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Current concepts in stone treatment Professor Damien Bolton

Current concepts in stone treatment Professor Damien Bolton. Epidemiology. Incidence 120-350 / 100,000 worldwide 3:1 Male: Female ratio High rates of stone recurrence 50% at 7-10 years Family history a factor Genetic factors. Important Stone Factors influencing Management.

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Current concepts in stone treatment Professor Damien Bolton

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  1. Current concepts in stone treatment Professor Damien Bolton

  2. Epidemiology • Incidence 120-350 / 100,000 worldwide • 3:1 Male: Female ratio • High rates of stone recurrence • 50% at 7-10 years • Family history a factor • Genetic factors

  3. Important Stone Factors influencing Management • Patient Factors • ? Single Kidney / Transplant kidney • Pregnancy • Sepsis • Renal Function • Anatomy • Size / Location / Focality • Kidney / Ureter (upper/middle/lower) • Obstruction • Hydronephrosis/ Hydroureter • Radio-opaque / Radiolucent

  4. Initial Investigations • Non-Contrast CT (Gold Standard) • Only Indinavir stones not detectable • XR KUB • Helps with determining type & helps with F/U • Urine dipstick & MCS • Bloods: FBC, CRP, Cr, Ca, Uric acid, ? Coags • Stone analysis (strain & send)

  5. Treatment Options • Conservative Management • Analgesia • Medical Expulsive Therapy (MET) • Temporizing measures • Nephrostomy • Retrograde JJ stent • Definitive Treatment • Ureteroscopy • PCNL (PerCutaneous NephroLithotomy) • ESWL (Extracorporeal Shock Wave Lithotripsy) • Nephrectomy

  6. Decision Tree • Patients not for conservative management • Septic obstructed system • Deteriorating Renal Function • Intractable pain • High stone burden • Previously failed conservative management • Single kidney (relative)

  7. Spontaneous Stone Passage % failed stone passage = 10 * width in mm

  8. Conservative Management • Analgesia • Regular NSAID (Preferably PR) • Regular Paracetamol • Opioids work poorly • Spasmolytics may help

  9. Conservative Management • Medical Expulsive Therapy (Alpha-Blocker) • Tamsulosin (Flomaxtra) • 400mcg od PO • $50-$60 / month (non-PBS) • Prazocin (Minipress/Pressin) • 0.5mg od to 1mg bd PO • PBS • Problems with hypotension

  10. Conservative Management • Dissolution Therapy • Uric acid stones (radiolucent) • Urinary alkalization • Potassium Citrate (expensive) • Sodium Citrate (watch Na load in CCF) • Ural (sodium citrotartate): 2 sachets tds • Need motivated patients • Urinary pH (7.0-7.2). Multiple daily dipsitcks.

  11. 36M • Left renal colic • Patient initially refused CT

  12. 4*6mm distal ureteric stone. Treated conservatively for 2/12 but stone impacted in L u/o and no further progression. Prev gastritis with NSAIDS. Rigid ureteroscopy, & basket of stone. Note moderate hydronephrosis.

  13. Ureteroscopy • Rigid ureteroscopy • Mid / distal ureteric stones • Risk of retropulsion • N-trap / Stone Cone / Backstop

  14. Ureteropyeloscopy • Huge advances in equipment over last few years. • Digital flexible ureterorenoscopes • 90° field of view • 2-50mm depth of field • 8.3F (2.8mm) outer diameter at tip • 3.6F (1.2mm) working channel • 180° flex up / 275° flex down • Access Sheaths

  15. Upper ureteric stone with minimal hydronephrosis not septic but pain not controlled with analgesia. Candidate for ESWL or Flexible Ureteroscopy

  16. 28F from Nepal Renal stone previously diagnosed there and treated conservatively. Increasing frequency of colic and size of stone. 18mm PUJ stone. ?Causing intermittent obstruction Flexible URS / laser lithotripsy. Stone cleared

  17. PCNL • For those with high stone burden • Traditionally staghorn stones / renal stones >2cm / lower pole stones >1cm • Highest morbidity,highest stone clearance • Traditionally supine. • Now prone; 2 surgeon with simultaneous flexible ureteropyeloscopy.

  18. Partial staghorn stone, faintly visible on XR KUB. ?Uric acid components. Failed trial of dissolution therapy. Had PCNL.

  19. Extra-corporeal Shock Wave Lithotripsy(ESWL) • Non-invasive • Day-case • Ideal for renal/upper ureteric calculi with small stone burden • May need JJ stent • May need multiple sessions

  20. ESWL • Least morbid but poorest stone free rates • Stone free rate for one session ESWL vs. Laser <10mm 80% vs. 100% >10mm 50% vs. 93% • Poorer with Lower pole stones (one session) • <10 mm 74% • 10-20 mm 56% • >20 mm 33% • Good clearance for upper ureteric stones • 82-88% clearance

  21. THANK YOU! Questions?

  22. Stone composition • Previous stone analysis • XR characteristics

  23. Stone Aetiology

  24. Decision Tree • In a patient who has a newly diagnosed ureteral stone < 10 mm and if active stone removal is not indicated, observation with periodic evaluation is an option as initial treatment. • Level 1a evidence • EAU: Grade A recommendation

  25. Temporizing Measures • Septic Obstructed Kidney • Blood Cultures / Urine Cultures / Coags • IV Antibiotics • Urgent percutaneous nephrostomy • Nephrostomy culture. • ICU • Later definitive management • Stone may pass spontaneously • Can be treated with ureteropyeloscopy in same admission when not septic • Antegrade stent. Home and readmission.

  26. Temporizing Measures • Retrograde JJ stent • Usually GA rigid cystoscopy with II • Can be LA flexible cystoscopy without II • May be necessary in pregnancy • Not fit for anesthetic • Unable / not appropriate to reverse anticoagulation

  27. Definitive Management • Ureteropyeloscopy • PCNL (Per-Cutaneous Nephro-Lithotomy) • ESWL (Extracorporeal Shock Wave Lithotripsy) • Nephrectomy

  28. Definitive Management – Decision Making • Depends on stone factors • Location / Size / Focality • Composition • Patient factors • Geography • Multiple vs. Single treatments • Need for absolute stone clearance (pilots) • Equipment factors • Access to lithotripter • Access to flexible ureterorenoscopy / laser

  29. Ureteroscopy

  30. Ureterorenoscopy – Energy Sources • Pneumatic lithotripter • Occasionally used • Newer handheld gas cartridge powered devices • Laser • Ho:YAG laser lithotripter • 270 micron fiber can be used down flexible ureterorenoscope.

  31. Ureterorenoscopy – Stone Retrieval

  32. 20M Presented to the Northern hospital with multiple small round lower pole stone and obstructing PUJ stone. Stented (stone retropulsed) and referred to Austin for flexi URS laser. PUJ obstruction treated with lap pyeloplasty. Unable to clear stones laparoscopically and brought back for flexi URS laser.

  33. Ureterorenoscopy • Advances in technology means that previous limitations no longer in place • Any size, anywhere • Only limitation is surgeon patience • Approx. 1hr / cm of stone • Bilateral staghorns cleared in 4 sittings

  34. ESWL • Only 1 public lithotripter in Melbourne • St Vincent's hospital • http://lithotripsy.svhm.org.au • Mobile service to: • RCH (3-4monthly + PRN) • Frankston (fortnightly) • Rural • Geelong/Ballarat/Bendigo/Shepparton (monthly) • Mildura (3-4monthly + PRN)

  35. ESWL • Absolute contraindications • AAA or Renal artery aneurysm • Pregnancy • Coagulopathy • UTI • Intra-renal vascular calcifications near shock wave focus • Relative contraindications • Stones >2cm, multiple stones • Cystine or matrix stones (too hard) • Obesity (too far to stone)

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