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    Urea( renal stone disease) is a disease associated with the formation of stones in the urinary system. This is one of the most common urological diseases, its frequency on average in Russia is 34.2%.Moreover, at present the incidence continues to grow, and if earlier it was thought that only adults are ill, more children are becoming ill. According to the Research Institute of Urology of the Ministry of Health of the Russian Federation, among the younger children's age group, the prevalence of urolithiasis reaches 19.9 per 100 000 population, and in adolescent - 81.7 patients per 100 000 population.

    Stones with urolithiasis can be found not only in the kidneys, but also in the ureter or in the bladder. However, within the framework of this section( and the book as a whole) only kidney stones, the so-called nephrolithiasis( nephro-kidney, lith-stone) will be considered. The stones in their chemical composition can be different - urate, phosphate, oxalate, cystine, etc. Specific forms of urolithiasis include coronary kidney stones, single kidney stones and kidney stones in pregnant women.

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    Urolithiasis is considered a multifactorial disease, in its development an important role is played by the conditions of the external environment, as well as by the internal processes of the organism. The leading role among them belongs to metabolic disorders - the so-called diathesis, which can be uric acid, purine, phosphate-calcium, oxalic acid. Disturbances in the exchange of calcium and phosphorus, purine bases and uric acid, oxalates( oxalic acid salts) can arise for various reasons, they are often congenital.

    Kidney stones are formed when certain substances( for example, calcium oxalate) are concentrated in the urine and combine into solid, strong formations. Stones containing calcium make up about 70 to 80 percent of all kidney stones( mainly oxalate and calcium phosphate).Other stones consist of uric acid or magnesium, ammonium and phosphate compounds.

    During urine production, both kidneys regulate the balance of fluid and electrolytes in the body and filter waste from the blood. Urine is collected in part of the kidney, called the renal pelvis. Then the urine passes from the kidney into the bladder through a narrow tube called the ureter. Kidney stones of can form in the renal pelvis, then pass through the ureter into the bladder before they can be excreted from the body with urine. Some stones are so small that they do not cause any symptoms and leave painlessly on their own;large stones can not get out of the kidney and can be detected only if the x-ray of the abdomen is done for other reasons.

    Sometimes a stone can enter the ureter and cause unstable severe pain( known as renal colic) that continues until the stone reaches the bladder;This process can take from several hours to several days. Pain during one attack is usually felt only on one side, however, stones can form in the second kidney, causing pain on the other side. Symptoms disappear as soon as the stone passes. Seizures usually recur, and the treatment is aimed at alleviating the symptoms, crushing or removing existing stones and preventing their formation.

    For all types of stones:

    Calcium stones;

    Magnesium-ammonium phosphate stones:

    • Urinary tract infections caused by certain bacteria that decompose urea can create a chemical environment that promotes the formation of kidney stones. In the urine, the content of ammonium increases, it becomes alkaline, and this can lead to the formation of magnesium-ammonium-phosphate stones.

    Stones from uric acid:

    • Excessive acid urine is the most common cause of the formation of stones from uric acid.

    The high uric acid content in the urine, sometimes associated with gout symptoms, can also lead to the formation of this type of stones.

    Among the external factors contributing to the development of urolithiasis, it should be noted the characteristics of climate, drinking water and nutrition, and therefore the disease has a predominant distribution in certain areas of the globe( countries with hot dry climate, mountain and northern territories).On the territory of the Russian Federation are the zones of the Volga, the Urals, the Far North.

    Purine bases are part of nucleic acids, that is, genes, and are contained in every cell of the human body. The final stage of the exchange of the body's own purines, as well as the purines that come with food, is uric acid. Violations of the exchange of purine bases and uric acid take place primarily with gout. In addition, an important role is played by the intake of high amounts of purines from food( excessive consumption of meat products, beans, coffee), as well as diseases that are accompanied by a significant disintegration of its own protein.

    Disorders of calcium and phosphorus metabolism are characteristic for a number of endocrine diseases, vitamin D overdose, frequent and prolonged intake of calcium salts and highly mineralized water, diseases of the musculoskeletal system, extensive fractures. As a result, the possibility of isolating soluble calcium phosphate is partially lost, with calcium and phosphorus being converted to an alkaline, slightly soluble compound. The pH of the urine in this case corresponds to an indicator of 7.0( neutral).

    Disturbances in oxalic acid metabolism arise from excessive intake of oxalic acid from food( sorrel, spinach, rhubarb, beetroot, parsley, coffee, cocoa) or increased formation of oxalic acid salts in the body, for example, under stressed stress. The solubility of oxalates is lost at a urine pH of about 5.5, and also with an increased release of ionized calcium.

    However, there is another very important factor in the development of urolithiasis - a local one. That is, the factor contributing to the disease directly in the kidneys and urinary tract, namely, urine retention at various levels of outflow tracts and the presence of infection there. In this regard, a special role is played by the presence of vesicoureteral and bowel reflux, as well as inflammatory diseases - pyelonephritis, cystitis, urethritis.

    The process of stone formation proceeds gradually. First, the so-called nucleus of the stone is formed, which can be a blood clot, a cluster of bacteria, leukocytes, cells lining the collecting system of the kidneys. Then, under appropriate conditions, salts are deposited on this organic matrix. It should be noted that the main condition for this is changes in the acid-base balance of urine. Normally, there is a mechanism of colloidal defense in the body that prevents precipitation of salts in the sediment and maintains in a soluble form a concentrated solution - urine. However, when urine pH changes, this protective factor loses most of its activity.

    The chemical composition of stones can be homogeneous and mixed. In women, phosphates are most often found( low-soluble calcium salts of phosphoric acid).In men - oxalate, somewhat less often - urate( salts of uric acid) and carbonates. Among the stones can also be protein, cholesterol, cystine and sulfonamide stones. The latter are formed with prolonged treatment with sulfanilamide drugs.

    Stones of different nature have different structure and density, differing even externally. Phosphates are usually rough or smooth stones of white color. Urates - smooth or granular dense stones of yellow color. Oksalaty - very dense stones with uneven surface, gray-black color, easily injuring the mucous membrane of the urinary tract. Cholesterol stones are very rare, they are dark, soft and light. Cystine stones( found in 1-3% of cases) have a dense consistency, usually colorless or whitish-yellow, have a smooth surface.

    In one kidney there can be as one stone, and several( from 20% to 50% of cases).As a rule, the disease affects only one of the kidneys, but in 15-20% of cases there are kidney stones on both sides. Stones in the calyx are less common than the pelvis stones.

    The stones also vary considerably in size - from extremely small( "sand") to the size of a hen's egg, and in weight - from 1-2 g to 2 kg. In the pelvis, usually there are oval stones. Coralloid stones occupy the entire renal pelvis, stopping at the ends of the appendages in cups, in shape they resemble casts of the cup-and-pelvis system with thickenings at the ends of the processes. Cone-shaped or oblong stones form in the ureters, but their location is not always the place of their formation. In the ureter, bladder or urethra, stones most often come from the kidney.

    The formation of stones leads to various disorders of the urinary system. If the stone is a serious obstacle to the outflow of urine, develop hydronephrosis followed by atrophy of the kidney tissue. Stagnation of urine contributes to the development( exacerbation) of the infectious process, purulent melting of the kidney tissue, purulent calculous pyelonephritis can occur. In some cases, the kidney completely ceases to function.

    Urolithiasis in certain patients can occur without significant manifestations. In such cases, kidney stones become an X-ray finding when conducting a survey for another reason. Sometimes the disease manifests blunt, mild-expressed pain in the lumbar region - usually it happens with large stones. But most often with urolithiasis there are typical attacks of renal colic, and it is characteristic that most often colic is noted with stones of small size.

    Seizures may provoke prolonged walking, riding on a rough road, shaking, lifting weights, but often colic occurs for no apparent reason. The frequency of seizures may range from several within a month to one in several years.

    A typical attack of renal colic is characterized by a sudden onset in the form of sharp pains in the lumbar region. Pain of considerable intensity, cutting character, is rapidly amplified to a degree unbearable. The patients are excited, groaning, rushing about in bed, trying to find a position that alleviates their suffering. In a number of cases, the onset of renal colic proceeds for a long time with short remissions for several days. Pain sensations start in the lumbar region, but then spread quickly to the abdomen along the ureter, into the inguinal region, in men pain often passes into the scrotum, to the glans penis, in women to the labia majora, the inner thighs.

    Often the intensity of pain is much higher in the abdomen and genital area than in the lumbar region. As a rule, a spasm of colic is accompanied by frequent urge to urinate, pain and incision when urinating. Especially it is characteristic at a departure of "sand" or a stone of the small size.

    In renal colic, symptoms such as stool and gas retention, abdominal distention, nausea and vomiting, dizziness when changing body position are often observed. Severe pain can cause a significant drop in blood pressure. A prolonged attack, on the contrary, causes an increase in blood pressure.

    If renal colic occurs against the background of pyelonephritis, a typical increase in body temperature to high digits. After an attack in the urine, the presence of erythrocytes and leukocytes is noted. Sometimes with a temporary blockage of the kidney, there is no change in the urine. In the general analysis of blood, an increase in ESR and leukocytes usually develops.

    During the interictal period, patients may have complaints about blunt low back pain, as well as changes in urinary sediment( red blood cells, leukocytes, salt in a significant amount) and the escape of "sand" or small stones. Often in the interictal period, any subjective sensations are generally absent. Almost always determined by a positive symptom Pasternatsky - soreness with effleurage in the lumbar region.

    The presence of erythrocytes in the urine is especially characteristic in the presence of oxalate stones, since their tuberous surface most severely traumatises the mucous membranes of the pelvis and ureters. Usually these phenomena increase after walking and exercise. Long-lasting red blood cells and especially leukocytes in the urine are characteristic for the attached chronic pyelonephritis, the further development of which is accompanied by the formation of new stones.

    Urolithiasis takes a long time, with a tendency to frequent exacerbations. As a result of the prolonged presence of kidney stones, irreversible changes are increasing, leading to the development of hydronephrosis, with concomitant infection - purulent complications.

    In case of renal stone disease in combination with chronic pyelonephritis, a persistent increase in blood pressure is noted.

    In 13-15% of patients, renal-stone disease is asymptomatic, the phenomena of pyelonephritis are not expressed, functional changes are absent. Just in such cases, the stones are an accidental finding during a survey on other occasions.

    Obstetric shots of the kidneys reveal most of the stones. However, urate or soft protein stones are not determined by x-ray methods. For their detection, use computer and magnetic resonance imaging, excretory urography. Excretory urography is indicated to clarify the function of the kidney after the survey images. It allows the most accurate determination of the localization of the stones( calyx, pelvis, ureter) and to reveal the presence and nature of the complications.

    The prognosis in the absence of pronounced disturbances in the structure of the renal tissue and its functions is favorable, with coral or multiple stones, especially the only kidney, serious. Timely removal of stones with appropriate anti-relapse treatment aimed at cessation of chronic inflammatory process and normalization of metabolic abnormalities, makes the forecast more optimistic. Otherwise, urolithiasis continues to develop further, leading to the emergence of severe complications. These include purulent calculous pyelonephritis, hydronephrosis of the kidney. An acute anuria of an attack of renal colic is the excretory anuria. Purulent calculous pyelonephritis( calculous - stone, associated with the presence of a stone) develops in the presence of purulent bacteria in the urine and often complicates the course of kidney stone disease. A characteristic feature of this complication is the property of any disturbances in the outflow of urine to lead to the development of a febrile state with pronounced inflammatory manifestations in the blood - high ESR and a large number of leukocytes, which requires an urgent hospitalization of the patient in a hospital. In the absence of timely assistance in such cases, a septic condition may develop.

    Hydronephrosis develops gradually as a consequence of disturbances in the outflow of urine, which lead to the expansion first of the pelvis, then the calyx, then the collecting tubules and the tubules of the nephron. As a result, pronounced changes in the tissue of the kidneys occur, followed by its atrophy. Stagnation of urine promotes the development of urinary tract infection, with the development of infected hydronephrosis. Increased pressure inside the pelvis, and then in the entire collecting system, leads to a decrease in the functional activity of the nephron tubules. The interstitial tissue of the kidney is impregnated with urine, it can not work further, and as a result, the kidney tissue is replaced by a connective( cicatrical) tissue. Loss of kidney functions is irreversible, they are not restored even after removal of the obstruction on the way outflow of urine.

    It is difficult to detect hydronephrosis on the background of urolithiasis without special examination methods. In the initial stages, the main sign is the attacks of renal colic, which are characteristic of renal and stone disease. In the future, dull pain may occur with predominant localization in the lumbar region. This is due to the replacement of tissues of the pelvis and calyxes on connective tissue, when they lose the opportunity to contract, which speaks of a far-gone process.

    Characteristic for hydronephrosis is the presence in the general urine analysis of red blood cells, but in small amounts. When performing excretory urography, slowing of the accumulation of radiocontrast in the enlarged pelvis and calyx is noted. With severe renal dysfunction, the contrast can only accumulate for 1-2 hours, or the affected kidney is not capable of excretion at all. With a high degree of certainty about hydronephrosis evidence of radioisotope scanning and renography. Together, they allow you to accurately determine the degree of expansion of the bowl-pelvis and the functionality of the kidney.

    Excretory anuria, or cessation of urination, the immediate cause of which is the occlusion of one of the ureters, is acute during an attack of renal colic. A question may arise: only one ureter obstructed by the stone, why does urination stop completely? The fact is that when the outflow from one of the kidneys is completely blocked, the second kidney also ceases to produce urine due to a special reflex.

    After an attack of renal colic, the patient stops urinating. During the next 1-3 days, symptoms of acute renal failure gradually appear, and the level of residual nitrogen in blood plasma increases. This complication also requires obligatory emergency intervention of urologists, therefore the patient should be immediately taken to the urological hospital.

    Treatment of urolithiasis in modern conditions is carried out in a complex, its tasks include: treatment of attacks of renal colic, timely removal of stones, treatment of infectious complications and prevention of repeated stone formation. Thus, in the treatment of urolithiasis, medicinal, non-drug conservative methods and modern surgical methods for removing stones are combined.

    To eliminate attacks of renal colic as a first aid, spasmolytics and terpenic preparations are widely used - avisan for 0.5-1 g, cystenal for 10-20 drops. Most patients are well helped by thermal procedures - a hot bath( water temperature 37-39 °) or a warmer on the waist. In the absence of the effect of these measures, the patient needs skilled care - atropine administration 0.1% 1 ml subcutaneously in combination with promedol 2% 1 ml or pantoponom 2% 1 ml subcutaneously, platifillin 0.2% 1 ml subcutaneously. In some cases, intravenous( very slow!) Injection of 5 ml of baralgina helps. If the patient does not have a positive reaction to the listed emergency measures, hospitalization in a specialized urological or surgical hospital is necessary.

    Antibiotics, nitrofuran preparations are used for the treatment of infection, less often sulfanilamides, given their ability to also precipitate in the form of salts. It is best to use the drugs taking into account the sensitivity of bacteria that are shed from urine. In the interictal period, it is advisable to take medications that tone the smooth muscles of the urinary tract: the extract of madder dye, avisan, cystenal, enatin, uralite, etc. They have mild spasmolytic and diuretic effects, contain terpenes - substances that cause a reduction in the urinary tract, which favorsthe end of the stones.

    Acceptance of terpene-containing drugs is justified in patients with single stones of small size, capable of independent withdrawal. It should be noted that independent removal of the stone is possible only if it has a smooth surface and a diameter of less than 1 cm. In such cases, in addition to terpenic preparations, long walks, copious drinking and antispasmodics( no-shpa,papaverine).

    However, the patient should clearly realize that neither the independent removal of stones nor their removal by surgery can not cure renal-stone disease. One of the main problems in the treatment of urolithiasis is repeated stone formation. To prevent the appearance of new stones, there is a need for targeted changes in metabolism.

    It is very difficult and with frequent repeated stone formation, there is a urolithiasis caused by impaired functions of parathyroid glands( a violation of calcium metabolism with its accumulation in tissues).In the presence of an adenoma of these glands, it is possible to perform a more rapid surgical removal, which somewhat improves the prognosis and course of nephrolithiasis.

    Gout, or urine acid diathesis, requires the appointment of a special diet. From food, one should completely exclude foods rich in purine bases, - roast meat, by-products - liver, kidneys, brains;meat broths;anchovies, sardines, sprats;cheeses;coffee. In the diet of patients, it is necessary to include mainly milk and vegetable food. Thus the share of dairy products should be moderate, whereas fruits and vegetables( except for salad, spinach and Brussels sprouts, and also beans) can be consumed in unlimited quantities.

    With oxalate stones, diet therapy should be aimed at excluding products rich in oxalic and ascorbic acids, as well as with calcium salts. Such products include: lettuce, sorrel, spinach, beets, rhubarb, parsley, legumes, grapes, plums, strawberries, gooseberries, tea, cocoa, chocolate. Patients should also not take large doses of vitamin C. Some products have the ability to enhance the excretion of oxalic acid from the body, so they are recommended to take patients in increased amounts. Such products include apples, pears, quince, and dogwood. The leaves of the pear, black currant and grape in the form of infusion also contribute to the enhancement of excretion of oxalic acid.

    In phosphate stones, the diet, on the contrary, should shift the pH of the urine to the acidic side. In addition, products containing a large number of calcium salts( milk and dairy products, vegetables, fruits, herbs) are excluded. Showed meats, flour dishes in all kinds, from vegetables - peas, pumpkin, Brussels sprouts, asparagus.

    You can prescribe ascorbic acid for 0.5-1 g per day, methionine for 3-4 grams per day. Favorable effect with phosphate and oxalate stones magnesium oxide at 0.15 g per day, and after surgery - methylene blue.

    In order to prevent repeated stone formation, patients with renal stone disease are prescribed plenty of drink - usually at least 2 liters per day. The mineral waters are used depending on the type of metabolic disturbance.

    With alkaline diathesis alkaline mineral waters of Zheleznovodsk, Truskavets, Borjomi, Essentuki( Essentuki No. 4 and No. 17) are recommended. With phosphate-calcium - acidic mineral waters of Kislovodsk, Truskavets, Zheleznovodsk, Arzni. Oksalatnye stones require the assignment of alkaline mineral waters - essentuki No. 20.

    In case of other metabolic disturbances leading to stone formation, mineral waters are used in accordance with the urine reaction: if it is acidic, use alkaline mineral waters( Essentuki, Borjomi, Pyatigorsk, Truskavets), if alkaline - acid( Kislovodsk, Truskavets, Zheleznovodsk).

    Surgical methods for the treatment of urolithiasis include traditional open surgical intervention, endoscopic surgical methods with percutaneous or transurethral access, and an unequivocal leader - remote shock wave lithotripsy( DLT).DLT - the most effective of modern methods, although the youngest one - it is not yet thirty years old. This is a method of contactless impact on a stone by a shock wave, formed with the help of a special device - a lithotripter, followed by an independent separation of the fragments of the stone. Modern lithotripters are electric wave generators of various types( electrohydraulic, electromagnetic and piezoceramic) in combination with a roentgenologic table that allows on site to conduct the necessary ultrasound and endoscopic studies and procedures. Virtually on all devices, the diameter of the "working zone" of the shock wave pulse is from 1.2 to 1.8 cm, so stones with a size of 1 to 2 cm are destroyed with the greatest efficiency( until the finely dispersed state). Larger stones require repeated sessions of DLT,for the formation of large heterogeneous fragments that can not depart independently. To destroy one stone should be no more than 3 sessions. Restoration of kidney function after a session of DLT in the absence of complications occurs after 5-7 days, with the development of complications - after 11-14 days.

    Currently, DPT as the main method of treatment is used for the early detection of small stones - up to 2 cm in the pelvis and up to 1 cm in the ureter. The stone should be located freely in the pelvis, the kidney should function normally, the urine should be free from infection, and there should be no obstruction to urinary outflow and anatomical abnormalities of the upper urinary tract. With the use of modern lithotriptors, absolute contraindications to DPT include: deformation of bones, excess weight, inability to visualize stone, pregnancy, aortic and / or renal aneurysms, disorders in the blood coagulation system.

    It should be noted that the best crushing indexes have urates and stones containing calcium oxalate dihydrate, while stones containing calcium oxalate monohydrate are destroyed somewhat worse, and cystine stones represent the greatest difficulty for DLT.

    There are also diseases, which are direct contraindications to remote lithotripsy. These include diseases of the cardiovascular system in the stage of decompensation, acute and chronic diseases of the gastrointestinal tract in the acute stage, acute purulent-inflammatory processes of any localization. Absolute contraindication to DLT is the combination of stones with a tumor and kidney tuberculosis. It is irrational to conduct a DLT in the presence of an obstruction to the outflow of urine below the location of the stone. In such cases, an open surgery or appropriate endourological intervention is usually performed.

    With regard to infectious and inflammatory diseases - acute and chronic pyelonephritis, it is first necessary to eliminate the infection, and then allow DPT after the installation of an internal catheter or stent of the kidney. In acute period( exacerbation) of the disease, lithotripsy is contraindicated, since shock-wave impulses negatively affect the functional state of the inflamed kidney tissue.

    Functional state of kidney tissue is one of the most important factors that determines the nature of the intervention in urolithiasis. In the presence of a deep decrease in kidney function in polycystic and chronic renal failure, DLT is considered impractical.

    In cases of multiple stones, as well as stones of a larger size and complex shape, a deficiency in the functional capacity of the kidney of more than 30%, a highly active infection, obstructions to urinary outflow and stone formation against an abnormal kidney development, a single and / or repeatedly operated kidney,the joint effect of DLT and endoscopic methods is more effective.

    Endoscopic urological methods are divided by access type to percutaneous - directly through the skin and transurethral - that is, through the urethra. Modern endoscopes allow you to perform complex operations through a minor cut or puncture or to penetrate the desired place through the entire length of the urinary tract.

    Percutaneous puncture nephrostomy( PNNS) is used in conjunction with EBT in the presence of obstacles to the outflow of urine, as well as in the presence of a stone that is not determined by X-ray examination. Transurethral endoscopic interventions include the insertion of a catheter or stent of the kidney, and also, if directly contacted with a stone located in the lumen of the ureter, to destroy it.

    Characteristically, with prolonged( more than 8 weeks) stone retention in one place in the ureter wall, edema and inflammatory reaction occur, which significantly worsens the results of remote lithotripsy. Such changes in the mucosa make it difficult to remove even the destroyed stone. In such cases, any transurethral endoscopic intervention - the installation of a stent or catheter to bypass the stone, putting it back into the pelvis - increases the effectiveness of the DLT.

    It should be noted that the location of the stone in the upper third of the ureter in the conditions of evolved pyelonephritis is a contraindication for both remote and contact endoscopic lithotripsy, which may require an open surgery.

    Traditional surgical operation is necessary and in the absence of the effect of DLT and endoscopic interventions, as well as with infected stones, the presence of obstructions to the outflow of urine contributing to the formation of hydronephrosis, with persistent discharge of a large number of erythrocytes in the urine.

    Coronoid kidney stones

    Coronoid kidney stones were isolated in a special form of urolithiasis due to certain differences in the origin, mechanism of development, manifestations and, accordingly, ways of treating this disease. First of all it should be noted that coral stones arise against the background of previous functional and / or structural inferiority of the kidneys, as well as violations of the constancy of the internal environment of the whole organism.

    Coral stones are distinguished by a special form resembling a cast of the cup-and-pelvis system. They occupy the entire space of the renal pelvis, with their appendages entering the cups, and at their ends there are thickenings. By composition, coral stones are usually carbonate apatites.

    Coral stones occur both in adults( in women more often than in men) and in children. One of the reasons for this stone formation is the presence of increased activity of parathyroid glands. Identify it by typical signs - increasing the level of calcium in the blood, reducing the level of phosphorus in the blood and increasing the release of calcium in the urine. Just this last factor leads to the rapid formation of kidney stones, often on both sides and with a tendency to re-stone formation.

    In other cases, the role of infection, especially bacteria, capable of producing a specific enzyme urease, due to which urine is alkalinized, is more distinct. Under conditions of an alkaline medium, as is well known, crystallization of phosphates occurs easily. First of all, among such bacteria, it should be noted proteus, which is often the causative agent of pyelonephritis, especially in pregnant women. On the other hand, even bacteria that can not produce urease can accumulate calcium, which allows them to become the basis for the formation of stones. Infection and impairment of urinary outflow in women are most often associated with physiological changes in the urinary system during pregnancy, and the existence of a connection between gestational pyelonephritis and coral stones has already been proven.

    Infection and inflammation also contribute to the stagnation of urine in the calyx-pelvis system and affect the work of nephrons. As a result, the kidney functions are broken in the urinary release of a number of substances( urea, citric acid, calcium, phosphates), which also promotes stone formation.

    After the coral stone formation, which aggravates the existing disorders of urination and pyelonephritis, gross functional changes develop in the kidney tissue. Activity of infection leads to purulent melting of kidney tissue - pionephrosis. First, multiple abscesses appear in the kidney tissue, which then can merge, subsequently the external envelope of the kidney is also involved in the process, which also extends to the periphyton fatty tissue. With a more favorable course of the disease with a low activity of calculous pyelonephritis, nephron function disorders gradually lead to the development of chronic renal failure.

    The disease develops gradually: a latent, initial period that precedes the period of pronounced manifestations. The latent period of the disease proceeds without any distinct external signs and corresponds to the stage of coral stone formation. At this time, nonspecific manifestations, more characteristic of chronic pyelonephritis, may be noted-weakness, increased fatigue, headache, and night-time probing. The initial period is characterized by the end of the formation of the stone, patients can make complaints about minor blunt pain in the lumbar region, and sometimes little-specific changes in urinalysis are determined. Coronal stones at this stage are found by chance in the survey radiography of the urinary tract.

    The period of pronounced manifestations differs in almost constant character of dull pain in the lumbar region. Attacks of renal colic are not typical for coral stones, are rare, provided that the small stone clogs the ureter. In the active course of pyelonephritis, periodic episodes of fever, increased fatigue, weakness, malaise, erythrocytes in the urine. At this stage, usually signs such as increased blood pressure. With a detailed study already at this stage, it is possible to identify the initial signs of renal failure.

    Then there are more distinct symptoms of chronic kidney failure. This is the final period of the disease, when thirst, dry mouth, weakness, increased fatigue, pain in the lumbar region, urination disorders, minor fever are pronounced. The outcome in the absence of adequate treatment is the development of chronic renal failure.

    The presence of coral calculous kidney stones requires a traditional surgical procedure. However, at present, when it is possible to use less traumatic types of interventions, an individual approach to each patient is necessary. If the doctor considers it acceptable, he can offer one of the modern urological methods. For example, percutaneous puncture lithotripsy( destruction of the stone) and subsequent lithoextraction( removal of stone fragments), which can be combined( in the absence of contraindications) with the DLT, which expands the possibilities of the method. But it is worth repeating once again that all this is strictly individual and the doctor must decide.

    From the methods of traditional surgery to date, operations with the maximal sparing of renal tissue and renal surgery with artificial hypothermia( cooling) are also used. DPT in such cases is used as an auxiliary method of treatment if after the operation there are still remains of stones, and not earlier than 21-28 days after the intervention.

    When coral stones kidneys in children, the use of DLT seems to be the most promising method of treatment, allowing, in addition, to avoid a traumatic surgical operation. In childhood, the density of stones is usually low, which makes it possible to use the minimum energy of the shock wave, while achieving fine-grained crushing of stones of any composition.

    Correction of metabolic disorders and treatment of calculous pyelonephritis are conducted according to general principles.

    The main manifestations, nature and mechanism of development in stone formation in a single kidney do not differ from urolithiasis as a whole, but the fact of having a single kidney requires special treatment. In this case, it is especially important that the doctor is guided by the main principle of medicine - do no harm. Therefore, choosing a method of treatment with stones of a single kidney is a very important step.

    Quite effective in general and the least traumatic way of treatment in such cases is DLT, however it is necessary to take into account all indications and contraindications, including the main criterion is the satisfactory functional state of the kidney. In cases of repeated stone formation, large stones, concomitant chronic pyelonephritis and a decrease in kidney function by more than 30%, it is necessary to use DLT with extremely low energy pulses in combination with pre-drainage of the kidney by an internal catheter( stent).The combination of DLT and stenting allows the kidney to recover faster, and also to avoid complications, including inflammatory ones. DPT with stones of a single kidney can be used even with stone sizes exceeding 2.0 cm( provided its mixed composition and low density).

    With a very high density of stone or large coral stone, as well as with active infection in the kidney, either a minimally traumatic open surgery with maximum preservation of the kidney tissue is used, or the possibility of using puncture nephrolithotomy in combination with DLT is considered.

    As already noted, during pregnancy, the female body undergoes significant changes, which naturally affect the urinary system. Already in the early stages of pregnancy, the tone of the urinary tract decreases significantly, which is why the dynamics of urination changes. In the future, with an increase in the term, the pregnant uterus leads to a shift in the normal anatomical location of both the abdominal cavity organs and the kidneys. Under such conditions, it is also possible that the primary formation of the urinary stone, usually associated with an obvious or latent urinary tract infection, and also the appearance of an already existing urolithiasis, whose external symptoms were previously absent, is also possible. The undoubted connection of gestational pyelonephritis with coral stone formation has already been proved.

    Usually, urolithiasis in pregnant women is erased, which is associated with a significant expansion of the upper urinary tract, increasing with an increase in gestation. A characteristic manifestation of the disease - renal colic - in such conditions occurs rarely, as a rule, complaints of periodically arising dull pain in the kidney area prevail. In the study of urine, inflammatory changes in the urinary sediment( bacteria, leukocytes, a little erythrocytes) are usually clearly pronounced. All this imitates the picture of gestational pyelonephritis, quite often stones are detected with ultrasound examination already in the postpartum period.

    Treatment of urolithiasis in pregnant women has certain limitations, since a woman during this period should be primarily concerned about carrying out the pregnancy and its safe completion. The main role is given to the treatment of pyelonephritis.

    In the postpartum period the patient should be regularly observed in the urologist, it is necessary to completely get rid of the urinary infection and decide on the method of further treatment. Then urolithiasis is treated according to general principles.