contemporary management of urinary tract stones mr andrew ballaro md, frcs(urol) consultant...
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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
• Urinary tract stones cause 1% of acute hospital admissions
• Lifetime chance 12%
• Incidence doubled since 1970s due to obesity
• 50% recurrence risk
How to diagnose- symptoms
• Large stones may be asymptomatic
• Renal stones may cause dull loin pain
• Small stones may cause most severe pain
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
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
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
Rigid Ureteroscopy
• Ureteric stones: stent vs primary clearance
• Rigid vs flexible ureteroscopy
• Laser vs lithoclast energy– Laser vastly more efficient– Reduces ureteric injuries– Reduced stricture rate– Propulsion
How to treat- renal stones
• Certain small renal stones can be dissolved
• Lithotripsy (ESWL) <1cm
• Laser Ureterorenoscopy < 2cm
• Percutaneous nephrolithotomy
ESWL
• Introduced in 1980s• Reduced effectiveness • Mobile vs static units• 40-50% success rates• Residual fragments• Difficult locations/drainage• Complications• Contraindications
Ureterorenoscopy-renal stones
• Requires flexible ureteroscopy skills• Primary or salvage treatment after ESWL• Minimally invasive state of the art treatment
Ureterorenoscopy-renal stones
• Enables stone clearance and retrieval• Replacing ESWL and PCNL• In skilled hands used for 2cm stones• Day case procedure
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
Stone burden(mm)
RFs<3mm
RFs>3mm
0-9 79% 5%
10-14 90% 9%
>15 87% 13%
Percutaneous Nephrolithotomy-Supine
• Allows simultaneous ureterorenoscopy• Reduces anaesthetic risks• Reduces theatre time• Equal stone clearance rates• 54 cases performed since 2011 at BLT
Stone Prevention
• Analyse all stones• Serum calcium/urate• Recurrent stone former
– Stone screen
• Dietry advice– High fluid– Low salt– Low animal protein– Low oxalate
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.
– [email protected]– Secretary: Anne 0208 970 8066
• Private- Tel. 07855412211 anytime