Transcript Slide 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 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 diagnoseinvestigations • 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 13% 87% 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. – [email protected] – Secretary: Anne 0208 970 8066 • Private- Tel. 07855412211 anytime