外科學課件：泌尿系梗阻（英文版）

Obstructionofurinarytract

Urinarysystem,fromurnaltubules,calys,pelvis,ureterbladdertourethra,istract.Anypartoftractobstructioncanbeoccured.Althoughobstructiveplacesaredifferent.Obstrutionresultsatlastinhydronephrosis,renalfunctiondamage,renalfunctionfailure.SectionIGeneralconsideration

Urinarytractobstructioncanbedividedinto,mechanicalobstructionanddynamicobstruction,majorityaremechanicalobstruction.upperurinarytractobstructionandlowerurinarytractobstruction.

Etiology

BasicpathologyofdilatationofurinarytractaboveobstructionSafetyvalveinkidney.Urinedoesn’tenterureterandenterrenalparenchyma.Veinandlymphaticvesselbackflow.Pathologicallesionofhydronephrosisispelvicdilatation.Pathophysiology

Pelvicwallbecomesthin;renalpapillabecomesatrophyandflat,renalparenchymabecomesatrophyandthin.Pelviccapacityincrease.Allkidneyformsadysfunctionalhugewatersac.Thebacterialenterbloodisverydangerous.

Theurinefromkidneyencountersobstruction,thatresultsinpressureincreasesinkidney,dilatationofcalyxandpelvicandatrophyofrenalparenchyma

.SectionIIHydronephrosis

Symptomsandphysicalsignofprimitivediseases.Manifestationofhydronephrosisislumpinabdomen.Sometimesshowsintermittentattackcalledintermittenthydronephrosis.DiagnosisLongtimeobstructionwhichproduceshydronephrosisresultsinrenalfunctiondecrease.Ifbilateralofseparatedkidneyisobstructed,renalfunctionfailure.UrineroutineandurineculturecanhelpthediagnosisofprimitivediseasesDiagnosisB-ultrasound:distinguishhydronephrosisfromrenaltumor,over1000mlofhydronephrosisisnamedhugehydronephrosis.DiagnosisIVP:ThedevelopingtimeofrenalparechymaprolongsCT-scanMRIandMRURenalscanandrenalpicturesofradioactiveisotopeDiagnosisTreatmentofcauses：Thebasictherapeuticpurposesare,removingthecauses,protectionofrenalfunction.Beforeobstructionhasnotbeencausedsevererenalfuntionimpairment,Whichcouldobtaingoodtherapeuticresults.Usetheappropriatemethodoftreatmentaccordingtothecauses,urinarytractmalformationsplasty,urolithiasislithotomy.TreatmentNephrostomy腎造口術(shù),

Hydronephrosiswithsevereinfection,poorrenalfunction,causesaretemporarilyunabletohandle.Inthesecases,temporaryorpermanentnephrostomyshouldbeused.Nephrectomy,serioushydronephrosisorpyonephrosis膿腎,contralateralrenalfunctionisnormal.

BPHisoneofthemostcommondiseaseofUrology,Whichmostlyoccurredinagedmen＞50ys.

BPHisanonmalignantenlargementoftheprostateglandcausedbycellularhyperplasiaofbothglandularandstromalelementsthatleadstotroublesomelowerurinarytractsymptoms(LUTS)SectionIIIBenignProstaticHyperplasia(BPH)

PeripheralzoneTransitionzoneUrethraWhatisBenignProstaticHyperplasia?

PeripheralzoneTransitionzoneUrethraBPHisoneofthemostcommondiseasesinagingmenandthemainclinicalmanifestationislowerurinarytractsymptoms(LUTS).

GeneralconsiderationTheetiologyofbenignprostatichyperplasiaisnotclear,ageingandfunctionaltestesmaybethebasicofBPH.Etiology(二)4.PrevalenceofBPHPathophysiology20%ofmenage41-5050%ofmenage51-6065%ofmenage61-7080%ofmenage71-8090%ofmenage81-90EtiologyWhatcausesBPH?BPHispartofthenaturalagingprocess,likegettinggrayhairorwearingglassesBPHcannotbepreventedBPHcanbetreated25-50%microscopicandmacroscopicBPHwilldevelopclinicalBPHTheprevalenceofclinicalBPHinmenages55-74years5-30%Only40%ofthemhaveLUTSandonly20%seekmedicaladvicePeripheralZone70%oftheyoungadult(60-70%ofCaP)CentralZone25%(5-10%CaP)TransitionZone5%(10-20%CaP)BPHEtiologyProstatetissuescomposedbyPeripheralzone,centralzone，transitionnalzoneandsurrounddingtheurethralzone.BPHoriginatedintransitionnalzone.Whileprostaticcancerinperipheralzone.PathologyTheprostateiscomposedofglandandstroma.PathologychangeofBHPisstromalhyperplasia.PathologyBPHcauseurinaryobstruction,theperformanceisofthefollowingthreefactors:1.Mechanicalobstructionduetoglandularenlargement,squeezingtheurethra,enlargedtissuesprotrudingtothebladder,causingbladderoutletobstrution(BOO).

2.Dynamicobstructionsecondarytocontractionofthesmoothmuscleoftheprostate,urethraandbladderneck.Thisdynamicobstructionisaresultofsympatheticnervoussystemmediatedstimulationofalpha-1adrenoceptors

腎上腺素能受體Pathology3.Secondarybladderdysfunction.Irritativesymptoms-detrusorinstabilityrelatedtodetrusormusclechangesinresponsetoobstruction,suchasbladderwallhypertrophyandcollagendepositioninthebladderPathology1.Voiding/Obstructivesymptoms:HesitancyIntermittencyIncompletevoidingWeakurinarystreamStrainingtopassurineProlongedmicturitionTerminaldribbling.clinicalmanifestation2.Storage/Irritativesymptoms:FrequencyofurinationNocturiaUrgency(compellingneedtovoidthatcannotbedeferred)UrgeincontinenceclinicalmanifestationDiagnosisMedicalHistory:(LUTS,previoussurgeryintheGUtract,STDandHxofurethralstricture,prescriptionmedsandoverthecountermeds).Symptomscore:internationalprostatesymptomscore(IPSS):mild0-7,moderate8-19andsevere20-39.Diagnosis3.PhysicalExaminationincludingdigitalrectalexamination(DRE)(Ca:nodules,asymmetry,hardenedridges,induration;Prostatitis:tenderness,bogginess;Analmalignancyanddetectundiagnosedneurologicconditionsbyevaluatingthesphinctertoneandperianalsensation;Abdomianlexamdistendedbladder.digitalrectalexamination(DRE)AUASymptomIndexScoring

SCORE INTERPRETATION 0-7 Mild 8-19 Moderate 20-35 Severe

Urinalysisbydipstickandroutinemicroscopy,urinecultureandsensitivitytoR/Oinfectionsandhematuria.Diagnosis

Serum(prostate-specificantigens)PSA-optionaltoR/OProstateCaUppertractimaging(IVP,CT,U/S)onlyinpresenceofconcomitanturinarytractdiseaseorcomplications-hematuria,UTI,renalinsufficiency,Hxofstonedisease.DiagnosisCystoscopy:onlyforpatientswhodon’trespondtomedicalTrxtodeterminetheneedforsurgicalapproachDiagnosisCystometrogramsandurodynamicprofileforpatientswithsuspectedneurologicdiseaseorthosewhofailedprostatesurgeryFlowrate,postvoidresidualvolumeofurine

determinationandpressureflowstudiesVoidingcharts(diaries)Diagnosis

Withtheliberal（大量）useofBtypeultrasound、computedtomography(CT)scansandmagneticresonanceimaging(MRI),benignprostatichyperplasiaarebeingdetectedmorefrequently.

DifferentialDiagnosisDetrusorinstabilityNeurogenicbladderPeripheralneuropathyBladdertumorsBladdercalculiBladderinfectionsDifferentialDiagnosis

DecreasebladderoutletobstructionImprovebladderemptyingLowerdetrusorinstabilityReverserenalinsufficiencyPreventfutureepisodesofgrosshematuria,UTIandurinaryretentionQualityoflifeandsexualityManagementdependsonseverity.Treatment“Watchfulwaiting”MedicationSurgicalapproachesMinimalinvasiveTURPInvasive“open”proceduresTreatmentoptionsLifestylemodificationWatchfulWaitingMedicalTherapyPhytotherapy(alternative)SurgicalTreatment:ConventionalSurgicalorMinimallyInvasiveTreatment.TreatmentMedicationFirstlineofdefenseagainstbothersomeurinarysymptoms

Twomajortypes:αblockers-relaxthesmoothmuscleofprostateandprovidealargerurethralopening 5-αreductaseinhibitor-Shrinktheprostategland

Distributionof

1-AdrenergicReceptors

Adrenoceptorsmaybefurthersub-dividedintoalpha1Aandalpha1Dsubtypes,withalpha1Apredominantintheprostateandalpha1Dinthebladder.Thusblockadeofalpha1Amaybenecessaryforreductionofobstructionwhereastheblockadeofalpha1DmayberequiredtorelievestorageSymptoms.Reduceoutflowresistance.TreatmentSurgicaltreatmentTransurethralresectionoftheprostate(TURP)isthegold-standardsurgicaltreatment.Openprostatectomyistheprocedureofchoiceforprostateslargerthan80-100cm3.photoselectivevaporizationoftheprostate,transurethralneedleablation,transurethralmicrowavetherapy,andholmiumlaserenucleationoftheprostate.Themostpromisingresultshavebeenproducedwiththelasertherapies,whichachievesimilarresultstothoseofTURP,butwithfewercomplicationsandsideeffects.Dataonlong-termef?cacyofthesenewertherapiesarelacking.Prostaticarteryembolization(PAE)Acuteurinaryretentionretentionofurineanisabnormal,involuntaryaccumulationofurineinthebladderasaresultofalossofmuscletoneinthebladder,neurologicdysfunctionordamagetothebladder,obstructionoftheurethra,oradministrationofanarcoticanalgesic,especiallymorphineAcuteurinaryretentionisamedicalemergency.Obstructiveanddynamicobstruction.Ifthereisanobstruction(kidneystones),urinecannotflowfreelythroughtheurinarytrack.Dynamic(non-obstructive)causesincludeaweakbladdermuscleandnerveproblemsthatinterferewithsignalsbetweenthebraina