrostomy tube
• Medical expulsive therapy
– Percutaneous irrigation chemolysis
– Oral chemolysis
10/9/2021 20
by mengistu.K
21. • General recommendations and precautions
for stone removal
– Antibiotic therapy
– Antithrombotic therapy
– Obesity
– Stone composition
10/9/2021 21
by mengistu.K
22. • Surgical management options
• Minimally invasive
– ESWL
– Percutaneous Nephrolithotomy
– Ureterorenoscopy
– Laparoscopic Approach to stones
• Open surgery
10/9/2021 22
by mengistu.K
23. Extracorporeal shock wave lithotripsy
(SWL)
• Shock waves generation
– Electromagnetic
– Electrohydraulic
– Piezoelectric
• Focused at stone
• Fragmentation
– Spall fracture
– Squeezing-splitting or
circumferential
compression
– Shear stress
– Superfocusing
– Cavitation
• Four main elements
– Energy source
– Focusing device
– Coupling device
– Localization device
10/9/2021 23
by mengistu.K
24. • The success of SWL
depends
– The efficacy of the
lithotripter
– size, location (ureteral,
pelvic or calyceal), and
composition (hardness) of
the stones and patient’s
habitus
– performance of SW
• Best clinical practice
– Stenting
– Pacemaker
– Shock wave rate
– Number of shock waves,
energy setting and repeat
treatment sessions
– Improvement of acoustic
coupling
– Pain control
– Antibiotic prophylaxis
– Medical therapy after SWL
10/9/2021 24
by mengistu.K
26. • Contraindications of extracorporeal SWL:
– Pregnancy, due to the potential effects on the
fetus
– Bleeding diatheses
– Uncontrolled UTIs
– Severe skeletal malformations and severe obesity,
which prevent targeting of the stone;
– Arterial aneurysm in the vicinity of the stone
– Anatomical obstruction distal to the stone.
10/9/2021 26
by mengistu.K
28. Percutaneous Nephrolithotomy
• The standard procedure for large renal calculi
• Standard access tracts are 24-30 F or Smaller
access sheaths, < 18 F
• Contraindications
– Uncorrected coagulopathy
– Untreated UTI
– Tumour in the presumptive access tract area
– Potential malignant kidney tumour
– Pregnancy
10/9/2021 28
by mengistu.K
30. • Best clinical practice
– Antibiotics
– Anesthesia
– Pre-operative imaging
– Positioning of the
patient
– Puncture
– Intracorporeal lithotripsy
– Dilatation
– Choice of instruments
– Nephrostomy and stents
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by mengistu.K
31. • Nephrostomy and stents: decision depends on
several factors including
– Presence of residual stones
– Likelihood of a second-look procedure
– Significant intra-operative blood loss
– Urine extravasation
– Ureteral obstruction
– Potential persistent bacteriuria due to infected stones
– Solitary kidney
– Bleeding diathesis
– Planned percutaneous chemolitholysis.
10/9/2021 31
by mengistu.K
32. • Post op
– Keep transurethral catheter for 6-24 hrs and
nephrostomy for 3 days
– Nephro-uretero-tomography is performed prior to
removal
10/9/2021 by mengistu.K 32
33. Complications
• Fever 10.8%
• Transfusion 7%
• Thoracic complication 1.5%
• Sepsis 0.5%
• Organ injury 0.4%
• Embolisation 0.4%,
• Urinoma 0.2%, and death 0.05%
10/9/2021 33
by mengistu.K
34. Ureteroscopic Stone Management
• Rigid ureteroscope: tip
diameter of < 8 French
(F)
– Lower ureteric stone
– Mid ureteric stone
– Upper ureteric stone – in
some cases
• Flexible ureteroscope –
very costly
– Upper ureteric stone
– Small renal stone
10/9/2021 34
by mengistu.K
35. • Best clinical practice in
ureteroscopy
– Access to the upper urinary
tract(retrograde and
antegrade
– Safety aspects
– Ureteral access sheaths
– Intracorporeal extraction
lithotripsy
– Stenting before and after URS
– Medical expulsive therapy
after ureteroscopy
• Complications
• Intraoperative
– Stone migration into the ureteral wall
– Mucosal trauma
– Ureteral perforation
– Ureteral avulsion
• Early Postoperative
– Gross hematuria
– Renal colic
– Residual stone
– Pyelonephritis
– Urinoma
– Ureteral stent symptoms
• Late Postoperative
– Ureteral stricture
– “Forgotten” encrusted ureteral stent
10/9/2021 35
by mengistu.K
36. Management of renal stone
• Optimal treatment for a given patient is not
always clear and depends on 3 factors
Stone related
factors(the most
important factor )
Anatomic factors Clinical factors
Size
Number
Location
Composition
Obstruction or stasis
Hydronephrosis
Ureteropelvicj unction
obstruction
Calyceal diverticulum
Horseshoe kidney
Renal ectopia or fusion
Lowerpole
Infection
Obesity
Body habitus deformity
Coagulopathy
Juvenile
Elderly
Hypertension
Renal failure or transplant
Solitary kidney
Urinary diversion
Pregnancy
Patient symptoms
10/9/2021 36
by mengistu.K
37. Indications for active removal of renal
stone
• Stone growth
• Stones in high-risk patients for stone formation
• Obstruction caused by stones
• Infection
• Symptomatic stones (e.g., pain or haematuria)
• Stones > 15 mm
• Stones < 15 mm if observation is not the option of choice
• Patient preference
• Comorbidity
• Proximal Ureteral Stone
• Social situation of the patient (e.g., profession or travelling)
10/9/2021 37
by mengistu.K
40. Staghorn stone
• Most are struvite but can also be cystine,
calcium oxalate monohydrate, and uric acid
• Ideal management is composed of 3 stages
– Complete surgical removal of the entire stone
burden
– Any metabolic abnormalities must be identified
and appropriately treated
– Assess for anatomic abnormalities
10/9/2021 by mengistu.K 40
41. • SWL, PNL, combined PNL and SWL, open surgery
• PNL, followed by either SWL or repeated PNL,
should be used for most patients with struvite
staghorn calculi
• SWL in small volume stones with normal or near
normal anatomy
• Nephrectomy non functioning kidney with
staghorn stone
10/9/2021 by mengistu.K 41
42. Treatment Decisions by Stone Burden
Non staghorn stones
• Stone burden(size and number) is the single most important
factor
• Calculi are less than 10 mm in diameter
– 50% to 60% of all solitary renal
– SWL is generally satisfactory
– PNL and ureteroscopy for those with anatomic
malformation causing obstruction, SWL failure
• Calculi between 10 and 20 mm
– SWL as first-line management
– Stone location and composition matters
– Cystine calculi and brushite calculi both respond poorly to SWL
10/9/2021 by mengistu.K 42
43. • Stones larger than 20 mm
– PNL
– Ureteroscopy: bleeding diathesis, obesity).
10/9/2021 by mengistu.K 43
44. Treatment Decisions by Stone Composition
• Patients with such stones (i.e., brushite, cystine, ca
oxalate monohydrate) should be treated by SWL only
when the stone burden is small ( <1.5 cm)
• For matrix caliculi
– Treated with PNL
– SWL is ineffective b/c the stone is gelatinous
– Ureteroscope is not also preferred b/c of large volume of the
stone
• Indinavir stones
– Hydration and analgesic therapy
– discontinuing the drug : temporarily or permanently
– intervention for prolonged renal obstruction, signs of sepsis, or
unremitting symptoms
10/9/2021 by mengistu.K 44
45. Renal Anatomic Factors
Ureteropelvic Junction Obstruction
• Options of management are
– Open pyeloplasty and stone extraction
– PNL+ endpyelotomy
– laparascopic pyeloplasty + pyelolitotomy
calyceal diverticula
– Percutaneous approach
– Retrograde ureteroscope for upper and middle
calyceal diverticula (stone <2cm)
10/9/2021 by mengistu.K 45
46. Horseshoe kidney and Renal ectopia
– 15-20% have stone disease
– Most are Ca oxalate stones
– Commonly located at renal pelvis and posterior lower pole calyces
– SWL,URS, PCNL, Laparascopy
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47. Factors Affecting Management of Ureteral Stones
• Stone-Related Factors
– Location
– Size
– Composition
– Degree of obstruction
• Technical Factors
– Available equipment
– Cost
• Clinical Factors
– Symptom severity
– Patient's expectations
– Associated infection
– Solitary kidney
– Abnormal ureteral
anatomy
– Coagulopathy
– Obesity
Management of ureteric stone
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48. Over all passage rate of ureteral stone
• Spontaneous passage by location
– Proximal ureteral stone: 25%
– Mid ureteral stone : 45%
– Distal ureteral stone: 70%
– Ureterovesical junction : 79%
• By size
– < or = 2mm : 95%
– 2-4mm : 83%
– > 4mm : 50%
– 4-6mm : 59%
– > 6mm : 21%
• > or = 7mm : chance of passage is very
low
• Average interval to
stone passage
– < or = 2mm : 31days
– 2-4mm : 40 days
– 4-6mm : 39 days
• Majority of stone pass
with in 4-6wks
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49. Option of management ureteral stone
• Expectant or Medical expulsive therapy
• SWL
• URS
• Percutaneous renal access with antegrade URS
• Laparoscopic or robotic ureterolithotomy
• Open ureterolithotomy
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51. Expectant management
• Candidate
– Stone < 6mm
– Normal renal function
– Well controlled pain
– Non obstructed
– Non infected
• Observation period 2-
4weeks
• Weekly KUB to see
progression of stone
• Medical expulsive therapy
– First line therapeutic
option for stone < 10mm
– Agents are: alpha blockers,
ca++ channel blocker &
corticosteroid
– Mechanism of action is it
relax ureteral smooth
muscle to restore normal
peristalsis
– Nefidipine - increase stone
passage rate by 9%
– Alpha-blockers- increase
stone passage rate by 20%
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52. Stone Factors
Treatment Decision by Localization
• Proximal and mid ureteric
– Primary options include SWL and URS, although PCNL
and antegrade nephroscopy may be indicated for
select cases
– A percutaneous and antegrade for very large
proximal ureteral calculi not amenable to either SWL
or URS
Distal utereric
• SWL and URS both remain the mainstays of
treatment of distal ureteral stones.
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53. Treatment Decision by Stone Burden
• In cases of high stone burden SWL is less effective
and needes adjuvant therapy
Treatment by Stone Composition
• Brushite (calcium phosphate) stones, calcium
oxalate monohydrate, and cysteine stones are all
more resistant to SWL therapy and can be
expected to have better rates at all sizes and
locations with URS
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54. Ureteral Anatomic Factors
• Megaureter
– nonobstructed megaureter: MET, SWL, and URS
– obstructed megaureter: manage both the stone and the underlying
pathology have included the following:
• Retropulsion of the stones then PCNL + ureteroneocystostomy
• Ureterolithotomy with ureteroneocystostomy
• Ureteroscopy with endoureterotomy (in short-segment cases <3 cm
• Duplicated Collecting System
– Retrograde pyleography
– URS
• Ureteric stricture and stenosis
– Endoureterotomy followed by URS
– Open, laparoscopic, or robotic-assisted laparoscopic treatment
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55. Treatment decision based on Clinical Factors
UTI
• PCNL and URS, when active stone extraction is possible
• UTI associated with an obstructing upper tract stone (ureteral
or renal) requires emergent urinary tract drainage
– ureteral stenting or percutaneous nephrostomy
Renal function test
• Nephrectomy : symptomatic upper tract stones located in
renal units with approximately 15% or less split function
Solitary kidney
• Asymptomatic stones are managed actively
55
56. • Morbid obesity
– Ureterorenoscopy and PCNL
• Old age and frailty
– PCNL , more blood transfusions
– SWL, perirenal hematoma
• Spinal Deformity or Limb Contractures
– PCNL and URS are preferred than SWL
• Uncorrected coagulopathy is a
contraindication to
– URS with little to no increase in surgical morbidity
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57. Open surgery
• PRINCIPLES
– To preserve as much as possible of the functioning
renal tissue and to prevent complications.
– There is no place for hypotensive anaesthesia in renal
surgery.
• Special considerations
– In bilateral kidney stone. operate on the most painful
side first then on the other side.
– In bilateral kidney stones with one non-functioning
(bad) kidney, operate on the healthy side first then
perform nephrectomy on the bad kidney.
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58. Indication for open renal surgery
• Failure of , or C/I to SWL or PNL
• Associated anatomic abnormalities
• Stone so large & complex
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59. Surgical techniques
Approaches to the kidney
• Flank Approaches
– Eleventh rib incision (classic flank):
Better access to renal hilum and upper
pole
– Subcostal flank incision
• Anterior Approaches
– Subcostal transperitoneal incision
– Bilateral subcostal transperitoneal
incision
– Thoracoabdominal incision
– Midline Abdominal Incisions
– Infraumblical incision
– Inguinal incision
Posterior approach
• Excellent procedure
for pylolitotomy and
upper third
ureterolitotomy
• Decreased pain and
shorter hospital stay
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60. Types of surgery
Anatrophic nephrolitothomy
– Massively sized , complete , fully branched staghorn stone
with infundibular stenosis
Radial nephrotomy : indicated for removal of solitary
caliceal stone or caliceal stone associated with larger
intrapelvic stone
Simple pyelolithotomy : renal stone + PUJ obstruction
Extended pyelolithotomy : indicated for trapped
caliceal & branched stones.
Pyelonephrolithotomy : removal of branched calculi
located with in the lower pole infundibulum.
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61. • Partial nephrectomy : lower pole stone +
infective destruction of parenchyma
• Nephrectomy : kidney destroyed by ;
obstruction + infection ( xanthogranulomatous
pyelonephritis
• Calyceal diverticulolithotomy : calyceal
diverticular stone
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62. Anatrophic Nephrolithotomy
• Gerota’s fascia is incised in cephalo-caudal direction
• The kidney is mobilized and the perinephric fat is
dissected of the capsule
• If the capsule is inadvertently incised, it can be
closed by fine catgut suture
• Main renal artery and posterior branch are identified
and dissected
62
63. • Renal pelvis and ureter are identified but not
dissected
• Avascular plane is identified
– Clamping the posterior segmental artery and injecting
20ml of methylene blue IV
– Using Doppler to localize area of minimal blood flow
– Using the brodel’s line after clamping the renal pedicle
• Incising the renal capsule at the lateral convexity of
the kidney and parenchyma incision is made 1-3cm
posterior to it
63
66. • 25mg mannitol administered
• Bowl bag and dry packs re placed around the
kidney
• Iced slush applied to core temperature of the
kidney to15-20min
• The renal parenchyma is bluntly dissected with
the back of the scalpel handle
• The ideal location to enter the collecting system
is at the base of the posterior infundibulum
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68. • After removal of all stone fragments, the renal
pelvis and calyces are copiously irrigated with
cold saline and the irrigant is aspirated
• Double J stent placed from the renal pelvis to
the bladder
• Reconstruction of the intrarenal collecting
system with correction of coexistent anatomic
abnormalities that may be present
• 5-0 or 6-0 chromic catgut sutures.
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69. • The renal capsule is closed with a running lock stitch of
4-0 chromic catgut suture or mattress sutures over
bolsters can be used.
• After capsule is repaired the renal artery is unclamped
and kidney is seen for hemostasis, color and turgor
• The kidney and proximal ureter are covered by Gerota’s
fascia omentum
• A Penrose or suction-type drain is placed within
Gerota’s fascia and brought out through a separate
stab incision
• Avoide nephrostomy tubes infection risk
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70. Pyelolithotomy
• Mobilization of the kidney after gerota’s fascia is
incised.
• The renal pelvis and upper ureter are identified and the
pelvis is approached posteriorly
• Two stay sutures are placed in the renal pelvis using 4-
0 chromic suture and a longitudinal incision made
• Removal of all stones
• The renal pelvis is closed with a 4-0 chromic
continuous suture.
• Drainage of the system is performed as described
previously
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71. Extended Pyelolithotomy
• The dissection is carried subparenchymally to
expose the renal pelvis and the infundibula.
• A curvilinear pyelotomy incision is made over
the stone and then extended to the superior
and inferior calyces.
• Stone removal
• The collecting system is closed with a
continuous 4-0 chromic catgut suture
• Drainage
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72. Ureterolithotomy
• The flank or posterior lumbotomy incision can be used
for the upper ureter
• An anterior extraperitoneal muscle splitting incision
can adequately expose the mid-ureter
• The lower ureter can be accessed via a Gibson,
Pfannenstiel, or midline suprapubic incision
• Distal ureterolithotomy, exposure of the ureter
requires certain other maneuvers.
– Identifying the iliac vessels
– Dividing the obliterated umbilical vessels can help.
– The bladder is reflected medially and kept decompressed
with a Foley catheter
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73. Upper ureterolithotomy
• Gerota’s fascia is opened and the upper ureter is
identified
• A Babcock forceps or vessel loop is placed on the ureter
above the stone expose the ureter downward
• A vertical ureterotomy and stone extraction
• Carefully irrigate the entire ureter and put double J stent
• Close the incision longitudinally with simple interrupted
5-0 sutures placed 1–2 mm apart.
• A Penrose or suction drain
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74. Postoperative management
• Intravenous fluids
• Postoperative antibiotics for 5–7 d guided by
preoperative urine culture and sensitivity
findings.
• The ureteral stent is removed cystoscopically at
approx 7 d postoperatively in uncomplicated
cases.
• A urine culture is checked for persistence of
infection. At 1–2 mo a follow-upintravenous
pyelogram is obtained
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75. Complications
• Pneumothorax
• Renal hemorrhage
• Renal arteriovenous fistula formation or a false aneurysm
• Renal injury and hypertension.
• Urinary extravasation
• Flank absess
• Loss of the stone intraoperatively, fistulas, and strictures
75
76. Bladder stone
• 5% of all the urinary
stone diseases
• Classified as
– Migrant : 3% to 17% of
bladder calculi
– primary idiopathic-
nutritional deficiency, most
common in children < 10
yrs, peak at 2 to 4 years
– secondary: associated
with an underlying bladder
pathology
• Clinical presentation
– Terminal hematuria : most
common presentation
– lower urinary tract
symptoms
– Pulling the penis
pathognomonic of bladder
stone in children
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77. Management
• Medical Management
– Chemo dissolution: time
consuming and not
completely efficient
• ESWL: option in
– Pts with artificial urinary
sphincters or a penile
prosthesis
– Stones in neobladders
– factors affecting the
outcome include the amount
of post void residue, the
stone composition, and the
stone size
• Endourologic Approach
– Cystolithotomy: intact
removal of stone
– Cystolithotripsy: fragmenting
the stone with energy source
– Cystolitholapaxy: mechanical
breakage of the stone
– Rout transurethral with
laser lithotripsy
• Percutaneous approach
patients who have
undergone previous bladder
neck reconstruction or
closures
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78. Open Surgery
• Open cystolithotomy
– Associated with the need for prolonged catherization
and hospital stay
– If transurethral or percutaneous access to the bladder is
contraindicaed
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79. Lower Tract Calculi in Special Situations
• BOO With Bladder
Lithiasis
– The presence of urolithiasis
secondary to BOO forms
the absolute indication for
treatment of BPH
• Bladder Calculi in Urinary
Diversions
– Causes : infection,
metabolic abnormalities,
and anatomic and
structural factors
– Mgt depends on type of
diversion
• Bladder Calculi in Patients
With Spinal Cord Injury
– Stone formation peaks at 3
months after injury
– Managed as general
population
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80. Urethral Calculi
• 0.3% to 1% of all stone
disease
• Obstructing urethral
calculus is a very rare
• More common in males,
• Bimodal age distribution
(early childhood and fourth
or fifth decades of life)
• Majority are migratory from
bladder and calcium oxalate
(85%–90%) of cases
• Common on prostatic and
bulbar urethra
• Clinical Presentation
– acute painful retention of
urine
– weak stream, interrupted
stream, or splaying, gross
hematuria, and dysuria
• Treatment
– Location within the urethra
– Distance from the internal or
the external urethral meatus
– Stone characteristics
– The ability of the stone to get
pushed into the bladder, and
– Associated structural
abnormalities of the urethra
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81. • Posterior urethra stones
– Pushed back into the bladder for ESWL(success rate of only
60%) or intracorporal lithotripsy (success rate of 85% to
90% )
• Anterior urethra stones
– Milking the stone : for small and smooth-surfaced stones
and near to external meatus
– For larger and more proximal anterior urethral stones
urethrotomy and stone extraction
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82. Summery
• Urinary stones are third most common affliction
of the urinary tract, exceeded only by UTI and
pathologic conditions of the prostate.
• Site of stone formation has migrated from the
lower to the upper urinary tract
• Radiographic evaluation Cornerstone in the
evaluation of stone disease
• PCN is the standard procedure for large renal
calculi
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83. Reference
• Campbell-walsh-wein urology twelfth edition
• European Association of Urology 2020 edition
• CURRENT CLINICAL UROLOGY
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