Contemporary Management of Urinary Tract Stones

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
• gt 5mm stones and hydronephrosis
• NCCT gold standard

5
When to treat and refer

• Stone factors- Size and location
• Symptoms
• Renal lt5mm vs gt5mm
• Ureteric lt5mm 80
• vs gt5mm 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 vs lithoclast 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) lt1cm
• Laser Ureterorenoscopy lt 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 gt700,000pop.
• 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 lt3mm RFs gt3mm
0-9 79 5
10-14 90 9
gt15 87 13
13
Percutaneous Nephrolithotomy

• gt 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
• lt15 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

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Summary

• Refer all renal stones other than lt5mm if
  asymptomatic first stone and patient does not
  want treatment.
• Refer ureteric stones if non-progressing or gt5mm
• Contact me
• NHS- BHRNHST Stone Clinic CAB Thursday am.
• andrew.ballaro_at_bhrhospitals.nhs.uk
• Secretary Anne 0208 970 8066
• Private- Tel. [phone] anytime