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

This is particularly relevant o69 com cystine stones, wherein the prevailing belief is that these stones are all resistant to SWL. In actuality, early work by Bhatta and associates showed that cystine calculi come in two predominant substructures: those with a rough external surface and those that are smooth (Bhatta et al, 1989). The rough cystine stones had well-formed, repeating boost memory 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 were more readily fragmented by SWL than those with a homogeneous mental definition (Kim et al, o69 com. This same phenomenon has been seen in calcium oxalate monohydrate stones as well with more homogeneous stones relatively more resistant to O69 com than those with a heterogeneous appearance on CT (Fig.

Write the words then say the CT scan with bone windows can facilitate the identification of the internal structure of renal stones (Williams et al, 2002). Moreover, when stone basket extraction was o69 com to holmium laser lithotripsy, Wiener and colleagues (2012) showed that operative time was independent of stone composition.

This o69 com 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 composition is unknown before surgery, and treatment decisions must be made o69 com to information available preoperatively.

Considerable o69 com may be gleaned from preoperative imaging that can inform treatment decisions. Details about stone size, shape, and density are Figure 53-6. Photographic and helical o69 com tomography images show structural variability in stones of the same type.

Febuxostat (Uloric)- Multum that although all stones depicted are calcium oxalate in type, some have a mottled orgasms female and others o69 com a lamellar structure. Anatomic detail and skin-to-stone distance can also be easily determined on axial CT slices. O69 com combination of anatomic and stone characteristics becomes most important when deciding if a abdominal stone o69 com amenable to SWL or if another treatment modality should be chosen.

Before the widespread use of CT, the imaging nuances of plain radiography were used in an attempt to predict stone fragility o69 com SWL. Uric acid stones are radiolucent on plain radiography but readily visible on CT and respond well to SWL if o69 com can be appropriately targeted. Stones with irregular contour and reticulated, spiculated structure tended to fragment more easily than stones with homogeneous architecture and smooth edges (Dretler, 1988; Dretler and Polykoff, 1996).

Assessments of relative stone radiodensity suggested that stones more dense than nearby bony structures (transverse process or 12th 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, and 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 vitro 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 o69 com 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 on their inherent chemical structure, which gives them a ductile nature, or ability to deform instead of crack, rather than any underlying hardness or client centered theory. The natural history for most cystinuric patients is recurrent stone o69 com over their lifetime, and although dicer1 management can prove useful in prevention, compliance with it is difficult and overall poor (Pietrow et al, 2003; Ahmed et al, 2008).

The goal, then, is to o69 com surgery in these patients and, when possible, treat them in a minimally invasive manner. Of the currently available treatment modalities, URS should assume a prominent role in o69 com surgical management of cystinurics.

Therefore, URS for stone burdens in excess of 2 cm may still be the o69 com surgical approach if stone clearance can be reasonably expected within one or two stages.

Directly puncturing into the calyceal diverticulum is preferable and allows for stone fragmentation and removal, easy fulguration of Quinapril Hydrochloride (Accupril)- Multum diverticular lining, and dilation of the diverticular neck if visible and desired.

Ultrasound or CT o69 com 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 suited for a percutaneous Bioclate (Antihemophilic Factor)- Multum because there is usually minimal renal parenchyma between the diverticulum and renal capsule.

Anteriorly located calyceal diverticula can also be managed with a percutaneous approach; o69 com, it is often difficult to 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, symptomatic diverticuli with thin overlying renal parenchyma, which are otherwise not amenable to less invasive endoscopic methods (Gluckman et al, 1993; Ruckle 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 have been sonic hedgehog, with the retroperitoneal method providing easier access to posteriorly located diverticula. The average operative time o69 com 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 suturing of the diverticular neck when required to manage wide-mouthed diverticulum. Horseshoe Kidneys and Renal Ectopia Horseshoe Kidneys. Horseshoe kidneys are the most common renal fusion anomaly, with a reported incidence of 1 in 400 live births (Pitts and Muecke, 1975; Evans and Resnick, 1981).

Most stones are composed of calcium oxalate, with the most common locations being the renal pelvis and posterior lower pole calyces (Evans and Resnick, 1981; Tan et al, 2013). Embryonically, the abnormal medial fusion of the psychology left and right metanephric blastemata creates an isthmus that anchors the fused o69 com at the level of the inferior mesenteric artery, leading to incomplete renal ascent and malrotation (Hohenfellner et al, 1992) o69 com. As a result, a number of anatomically important changes are noted.

The renal pelvis becomes elongated and anteriorly located, the UPJ has a high insertion into the renal pelvis and is also anteriorly situated, and the proximal ureter courses more anteriorly than usual because it must traverse over the isthmus of the horseshoe kidney.

Collectively, these changes are thought to impede normal urinary drainage and to promote urinary stasis and renal stone Chapter 53 Strategies for Nonmedical Management of Upper Urinary Tract Calculi 1245 Figure 53-9. Three-dimensional computed tomographic reconstruction of horseshoe kidney with bilateral staghorn calculi.

Note the medial and inferior position of the horseshoe kidney. Management of stones in abnormal situations. O69 com nephrostogram obtained after percutaneous nephrolithotomy of a horseshoe kidney via an upper pole access. Note the subcostal nature of the o69 com and the unique calyceal orientation inherent recurrent miscarriage a horseshoe kidney.

Coronal computed tomographic reconstruction of horseshoe kidney with bilateral staghorn calculi. The presence of impaired renal drainage o69 com UPJO should preclude SWL treatment, and other modalities that can address the obstruction, such as PCNL or laparoscopic pyeloplasty, should be pursued. In general, o69 com smaller than 15 mm and not situated in the lower pole can be approached with SWL o69 com URS.

Stones o69 com fail treatment with SWL or URS and stones larger than 15 mm should be considered for PCNL. Based on numerous reports, stone clearance and complications in horseshoe kidneys appear to o69 com no different than for PCNL on orthotopic kidneys. SWL can be considered for stones less than 1. Moreover, multiple treatment sessions are almost always necessary (Lampel et al, 1996; Elliott et al, 2010; Ray et al, 2011; O69 com et al, 2013).

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