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The Modern Management of Urinary Stone Disease

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1 The Modern Management of Urinary Stone Disease
Mr C Dawson Consultant Urologist Edith Cavell Hospital

2 Historical Aspects of stone treatment
Ancient Egyptians - No surgical treatments “Pill of wheat, yellow ochre, water taken for four days” Susruta (5th Cent AD, India), author of the Ayurveda described the symptoms of renal colic and thought that stones were formed from “phlegm, bile, air or semen” Hindu treatments relied on a Vegetarian diet and exercise The oldest stone so far discovered was a vesical calculus found among the pelvic bones of a teenage boy in a pre-historic tomb at El Amara in 1901. It is doubtful that treatments for stones were available at this time, and there is no evidence for any surgical procedures in ancient Egypt. Later Egyptian surgical treatments were described by the Italian Physician Prosper Alpino in the 16th Cent.

3 Historical Aspects of stone treatment
Lithotomy first described by Celsus, a Roman physician (25BC to 25 AD) His book De Re Medecina served as the basis of teaching for the next 15 centuries! His procedure became known as the “petit appareil” because of the small number of instruments used

4 Lithotomy Modification of lithotomy, using a urethral sound led to the “grand appareil” also known as “cutting on the staff” One of its best known exponents was Jacques de Beaulieu - Frere Jacques Jacques de Beaulieu was born in Burgundy in His upbringing was poor and his education meagre. He served for five years as a trooper in the French Cavalry and on being discharges became apprenticed to Pauloni, an itinerant Italian Lithotomist. From Pauloni he learnt the techniques of the petit appareil and the grand appareil. Between 1688 and 1690 he adopted monk-like clothes and began calling himself Frere Jacques. At the age of 46 he went to Paris with the intention of teaching his technique of cutting for the stone. Armed with certificates of cure he went to the Chariot and the Hotel Dieu but was met with scorn and derision. After a thrilling demonstration in front of the first surgeon of the Hotel Dieu he was allowed to operate. Frere Jacques had modified the grand appareil so that the dissection passed laterally between the ischio-cavernosus and the bulbo-cavernosus without injuring either and so reducing blood loss. After an initially favourable start, Jacques luck turned. He cut 60 patients in four months of whom 25 died and 13 cured and he was forced to leave.

5 Lithotrity First performed by Jean Civiale - 1823 Sir Henry Thompson
Emperor Napoleon III of France (1852) developed symptoms of stones about four years before seizing power. His symptoms worsened just before the outbreak of the Franco-Prussian war in At Sudan, finding himself surrounded, he is said to have exposed himself to enemy fire such was the intensity of his symptoms. Surrender followed and he was exiled to England where he was treated by Sir Henry Thompson.

6 Modern Management of Urinary Stone Disease

7 Renal Colic Typically occurs at night / early morning. Abrupt onset, affecting patient at rest Begins in flank, radiates around abdomen. As stone progresses down ureter may get pain in groin and testes / labia Nausea, vomiting, intestinal ileus common ? Strangury

8 Features on examination
Typically severe discomfort, and inability to find comfortable position (cf peritonitis) Pale, sweating, tachycardic Mild tenderness on affected side Genital and rectal examination essential Fever uncommon, but may suggest coexisting infection

9 Differential Diagnosis of renal colic
Gastro-enteritis Acute appendicitis Diverticulitis Salpingitis Cholecystitis Pyelonephritis Ruptured Aortic Aneurysm

10 Initial Investigations
Dipstick testing of urine - confirms haematuria in about 90% of patients. Absence of haematuria should suggest other possible diagnoses KUB +/- IVU

11 Management of Stones Has been revolutionised by technological advances
Dependant on expertise and availability of equipment Dictated by size and position of stone(s)

12 Management of Stones Conservative Management
Extra corporeal Shock Wave Lithotripsy (ESWL) Percutaneous Nephrolithotomy (PCNL) Ureteroscopy (URS) Open procedures Management of stones in Pregnancy Bladder stones

13 Conservative Management
Is the initial management of most stones Analgesia and antiemetics +/- IV fluids (no benefit from forced diuresis) Size of stone dictates outcome Diameter (mm) % of stones passing spontaneously < >

14 Extracorporeal Shock Wave Lithotripsy
First described by Christian Chaussy in 1982 Now the treatment of choice for the majority of renal and ureteric stones Performed on a day case or outpatient basis Minimal complication rate High success rates, though repeat procedures usually necessary

15 Complications of ESWL Sepsis
Haematuria, usually minor % have perirenal haematomas on CT or MRI scanning Transient renal dysfunction (enzymuria) Obstruction from stone fragments (“steinstrasse”) -increasing pain Theoretical risk of Hypertension - unproven

16 Percutaneous Nephrolithotomy
For renal, or upper ureteric stones too large for ESWL Initial management of choice for Staghorn stones where renal function worth preserving Track into kidney made by radiologist Stones fragmented under direct vision

17 Ureteroscopy Made much safer and easier by development of miniature ureteroscopes Ureteroscopy performed under GA Trauma to ureter from ureteroscope is main complication Stone may be removed by Dormia Basket Fragmented by ultrasound, laser, Lithoclast

18 Open Procedures Now restricted to:
Stones that cannot be removed by other means In a morbidly obese patient (other procedures technically impossible) In a patient whose poor health precludes other (lengthier) procedures For large, complex, staghorn calculi

19 Management of stones in Pregnancy
Stones neither more nor less common during pregnancy Most of the usual symptoms of stones are also common in pregnancy - therefore imaging required to confirm stones IVU relatively contraindicated U/S may show hydronephrosis - compatible with normal pregnancy Hydronephrosis, decreased ureteric peristalsis, infection and calcium supersaturation are offset by increased excretion of stone inhibitors (magnesium, citrate, and glycosaminoglycans) - Gillenwater p358 IVU contributes about 1.5 rad to the foetus. Significant doses to the pelvis (5-15 rad) during the first trimester increase risk of foetal anomalies from 1% to 3% In asymptomatic patients the normal renal pelvic diameters are Right Left First Trimester 5+/- 1 mm 3+/-1 mm Second 10+/- 3 mm 4+/-1 mm Third 12+/-2 mm 5+/-1 mm

20 Management of stones in Pregnancy
Most symptomatic stones in pregnancy are ureteric Management in most cases is conservative since the majority of stones will pass spontaneously If stones remain symptomatic then ureteric stenting is most common outcome

21 Management of stones in Pregnancy
Other choices include percutaneous nephrostomy tube drainage, and open lithotomy ESWL is considered contraindicated (?effects on foetus, use of x rays) Open surgery is contraindicated in last half of pregnancy for lower ureteric stones There is not enough room in the pelvis to operate and it would be difficult to correct any surgical complications (Gillenwater p 359)

22 Management of bladder stones
Endemic bladder stones of SE Asia do not recur when removed Bladder stones do not occur in western population in the absence of significant obstruction, which must also be corrected Choice of procedures ESWL Litholopaxy Open Lithotomy

23 Medical Management 63% of adult men with a single stone episode will form further stones Patients with a single stone have the same incidence and severity of metabolic derangements as recurrent stone formers A metabolic cause can be found in approximately 97% of those evaluated Cost and inconvenience of metabolic evaluation must be balanced against risk of further stones

24 Medical Management Therefore one solution is to reserve full evaluation for high risk patients Middle aged Caucasian men with a family history of stones Patients with chronic diarrhoeal states, pathological fractures, osteoporosis, gout, UTIs Any patient with cystine, uric acid, or struvite (infection) stones All children

25 Medical Management Low risk patients should have evaluation of
Serum calcium, uric acid and phosphate 24 hour urine pH, oxalate, phosphate, uric acid and calcium Single urine sample for cystine

26 Conclusions The Investigation and modern management of urinary stones, though challenging, has been transformed by recent technological advances ESWL remains the initial treatment for most stones Overall success rates for stone treatments are very good

27 Conclusions The management of stones in pregnancy remains a challenge to the Urologist Limited metabolic evaluation is worthwhile in the majority of patients

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