The Modern Management of Urinary Stone Disease

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

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

5. Lithotrity • First performed by Jean Civiale - 1823 • 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 <4 90 4-6 50 >6 10

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. 25-30% 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

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

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