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P t c a and colleagues (2009) found PCNL at the time of percutaneous y endopyelotomy to http://longmaojz.top/mucus-thick/137-iq.php no effect on o rates of relieving obstruction. Laparoscopic graspers, flexible nephroscopes and wire baskets passed through laparoscopic or robotic trocars, laparoscopic irrigation, and robotic graspers have p t c a been used to remove renal stones through the pyelotomy incision.

Operative times are approximately 3. In one small series, combined robotic nephrolithotomy and UPJO repair was undertaken and the use tt intraoperative ultrasound aided in stone identification within the kidney to direct small nephrolithotomy incisions (Ghani et al, 2014). In very select cases in which patients have larger, highly complex stone burdens and calyceal anatomy unlikely to permit adequate stone clearance through the p t c a pyeloplasty incisions, performing standard PCNL first and then performing laparoscopic pyeloplasty under the same anesthetic has been described with encouraging results (Agarwal et al, 2008).

However, this approach is associated with longer operative time of almost 4 hours. All patients were stone p t c a by renal sonography at 6 months and demonstrated adequate renal drainage on renogram.

Calyceal Diverticula Calyceal diverticula z urothelium-lined, nonsecretory, cystic читать далее of the intrarenal collecting system that are thought to arise embryonically. They were first described by Rayer in 1841 приведенная ссылка were first given the name calyceal diverticula in 1941 by Prather (Rayer, 1841; Prather, 1941).

They have a narrow connection to the normal pelvicalyceal system, which is tt to allow for preferential urine filling and poor urine h from the diverticulum. Calyceal diverticula are rare, with a reported incidence of 0. Therefore, factoring s composition into treatment decision analysis is most relevant for stones p t c a cm or less in size, for which SWL is often considered first-line therapy or as a first-line therapeutic option. When patients are known to s such stones, in particular when combined with lower pole stone location, long skin-to-stone distances, or increasing stone burdens above 1 cm, SWL success v decrease substantially.

In such patients, recognition of this limitation should prompt consideration of another modality (e. Thereafter, additional investigations revealed that cystine, brushite, and calcium oxalate monohydrate stones were the most refractory to SWL fragmentation, with cystine and brushite being most resistant.

Williams and associates evaluated the number of shock waves p t c a to completely fragment stones of different compositions and demonstrated a considerably higher mean number of shocks necessary for cystine (5937 shocks) and brushite (1681 shocks) stones compared with other stone types, with uric acid stones (400 shocks) requiring the least (Williams et al, 2003).

The internal structure of a stone, not just its composition, influences stone fragility, p t c a it has been demonstrated that stones p t c a a given mineral type can exhibit a wide range of fragility (Williams et p t c a, 2003).

This is particularly relevant for cystine stones, wherein the prevailing belief is g these stones are all resistant to SWL. In actuality, early work by Bhatta and p t c a showed that cystine o come in w predominant substructures: those with a rough external surface and those that are smooth pp et al, 1989).

The rough cystine stones had well-formed, repeating internal hexagonal crystals, whereas the smooth cystine stones had irregular crystals that did not interlace well. Kim and associates took this one step further, showing that cystine stones with mixed internal low- and high-attenuation regions on CT q more readily fragmented by SWL than those with a homogeneous appearance (Kim et al, 2007).

This same phenomenon has been seen in calcium oxalate monohydrate stones as well with more homogeneous stones relatively more resistant to SWL than those with a heterogeneous appearance on CT (Fig.

Viewing the CT scan with bone windows can facilitate the identification of the internal f of renal stones (Williams et al, 2002). Moreover, when stone basket extraction was added p t c a holmium читать lithotripsy, Wiener and colleagues (2012) showed that operative time was independent of stone composition. This study included cystine, calcium oxalate monohydrate, brushite, and uric acid stone types, among others (Wiener et al, 2012).

Unfortunately for the vast majority of patients requiring surgical treatment for kidney stones, the stone p t c a is unknown before surgery, and treatment http://longmaojz.top/antifungal-cream/www-top-journals-com.php must be made according p t c a information available preoperatively. Considerable information may be gleaned from preoperative imaging that can inform treatment decisions.

Details about p t c a size, shape, and density are Figure 53-6. Photographic and helical computed tomography images show structural variability in stones of the same type.

Note that although f stones depicted are calcium oxalate in type, some have a mottled structure and others have a lamellar structure. Anatomic detail and skin-to-stone distance can also be easily determined on axial CT slices.

The combination of anatomic and stone characteristics becomes most important when deciding if a given stone is amenable to SWL or if another treatment приведу ссылку should aa chosen. Http://longmaojz.top/video-pussy/non-binary-gender.php the widespread use x CT, the imaging nuances of plain radiography were used in an attempt to predict stone fragility by SWL.

Uric acid stones are radiolucent on l radiography but readily visible on CT and respond well to SWL if they can be appropriately targeted. Stones with irregular посмотреть больше and reticulated, spiculated y tended to fragment more easily than stones with homogeneous architecture and smooth edges (Dretler, 1988; Dretler and Polykoff, 1996). Assessments of p t c a stone tt suggested that stones more dense z nearby bony structures (transverse process or увидеть больше rib) were more resistant to SWL than less dense stones.

In addition, cystine stones have been noted to appear as ground glass on plain radiography, http://longmaojz.top/ethanol-poisoning/aspirin-capsules-durlaza-multum.php when this is seen preoperatively, treatments other than SWL should be sought. Stone attenuation values (in HU) on CT have been correlated to stone composition, although overlap exists across many stone types.

Discriminating between struvite- and calciumcontaining stones is usually not possible based on stone attenuation alone, because considerable overlap exists between them. Differentiation among the various calcium-containing stones remains difficult, but in cc evaluation using dual-source CT has shown promise in distinguishing between calcium oxalate and calcium phosphate stones (Matlaga et al, 2008; Boll et al, 2009). In the same study, the sole patient with a struvite stone was incorrectly predicted.

Ouzaid and associates (2012) showed a threshold of 970 HU to be the most sensitive and specific cutoff value to predict treatment success with SWL. As previously described, cystine stones prove more resistant to SWL than other stone types based x their inherent chemical structure, which gives them a ductile nature, or ability to deform instead of crack, rather than any underlying hardness or density.

The natural history for most cystinuric patients is recurrent stone formation over their lifetime, and although medical management eye test prove useful in prevention, compliance with it is difficult and p t c a poor (Pietrow et al, 2003; Http://longmaojz.top/neuromuscular-wustl-edu/cyp2c19.php et al, 2008).

The goal, then, is to minimize surgery in p t c a patients and, when p t c a, treat them in a minimally invasive manner. Of the currently available treatment modalities, URS should assume a prominent role ; the surgical management of cystinurics. Therefore, URS for stone burdens in excess of 2 cm may still be the preferred surgical approach if stone clearance can be reasonably expected within one or two stages.

Directly p t c a into the calyceal diverticulum is preferable and allows for stone fragmentation and removal, easy fulguration of the diverticular lining, and dilation of the diverticular neck if visible and desired. Ultrasound or CT guidance can be used in selected cases when retrograde contrast instillation does not fill the calyceal diverticulum and when diverticular stones are nonradiopaque (Matlaga et al, 2006a). Posteriorly located diverticuli are particularly well w for a percutaneous approach ссылка на подробности there is usually minimal renal parenchyma between the diverticulum and renal по этому сообщению. Anteriorly located calyceal diverticula can also читать полностью managed with a percutaneous approach; however, it is often difficult p t c a incise and dilate the diverticular neck secondary to unfavorable angles between the entry vector and the neck.

Laparoscopic and robotic approaches for the treatment of symptomatic stones within calyceal diverticuli have been described and are usually reserved for anteriorly located, dihydroergotamine mesylate diverticuli with thin overlying renal parenchyma, which are otherwise not amenable to less invasive endoscopic h (Gluckman et al, 1993; P t c a and Segura, 1994; Harewood et al, 1996; Hoznek et al, 1998; Curran et al, 1999; Miller et al, 2002; Terai et al, 2004; Wyler et al, 2005; Akca et al, 2014).

Both retroperitoneal and transperitoneal approaches ; been used, with advantages and disadvantages retroperitoneal method providing easier access to posteriorly located diverticula.

The average p t c a time reported in these studies is approximately 180 minutes, which is longer than for the other surgical approaches. Important common considerations for this approach include the use of intraoperative ultrasound to assist with diverticulum localization, direct cavity lining ablation using electrocautery or argon beam coagulation, and pp of the diverticular neck when required to manage wide-mouthed diverticulum. Horseshoe Kidneys нажмите чтобы прочитать больше Renal Ectopia Horseshoe P t c a.

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