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Contemporary Management of Urinary Tract Stones

Contemporary Management of Urinary Tract Stones. Mr Andrew Ballaro MD, FRCS( Urol ) Consultant Urological Surgeon Specialist interest in Stone Surgery and Endourology Barking Havering Redbridge NHS Trust Spire Roding Hospital. Introduction.

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Contemporary Management of Urinary Tract Stones

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  1. Contemporary Management of Urinary Tract Stones • Mr Andrew Ballaro MD, FRCS(Urol) • Consultant Urological Surgeon • Specialist interest in Stone Surgery and Endourology • Barking Havering Redbridge NHS Trust • Spire Roding Hospital

  2. Introduction • Urinary tract stones cause 1% of acute hospital admissions • Lifetime chance 12% • Incidence doubled since 1970s due to obesity • 50% recurrence risk

  3. How to diagnose- symptoms • Large stones may be asymptomatic • Renal stones may cause dull loin pain • Small stones may cause most severe pain

  4. How to diagnose- investigations • Microhaematuria in 80% stones • X-ray for follow-up but 10% radiolucent • Ultrasound reasonably sensitive for > 5mm stones and hydronephrosis • NCCT gold standard

  5. When to treat and refer • Stone factors- Size and location • Symptoms • Renal: <5mm vs >5mm • Ureteric: <5mm 80% vs >5mm 50% chance passing • Patient factors • Elderly lady vs airline pilot • Patient wishes • Fitness

  6. How to treat-renal colic • Analgesia NSAID vs opiate • Conservative vs active treatment • Medical expulsive therapy • Indications for intervention • Uncontrolled pain • Sepsis • Failure of stone progression • Solitary kidney or bilateral ureteric stones

  7. Rigid Ureteroscopy • Ureteric stones: stent vs primary clearance • Rigid vs flexible ureteroscopy • Laser vslithoclast energy • Laser vastly more efficient • Reduces ureteric injuries • Reduced stricture rate • Propulsion

  8. How to treat- renal stones • Certain small renal stones can be dissolved • Lithotripsy (ESWL) <1cm • Laser Ureterorenoscopy < 2cm • Percutaneous nephrolithotomy

  9. ESWL • Introduced in 1980s • Reduced effectiveness • Mobile vs static units • 40-50% success rates • Residual fragments • Difficult locations/drainage • Complications • Contraindications

  10. Ureterorenoscopy-renal stones • Requires flexible ureteroscopy skills • Primary or salvage treatment after ESWL • Minimally invasive state of the art treatment

  11. Ureterorenoscopy-renal stones • Enables stone clearance and retrieval • Replacing ESWL and PCNL • In skilled hands used for 2cm stones • Day case procedure

  12. My laser service results • Sole surgeon for >700,000pop. • 129 procedures since March 2011 • 40% for failed ESWL • 100% clearance for ureteric stones • 79-90% clearance for renal stones up to 2cm • 92% day case rate • 11% minor complications • No major complications • Favourably benchmarked with BLT

  13. Percutaneous Nephrolithotomy • > 2cm and staghorn stones • More invasive • 2-3 day admission

  14. Percutaneous Nephrolithotomy-Supine • Allows simultaneous ureterorenoscopy • Reduces anaesthetic risks • Reduces theatre time • Equal stone clearance rates • 54 cases performed since 2011 at BLT

  15. Nephrectomy • Laparoscopic vs open • Indications • Pain • HTN • <15% function • Infections

  16. Stone Prevention • Analyse all stones • Serum calcium/urate • Recurrent stone former • Stone screen • Dietry advice • High fluid • Low salt • Low animal protein • Low oxalate

  17. Summary • Refer all renal stones other than <5mm if asymptomatic first stone and patient does not want treatment. • Refer ureteric stones if non-progressing or >5mm Contact me: • NHS- BHRNHST Stone Clinic CAB Thursday am. • andrew.ballaro@bhrhospitals.nhs.uk • Secretary: Anne 0208 970 8066 • Private- Tel. 07855412211 anytime

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