Urolithiasis

　　(One) Epidemiological factors

　　Including factors such as age, gender, occupation, socio-economic status, dietary components and structure, water intake, climate, metabolism, and genetics. Upper urinary tract stones are more common in people aged 20 to 50. Males are more prevalent than females. The peak age of onset in males is 35 years old. Females have two peaks, at 30 and 55 years old. During World War II, the incidence of upper urinary tract stones decreased, but it greatly increased during the intervals and in the past forty years, suggesting a relationship with changes in economic income and dietary structure. Experiments have shown that an increase in animal protein and refined sugar in the diet, along with a decrease in fiber, promotes the formation of upper urinary tract stones. Drinking plenty of water dilutes urine, which can reduce the formation of crystals in the urine. Factors such as high temperatures and reduced activity also contribute to the influence, but occupation and climate are not single determining factors.

　　(Two) Urine factors

　　1. Excessive excretion of substances forming calculi: The excretion of calcium, oxalate, and uric acid in urine increases. Long-term bed rest, hyperparathyroidism (reabsorptive hypercalcemia), idiopathic hypercalcemia (reabsorptive hypercalcemia due to increased intestinal calcium absorption or renal hypercalcemia due to reduced reabsorption of calcium by the renal tubules), other metabolic abnormalities, and renal tubular acidosis, all cause an increase in the excretion of calcium in urine. Gout, persistent acidic urine, chronic diarrhea, and thiazide diuretics all increase the excretion of uric acid. Increased endogenous synthesis of oxalate or increased intestinal absorption of oxalate can cause hyperoxaluria.

　　2. The uric acid decreases, and the pH increases.

　　3. The amount of urine decreases, causing an increase in the concentration of salts and organic substances.

　　4. The content of substances inhibiting crystal formation in urine decreases, such as citrate, pyrophosphate, magnesium, acidic mucopolysaccharides, and certain trace elements.

　　(Three) Abnormal anatomical structure

　　For example, urinary tract obstruction can lead to the deposition of crystals or matrix in poorly drained areas, urine stasis secondary to urinary tract infection, which is conducive to the formation of calculi.

　　(Four) Urinary tract infection

　　The cause of most calcium oxalate calculi is unknown. Calcium phosphate and magnesium ammonium phosphate calculi are related to infection and obstruction. Uric acid calculi are related to gout and other diseases. Cystine calculi are rare familial hereditary diseases caused by the excretion of a large amount of cystine in urine.

　　The main harm of urinary system calculi to health is manifested in three aspects: local injury caused by calculi to the urinary tract, urinary tract obstruction caused by calculi, and concurrent urinary tract infection.

　　1. Local injury:

　　Small stones can move freely within the urinary tract, easily causing local injury to the urinary tract mucosa, leading to bleeding and renal colic, but this kind of local injury is relatively mild. Large, more fixed or staghorn-shaped urinary system calculi, although the pain is not severe, can compress the urinary tract mucosa for a long time, causing epidermal shedding, tissue ulceration, and even adhesion between the calculi and the ureteral wall. In severe cases, it may even cause cancer.

　　2. Urinary tract obstruction:

　　Kidney and ureteral calculi are most likely to stay at the renal pelvis ureteral junction (the first narrow place), the ureteral crossing over the iliac artery (the second narrow place), and the ureteral bladder entrance (the third narrow place), causing urinary tract obstruction. After urinary tract obstruction, the upper ureter and renal pelvis above the obstruction will expand and accumulate water, and renal pelvis积水 can be divided into mild, moderate, and severe renal pelvis积水. When renal pelvis积水 occurs, the kidney parenchyma is compressed, affecting kidney function. If renal pelvis积水 is not relieved for a long time, severe cases may cause the entire kidney to lose function. If both sides of the urinary tract are severely obstructed, it may also lead to uremia.

　　3. Urinary tract infection:

　　Urinary tract obstruction accompanied by bacterial infection, and secondary infection after renal pelvis积水 can lead to pyonephrosis. Severe urinary tract infection may also cause sepsis, threatening human life. In addition, urinary tract infection also promotes the formation of calculi, causing the volume of existing calculi to increase rapidly.

　　Therefore, once urinary system calculi are found, enough attention should be paid to and active treatment should be carried out.

　　The clinical manifestations of urological stones vary greatly. Mild cases may be asymptomatic, with clinical symptoms such as sudden onset, severe flank pain, which is usually continuous or intermittent, and radiates to the iliac fossa, perineum, and scrotum, etc. Blood in urine or pus in urine, difficulty in urination, or interruption of urine flow may occur, and some may present with symptoms of urinary tract infection such as frequent urination, urgency, and dysuria. Severe cases can lead to urinary tract obstruction and renal function damage. The main components of stones are 6 types, arranged in order of proportion as follows: calcium oxalate, calcium phosphate, magnesium ammonium phosphate, uric acid (uric acid), cystine, and xanthine stones. Most stones are mixed with two or more components.

　　Life prevention

　　1. Pay attention to dietary structure. There is a certain relationship between the formation of urinary stones and dietary structure. Therefore, adjusting dietary structure can prevent the recurrence of stones. According to the different composition of urinary stones, different dietary adjustment plans should be adopted. For example, patients with calcium oxalate stones should eat less food with high calcium oxalate content, such as spinach, tomatoes, potatoes, strawberries, etc.

　　2. Treat certain primary diseases that cause urological stones, such as hyperparathyroidism (parathyroid adenoma, adenocarcinoma, or hyperplastic changes, etc.), which can cause a disorder of calcium-phosphorus metabolism in the body and induce calcium phosphate stones. Therefore, it is necessary to treat the parathyroid first. Obstructive factors in the urinary tract, such as tumors, benign prostatic hyperplasia, and urethral stricture, can cause urine retention, leading to the 'aging' phenomenon of urine. The organic matter in the urine can precipitate and 'age', possibly increasing in size and becoming amorphous microstones. Therefore, treating certain primary diseases that cause urological stones is also very important for preventing stone recurrence.

　　3. Prevent and treat urinary system infections. Urinary system infections are the main local factors in the formation of urinary stones and are directly related to the prevention and treatment effects of urolithiasis.

　　4. Take traditional Chinese medicine at regular intervals. It is beneficial to take a decoction of traditional Chinese medicine Jin Qian Cao and Hai Jin Sha to excrete small stones in the body. If conditions permit, it is also possible to find a TCM physician to prescribe a simple Chinese medicine prescription for decoction according to the patient's condition.

　　5. Drink more water. It is advisable to develop the habit of drinking more water to increase urine output, known as 'internal cleaning', which is beneficial for the excretion of various salts and minerals in the body. Of course, attention should be paid to water hygiene and water quality, and it is best to avoid drinking water with high calcium content.

　　6. Engage in more physical activity. It is recommended to be more active in daily life, such as walking and jogging. When physically fit, jumping in place can also be beneficial for preventing the recurrence of urological stones.

　　Dietary prevention

　　Urological stones are common diseases of the urinary system, including kidney stones, ureteral stones, urethral stones, and bladder stones. Kidney stones are composed of calcium oxalate, which can cause renal colic. Currently, doctors recommend reducing calcium intake in the diet as a method to prevent the recurrence of kidney stones.

　　Dietary structure should be adjusted according to the composition of the stones to determine the diet for preventing stones.

　　1. Uric acid stones should be treated with a low purine diet, while bladder acid stones should be treated with a low methionine diet. Fruits and vegetables can make urine alkaline, which is beneficial for preventing uric acid and cystine stones. Meat foods make urine acidic, which is beneficial for preventing infection stones.

　　3. Adopt a high-fiber diet. It is generally believed that patients with kidney stones should eat less salt and animal protein, stick to drinking plenty of water, and maintain urine output at 2000 to 3000 milliliters per day. This not only helps prevent the recurrence of kidney stones but also ensures calcium intake, which is beneficial to other aspects of the body.

　　2. For phosphatic calculi, adopt a low-calcium, low-phosphorus diet. For calcium-containing renal calculi, it is advisable to avoid high-calcium, high-salt, high-oxalate, high-animal protein, high-animal fat, and high-sugar diets.

　　X-ray diagnosis

　　Abdominal plain film: Abdominal plain film is the basic examination method for diagnosing urinary system calculi. It can understand the size, location, and physical shape of calcium-containing calculi. The opacity of urinary system calculi is related to their constituent components, about 90% of urinary tract calculi cannot be penetrated by X-rays and can be displayed on abdominal plain films, which are habitually called positive calculi. The calculi that can penetrate X-rays are called negative calculi. The types of calculi from completely penetrable by X-rays to not penetrable by X-rays are: uric acid calculi, cystine calculi, magnesium ammonium phosphate calculi, mixed calculi, calcium oxalate calculi, and the least penetrable calcium phosphate calculi. On abdominal plain films, calcium phosphate calculi appear dense, smooth, and hard; calcium oxalate calculi have lower density and appear mulberry-like. The opacity of the calculi on the abdominal plain film can be used to preliminarily judge and predict the effect of extracorporeal shock wave lithotripsy.

　　Intravenous pyelography

　　To further clarify the diagnosis of negative urinary tract calculi, differentiate between calcified spots and pelvic venous stones, and understand renal anatomical and functional abnormalities, intravenous pyelography on the basis of abdominal plain film is very necessary. Intravenous pyelography can also determine the degree of hydronephrosis, the residual renal parenchyma, the degree of renal function damage, and the presence of urinary tract malformation. This information is very helpful for choosing treatment methods and predicting treatment outcomes. Before percutaneous nephrostolithotomy and nephrolitholapaxy, intravenous pyelography can help in choosing the renal puncture approach.

　　According to the findings of intravenous pyelography, hydronephrosis can be divided into 4 grades: Grade I: Renal pelvis and calyces are dilated. The renal cup II is flattened, and renal function is not damaged; Grade II: The calyces show club-shaped, renal function is slightly damaged; Grade III: The kidneys are cystically dilated. The contrast agent appears delayed, the renal parenchyma is thin, and renal function is severely damaged; Grade IV: The renal pelvis is spherically dilated, the contrast agent appears delayed or not at all, and the renal parenchyma is thin.

　　Retrograde urography

　　Retrograde urography is a supplement to intravenous pyelography and is mainly used for patients allergic to intravenous pyelographic agents. It can clearly show the site of stone obstruction and anatomical abnormalities of the ureter and renal pelvis. Retrograde urography can cause certain pain to patients and may lead to retrograde infection. It is not suitable for routine use and can be replaced by CT three-dimensional reconstruction.

　　Ultrasound examination

　　Ultrasound examination has the advantages of being non-invasive, repeatable, convenient, and highly accurate, and has become a routine examination item. It can display the size, location, hydronephrosis, renal parenchyma thinning, and urinary tract malformation of urinary system calculi. In general, clinical symptoms, urine examination, B-ultrasound, and abdominal plain film can basically clarify the diagnosis of urinary system calculi.

　　Dietary precautions for the treatment of urinary tract calculi:

　　1. Fat: The intake of high-fat foods should be reduced in the diet.

　　2. Sodium: High-sodium diets can increase the tendency of calcium salt calculi in urine. The amount of salt in the diet should be

　　3. Protein: High-protein, high-sugar, and high-fat diets increase the risk of calculus formation. It is advisable to eat more coarse grains and vegetarian foods in daily life.

　　4. Calcium: Calcium salts are the main component of urinary calculi. It is generally believed that an increase in calcium intake increases the risk of calculus formation. However, overly restricting calcium intake not only fails to reduce but may actually increase the incidence of calculi. It is recommended to maintain a normal calcium intake, with 1000 mg per day for adults and 1200 mg per day for those over 50 years old.

　　5. Oxalates: Most stones contain oxalates, so reducing urinary oxalate can reduce the incidence of calculi. High-dose vitamin C intake can increase urinary oxalate levels, and it is advisable to avoid excessive consumption of foods that may cause hyperoxaluria, such as strong tea, large amounts of chocolate, spinach, beetroot, oranges, rhubarb, nuts, strawberries, wheat bran, mushrooms, potatoes, chili, chestnuts, coffee, cocoa, persimmons, and loquats.

　　6. Water: Chronic dehydration or insufficient water intake is closely related to the formation of urinary stones. Drinking plenty of water can reduce the incidence of urinary calculi. Drinking 2500 ml of fluid per day can prevent the occurrence of new stones in individuals with high urinary calcium. It is usually recommended to drink 250 ml of water every 4 hours, plus 250 ml with each meal. The type of fluid consumed should be non-milk and low-oxalate. Water does not need to be strictly soft or hard, and the amount is the key, and it needs to be taken care of day and night.

　　7. Citrate: Citrate is a natural inhibitor of urinary stone formation, which can reduce the concentration of urinary calcium and the saturation of calcium oxalate and calcium phosphate in urine. Supplementing 2036.7 mmol of potassium citrate per day can significantly increase urinary citrate and urine pH, and reduce the recurrence rate of urinary calculi. Excessive intake of citrate can also lead to hyperuricuria, which may offset the benefits of increasing dietary citrate. Citrus fruits are commonly used as adjuvant therapy for low-citrate calcium kidney stones.

　　8. Alcohol: Long-term and excessive alcohol consumption leads to higher levels of urinary calcium and phosphorus, which are more likely to form calculi. On the contrary, moderate alcohol consumption can induce diuresis, reduce the concentration of urinary components, and lower the incidence of calculi. In summary, moderate alcohol consumption does not increase the risk of calculus formation.

　　1. Pain relief

　　The following drugs can relieve pain through different routes of administration; diclofenac sodium (Futharin), indomethacin (anti-inflammatory), dihydrocodeine hydrochloride + atropine sulfate (dihydrocodeine atropine), anilerin, pentazocine, and tramadol.

　　When there is a possibility of spontaneous excretion of calculi, the use of 50mg diclofenac sodium tablets or suppositories twice a day for 3-10 days is effective in reducing ureteral edema and reducing the recurrence rate of pain.

　　When pain cannot be relieved by medication, stents or percutaneous nephrostomy should be placed, and stone removal surgery should be performed to achieve the purpose of draining urine.

　　2. Stone Fragmentation

　　With the development of relevant disciplines and the continuous innovation of medical devices, it is generally not necessary to undergo surgery for urinary tract stones now, which is the merit of extracorporeal shock wave lithotripsy machines. Extracorporeal lithotripsy does not require surgery, has less trauma, and less pain. Stones inside the body can be fragmented outside the body, and the fragmented stones can be as large as mung beans and as small as fine sand, and can be excreted out of the body with urine. Therefore, extracorporeal shock wave lithotripsy is called the 'revolution in urinary tract stone treatment'. Extracorporeal shock wave lithotripsy machines can treat kidney stones Ureteral stones, bladder stones, and other stones are the first-line treatment methods. Of course, for individual patients with larger stones or stones with complications, endoscopic surgery is required, which requires specific treatment for specific problems.

　　3. Stone Dissolution

　　Stones suitable for dissolution therapy include uric acid stones, cystine stones, and infections Sexual stones. We have carried out dissolution therapy for cystine stones, which are visible on X-ray films due to their high sulfur content. We have corrected the misconception that cystine stones are negative stones. We use triethanolamine to dissolve uric acid stones and carry out intravenous infusion of sodium lactate to dissolve uric acid stones, etc. Cystine stones are prone to recurrence after surgery, and extracorporeal shock wave lithotripsy often cannot fragment them. The residual stone rate after percutaneous nephrolithotomy is relatively high. Chemical dissolution of cystine stones can greatly improve the cure rate. For larger staghorn cystine stones, the optimal treatment plan is to combine extracorporeal shock wave lithotripsy or percutaneous nephrolithotomy with chemical dissolution therapy.

　　4. Stone Removal

　　Stones with a diameter less than 4mm can be spontaneously excreted in 80% of cases.

　　Stones with a diameter greater than 7mm have a low chance of spontaneous excretion, and stone removal or fragmentation treatment is usually required.

　　The overall excretion rates for proximal, middle, and distal ureteral stones are 25%, 45%, and 70%, respectively. Stones with a diameter greater than 6-7mm usually require stone removal.

　　Definite indications for stone removal or fragmentation include: pain that cannot be relieved by medication, persistent obstruction accompanied by kidney function damage, urinary tract infection, renal calculi, or the risk of pyuria, bilateral obstruction, or obstruction of a solitary functioning kidney.