Dobromir N.1, Nasaudean J.1, Morariu C2,

Stoican N.1

"Spitalul de Urgenta Suceava"

1 Departamentul de Urologie

2 Departamentul de Radiologie §i Imagistica

Introducere: Litiaza Renala netratata poate distruge parenchimul renal prin obstructia caii urinare, secundar hiperpresiunü retrograde , la care se poate asocial infectia urinarä . Cand se asociaza si un obstacol subvezical , consecintele se amplifica.

Obiectiv: Prin rezolvarea nuantata si ierarhizata a acestui caz , am realizat reabilitarea morfofunctionala a aparatului urinar - copromis reversibil , initial.

Material si metoda: Bolnav M.V. 71 de ani ( F.O. 445/26.01.2010 ) se interneaza de urgenta pentru colica renala dreapta - oligoanurie. Clinic si paraclinic , se deceleaza diagnostícele:

1. Calcul ureteral juxtavezical drept - partial obstructiv cu u rete roh id ro nef roza grd. Ill - IV.

2. Calcul coraliform srang C2B1 R1 grd. Ill .

3. Adenom de prostata - Ureterohidronefroza stanga grd. Ill - (T.R. diametrul 5/6 cm - ECHO - PSA 2.5 ng/mL)

4. Infectie urinarä cu E. Coli

- Probe de functie renala la limita superioara a normalului.

- Pregatire preoperatorie ( 72 de ore - sub sonda uretro - vezicala si protectie cu Cefort 1 g/8 ore ).

- Se decide si se practica sub anesezie generala cu I.O.T., in aceeasi sedinta:

1. Extractia calcului ureteral drept cu sonda Dormia - drenaj intern cu sonda Cook.

2. Extractia chirurgicalä a calcului coraliform renai stg. prin pielocalicolitotomie si drenaj intern cu sonda Cook.

- Evolutie simpla - externare in a 9 a zi postOperator .

- Controlul la 14 zile - confirma evolutia favorabila ( diureza 1 600 mi / 24 de ore - probe de functie renala normale ) .

- La 2 luni de la prima interventie , se reinterneaza pentru Hématurie totala intermitenta , sindrom vezical intens ( F.O. 12807/15.03.2010).

Imagistic - RVS - sonde Cook pozitionate corect.

Paraclinic - probe de functie renala normale, urocultura sterila.

- Se decide si se practica endoscopie , suprimarea sondelor Cook si TUR - P pentru HBP . Se rezeca 70 gr. tesut adenomatös PSA - 2.5 ng/ml .

- Evolutie simpla postoperatorie - se suprima sonda in a - 8 - a zi postoperatorie . Se externeaza in a - 1 0 - a zi .

- UIV de control , probele de functie renala normale si urocultura sterile confirma recuperarea integrala morfofunctionala a aparatului urinar .

Concluzi:

- Patologia urologica , complexa , neglijata a cazului a impus prima interventie ( endoscopie ptr. Calculul ureteral drept si chirurgical pentru calculul coraliform renal stg. ) . Drenajul intern bilateral a fost impus de distensia aparatului urinar superior.

- Suprimarea sondelor Cook si TUR - P a fost impusa de ameliorarea distensiei ap.urinar superior ( ECHO ) si de persistenta obstacolului subvezical HBP .

- Tratamentul nuantat - ierarhizat a permis recuperarea morfofunctionala a aparatului urinar .

- Tratamentul antiseptic urinar alternativ si continuu cu cefalosporine -chinolone a permis sterlizarea urinei .

Succesive urological emergency adequate - hierarchised treatment

Dobromir N.1, Nasaudean J.1, Morariu C2,

Stoican N.1

County Emergency Hospital Suceava

1 Department of Urological Surgery

2 Department of Radiology and Medical Imaging

Introduction: Untreated renal lithiasis can lead to completely damage of the renal parenchyma, due to obstruction of the urinary tract, secondary to the retrograde hyperpressure. Sometimes, urinary sepsis can be associated to this condition. The consequences of this impairment can be amplified when an obstacle beneath the urinary bladder is over -added.

Purpose: By approaching and hierarchising the treatment of this medical case, we realized the morphological and functional rehabilitation of the renal system, which was partially and reversibly degraded, in the beginning.

Material and methods: M. V. , 71 year - old patient (file number 445 / 26.01.2010) is admitted as emergency, presenting oligoanuria and the symptoms of right - renal colicative pain. Clinically and with the contribution of lab - tests, the following diagnosis is established:

1. Right juxtavesical urethral stone, partially obstructive, associated with uretero - hydronephrosis grade III - IV.

2. Left coraliform stone C2B1 R1 - grade III .

3. Prostate adenoma (measuring 5/6 cm in diameter) - left uretero - hydronephrosis, grade III - detected by rectal examination, ultrasound and PSA level of 2.5 ng/ml.

4. Urinary sepsis generated by E. coli.

The functional renal tests were at the upper limit of normal values.

Presurgical preparation (72 hours) using a urethra - bladder catheter and also a protection against infection using antibiotics (Cefort - 1 g /8 h) were realized.

We decided and we performed at the same time under general anesthesia with orotracheal intubation, the following surgical procedures:

1 . Right ureteral stone extraction with a Dormia catheter and internal drainage with a Cook catheter .

2. A pyelocaliceal lithotomy of the left kidney with surgical removementofthe left coraliform stone, followed by internal drainage with a Cook catheter.

The clinical status was very satisfying , the patient being released the 9th day after surgery .After a period of 14 days , the favorable evolution was confirmed by a diuresis of 1600 ml / 24 h and by the normal values of renal tests.

After 2 months from the first surgical procedure, the patient is readmitted with discontinuous total haemathuria associated with a very intensive, painful urinary bladder syndrome (file number 12807 / 15.03.2010). At this time, a simple renal radiography shows correctly positioned Cook catheters, function renal test in normal range and sterile urine.

Endoscopical examination, removal of Cook sondes and transurethral resection of the prostate for benign prostate hypertrophy were decided and performed. The level of PSA was 2.5ng/ml and 70 g adenomatous tissue was resected. The post - surgical outcome was easygoing , without significant complications , the stoned was suppressed the 8th day after the intervention and the patient was released after 10 days from admission The normal aspect of intravenous urography , urinary functional tests and sterile urine certify the complete morpho - functional recovery of the urinary system .

Conclusions: The complex urological pathology of this case, as well as the neglection of the disease by the patient himself, required two different therapeutically attitudes towards the first intervention - endoscopical for the right urethral stone and surgical for the left renal coraliform calculus. The internal drainage was performed with the purpose of reducing the upper urinary system distension. The withdrawal of Cook sonds, as well as cancelling of the sub - vesicle obstacle in the same time (TUR - P) led to the improvement of the upper tract stasis (proved by ultrasound exam) and to the solving of the benign prostate hypertrophy. The adequate hierarchised treatment allowed the morpho - functional recovery of the urinary system.