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

• > 2cm and staghorn stones• More invasive• 2-3 day admission

Percutaneous Nephrolithotomy-Supine

• Allows simultaneous ureterorenoscopy• Reduces anaesthetic risks• Reduces theatre time• Equal stone clearance rates• 54 cases performed since 2011 at BLT

Nephrectomy

• Laparoscopic vs open• Indications

– Pain– HTN– <15% function– Infections

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.

– andrew.ballaro@bhrhospitals.nhs.uk– Secretary: Anne 0208 970 8066

• Private- Tel. 07855412211 anytime