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

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Presentation on theme: "The Modern Management of Urinary Stone Disease Mr C Dawson Consultant Urologist Edith Cavell Hospital."— Presentation transcript:

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

2 Historical Aspects of stone treatment n Ancient Egyptians - No surgical treatments –“Pill of wheat, yellow ochre, water taken for four days” n 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” n Hindu treatments relied on a Vegetarian diet and exercise

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

4 Lithotomy n Modification of lithotomy, using a urethral sound led to the “grand appareil” also known as “cutting on the staff” n One of its best known exponents was Jacques de Beaulieu - Frere Jacques

5 Lithotrity n First performed by Jean Civiale n Sir Henry Thompson

6 Modern Management of Urinary Stone Disease

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

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

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

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

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

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

13 Conservative Management n Is the initial management of most stones n Analgesia and antiemetics +/- IV fluids (no benefit from forced diuresis) n Size of stone dictates outcome Diameter (mm)% of stones passing spontaneously < >610

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

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

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

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

18 Open Procedures n 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 n Stones neither more nor less common during pregnancy n Most of the usual symptoms of stones are also common in pregnancy - therefore imaging required to confirm stones n IVU relatively contraindicated n U/S may show hydronephrosis - compatible with normal pregnancy

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

21 Management of stones in Pregnancy n Other choices include percutaneous nephrostomy tube drainage, and open lithotomy n ESWL is considered contraindicated (?effects on foetus, use of x rays) n Open surgery is contraindicated in last half of pregnancy for lower ureteric stones

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

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

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

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

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