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7/28/2019 The Modern Management of Stone Disease
http://slidepdf.com/reader/full/the-modern-management-of-stone-disease 1/27
The Modern Management of Urinary
Stone Disease
Mr C Dawson
Consultant Urologist
Edith Cavell Hospital
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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
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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
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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 wasJacques de Beaulieu - Frere Jacques
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Lithotrity
First performed by Jean Civiale - 1823
Sir Henry Thompson
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Modern Management of Urinary
Stone Disease
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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
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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
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Differential Diagnosis of renal
colic
Gastro-enteritis
Acute appendicitis
Diverticulitis
Salpingitis
Cholecystitis
Pyelonephritis
Ruptured Aortic Aneurysm
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Initial Investigations
Dipstick testing of urine - confirms
haematuria in about 90% of patients.
Absence of haematuria should suggest other
possible diagnoses KUB +/- IVU
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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
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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
<4 904-6 50
>6 10
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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
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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
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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
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Ureteroscopy
Made much safer and easier by
development of miniature ureteroscopes
Ureteroscopy performed under GA
Trauma to ureter from ureteroscope is maincomplication
Stone may be
– removed by Dormia Basket – Fragmented by ultrasound, laser, Lithoclast
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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
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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 - thereforeimaging required to confirm stones
IVU relatively contraindicated
U/S may show hydronephrosis - compatiblewith normal pregnancy
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Management of stones in
Pregnancy
Most symptomatic stones in pregnancy are
ureteric
Management in most cases is conservative
since the majority of stones will passspontaneously
If stones remain symptomatic then ureteric
stenting is most common outcome
f i
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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
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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 significantobstruction, which must also be corrected
Choice of procedures
– ESWL
– Litholopaxy
– Open Lithotomy
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Medical Management
63% of adult men with a single stoneepisode 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 metabolicevaluation must be balanced against risk of
further stones
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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
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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
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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
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Conclusions
The management of stones in pregnancy
remains a challenge to the Urologist
Limited metabolic evaluation is worthwhile
in the majority of patients