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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.

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Presentation Transcript
slide1

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
Introduction
  • Urinary tract stones cause 1% of acute hospital admissions
  • Lifetime chance 12%
  • Incidence doubled since 1970s due to obesity
  • 50% recurrence risk
slide3

How to diagnose- symptoms

  • Large stones may be asymptomatic
  • Renal stones may cause dull loin pain
  • Small stones may cause most severe pain
slide4

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
slide5

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
slide6

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
slide7

Rigid Ureteroscopy

  • Ureteric stones: stent vs primary clearance
  • Rigid vs flexible ureteroscopy
  • Laser vslithoclast energy
    • Laser vastly more efficient
    • Reduces ureteric injuries
    • Reduced stricture rate
    • Propulsion
slide8

How to treat- renal stones

  • Certain small renal stones can be dissolved
  • Lithotripsy (ESWL) <1cm
  • Laser Ureterorenoscopy < 2cm
  • Percutaneous nephrolithotomy
slide9

ESWL

  • Introduced in 1980s
  • Reduced effectiveness
  • Mobile vs static units
  • 40-50% success rates
  • Residual fragments
  • Difficult locations/drainage
  • Complications
  • Contraindications
slide10

Ureterorenoscopy-renal stones

  • Requires flexible ureteroscopy skills
  • Primary or salvage treatment after ESWL
  • Minimally invasive state of the art treatment
slide11

Ureterorenoscopy-renal stones

  • Enables stone clearance and retrieval
  • Replacing ESWL and PCNL
  • In skilled hands used for 2cm stones
  • Day case procedure
slide12

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
slide13

Percutaneous Nephrolithotomy

  • > 2cm and staghorn stones
  • More invasive
  • 2-3 day admission
slide14

Percutaneous Nephrolithotomy-Supine

  • Allows simultaneous ureterorenoscopy
  • Reduces anaesthetic risks
  • Reduces theatre time
  • Equal stone clearance rates
  • 54 cases performed since 2011 at BLT
slide15

Nephrectomy

  • Laparoscopic vs open
  • Indications
    • Pain
    • HTN
    • <15% function
    • Infections
slide16

Stone Prevention

  • Analyse all stones
  • Serum calcium/urate
  • Recurrent stone former
    • Stone screen
  • Dietry advice
    • High fluid
    • Low salt
    • Low animal protein
    • Low oxalate
slide17

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