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
> 5mm stones and hydronephrosis
NCCT gold standard

5. 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

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 6

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) <1cm
Laser Ureterorenoscopy < 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 >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
>3mm
0-9
79% 5%
10-14
90% 9%
>15
87%
13%

13. Percutaneous Nephrolithotomy
> 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 <15% 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

17. 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.
Secretary: Anne
Private- Tel anytime