The Modern Management of Urinary The Modern Management of Urinary Stone DiseaseStone Disease

Mr C DawsonMr C Dawson

Consultant UrologistConsultant Urologist

Edith Cavell HospitalEdith Cavell Hospital

Historical Aspects of stone Historical Aspects of stone treatmenttreatment

Ancient Egyptians - No surgical treatmentsAncient Egyptians - No surgical treatments– ““Pill of wheat, yellow ochre, water taken for four Pill of wheat, yellow ochre, water taken for four

days”days” Susruta (5th Cent AD, India), author of the Susruta (5th Cent AD, India), author of the

AyurvedaAyurveda described the symptoms of renal colic described the symptoms of renal colic and thought that stones were formed from and thought that stones were formed from “phlegm, bile, air or semen”“phlegm, bile, air or semen”

Hindu treatments relied on a Vegetarian diet and Hindu treatments relied on a Vegetarian diet and exerciseexercise

Historical Aspects of stone Historical Aspects of stone treatmenttreatment

Lithotomy first described by Celsus, a Lithotomy first described by Celsus, a Roman physician (25BC to 25 AD)Roman physician (25BC to 25 AD)

His book His book De Re MedecinaDe Re Medecina served as the served as the basis of teaching for the next 15 centuries!basis of teaching for the next 15 centuries!

His procedure became known as the “petit His procedure became known as the “petit appareil” because of the small number of appareil” because of the small number of instruments usedinstruments used

LithotomyLithotomy

Modification of lithotomy, using a urethral Modification of lithotomy, using a urethral sound led to the “grand appareil” also sound led to the “grand appareil” also known as “cutting on the staff”known as “cutting on the staff”

One of its best known exponents was One of its best known exponents was Jacques de Beaulieu - Frere JacquesJacques de Beaulieu - Frere Jacques

LithotrityLithotrity

First performed by Jean Civiale - 1823First performed by Jean Civiale - 1823 Sir Henry ThompsonSir Henry Thompson

Modern Management of Urinary Modern Management of Urinary Stone DiseaseStone Disease

Renal ColicRenal Colic

Typically occurs at night / early morning. Typically occurs at night / early morning. Abrupt onset, affecting patient at restAbrupt onset, affecting patient at rest

Begins in flank, radiates around abdomen. Begins in flank, radiates around abdomen. As stone progresses down ureter may get As stone progresses down ureter may get pain in groin and testes / labiapain in groin and testes / labia

Nausea, vomiting, intestinal ileus commonNausea, vomiting, intestinal ileus common ? Strangury? Strangury

Features on examinationFeatures on examination

Typically severe discomfort, and inability to Typically severe discomfort, and inability to find comfortable position (cf peritonitis)find comfortable position (cf peritonitis)

Pale, sweating, tachycardicPale, sweating, tachycardic Mild tenderness on affected sideMild tenderness on affected side Genital and rectal examination essentialGenital and rectal examination essential Fever uncommon, but may suggest Fever uncommon, but may suggest

coexisting infectioncoexisting infection

Differential Diagnosis of renal Differential Diagnosis of renal coliccolic

Gastro-enteritisGastro-enteritis Acute appendicitisAcute appendicitis DiverticulitisDiverticulitis SalpingitisSalpingitis CholecystitisCholecystitis PyelonephritisPyelonephritis Ruptured Aortic AneurysmRuptured Aortic Aneurysm

Initial InvestigationsInitial Investigations

Dipstick testing of urine - confirms Dipstick testing of urine - confirms haematuria in about 90% of patients. haematuria in about 90% of patients. Absence of haematuria should suggest other Absence of haematuria should suggest other possible diagnosespossible diagnoses

KUB +/- IVUKUB +/- IVU

Management of StonesManagement of Stones

Has been revolutionised by technological Has been revolutionised by technological advancesadvances

Dependant on expertise and availability of Dependant on expertise and availability of equipmentequipment

Dictated by size and position of stone(s)Dictated by size and position of stone(s)

Management of StonesManagement of Stones

Conservative ManagementConservative Management Extra corporeal Shock Wave Lithotripsy Extra corporeal Shock Wave Lithotripsy

(ESWL)(ESWL) Percutaneous Nephrolithotomy (PCNL)Percutaneous Nephrolithotomy (PCNL) Ureteroscopy (URS)Ureteroscopy (URS) Open proceduresOpen procedures Management of stones in PregnancyManagement of stones in Pregnancy Bladder stonesBladder stones

Conservative ManagementConservative Management

Is the initial management of most stonesIs the initial management of most stones Analgesia and antiemetics +/- IV fluids (no Analgesia and antiemetics +/- IV fluids (no

benefit from forced diuresis)benefit from forced diuresis) Size of stone dictates outcomeSize of stone dictates outcome

Diameter (mm)Diameter (mm) % of stones passing% of stones passing

spontaneouslyspontaneously

<4<4 9090

4-64-6 5050

>6>6 1010

Extracorporeal Shock Wave Extracorporeal Shock Wave LithotripsyLithotripsy

First described by Christian Chaussy in 1982First described by Christian Chaussy in 1982 Now the treatment of choice for the majority Now the treatment of choice for the majority

of renal and ureteric stonesof renal and ureteric stones Performed on a day case or outpatient basisPerformed on a day case or outpatient basis Minimal complication rateMinimal complication rate High success rates, though repeat procedures High success rates, though repeat procedures

usually necessaryusually necessary

Complications of ESWLComplications of ESWL

SepsisSepsis Haematuria, usually minor. 25-30% have Haematuria, usually minor. 25-30% have

perirenal haematomas on CT or MRI perirenal haematomas on CT or MRI scanningscanning

Transient renal dysfunction (enzymuria)Transient renal dysfunction (enzymuria) Obstruction from stone fragments Obstruction from stone fragments

(“(“steinstrassesteinstrasse”) -increasing pain”) -increasing pain Theoretical risk of Hypertension - unprovenTheoretical risk of Hypertension - unproven

Percutaneous NephrolithotomyPercutaneous Nephrolithotomy

For renal, or upper ureteric stones too large For renal, or upper ureteric stones too large for ESWLfor ESWL

Initial management of choice for Staghorn Initial management of choice for Staghorn stones where renal function worth stones where renal function worth preservingpreserving

Track into kidney made by radiologistTrack into kidney made by radiologist Stones fragmented under direct visionStones fragmented under direct vision

UreteroscopyUreteroscopy

Made much safer and easier by development Made much safer and easier by development of miniature ureteroscopesof miniature ureteroscopes

Ureteroscopy performed under GAUreteroscopy performed under GA Trauma to ureter from ureteroscope is main Trauma to ureter from ureteroscope is main

complicationcomplication Stone may be Stone may be

– removed by Dormia Basketremoved by Dormia Basket– Fragmented by ultrasound, laser, LithoclastFragmented by ultrasound, laser, Lithoclast

Open ProceduresOpen Procedures

Now restricted to:Now restricted to:

– Stones that cannot be removed by other Stones that cannot be removed by other meansmeans

– In a morbidly obese patient (other In a morbidly obese patient (other procedures technically impossible)procedures technically impossible)

– In a patient whose poor health precludes In a patient whose poor health precludes other (lengthier) proceduresother (lengthier) procedures

– For large, complex, staghorn calculiFor large, complex, staghorn calculi

Management of stones in Management of stones in PregnancyPregnancy

Stones neither more nor less common during Stones neither more nor less common during pregnancypregnancy

Most of the usual symptoms of stones are Most of the usual symptoms of stones are also common in pregnancy - therefore also common in pregnancy - therefore imaging required to confirm stonesimaging required to confirm stones

IVU relatively contraindicatedIVU relatively contraindicated U/S may show hydronephrosis - compatible U/S may show hydronephrosis - compatible

with normal pregnancywith normal pregnancy

Management of stones in Management of stones in PregnancyPregnancy

Most symptomatic stones in pregnancy are Most symptomatic stones in pregnancy are uretericureteric

Management in most cases is conservative Management in most cases is conservative since the majority of stones will pass since the majority of stones will pass spontaneouslyspontaneously

If stones remain symptomatic then ureteric If stones remain symptomatic then ureteric stenting is most common outcomestenting is most common outcome

Management of stones in Management of stones in PregnancyPregnancy

Other choices include percutaneous Other choices include percutaneous nephrostomy tube drainage, and open nephrostomy tube drainage, and open lithotomylithotomy

ESWL is considered contraindicated (?ESWL is considered contraindicated (?effects on foetus, use of x rays)effects on foetus, use of x rays)

Open surgery is contraindicated in last half Open surgery is contraindicated in last half of pregnancy for lower ureteric stonesof pregnancy for lower ureteric stones

Management of bladder stonesManagement of bladder stones

Endemic bladder stones of SE Asia do not recur Endemic bladder stones of SE Asia do not recur when removedwhen removed

Bladder stones do not occur in western Bladder stones do not occur in western population in the absence of significant population in the absence of significant obstruction, which must also be correctedobstruction, which must also be corrected

Choice of proceduresChoice of procedures– ESWLESWL

– LitholopaxyLitholopaxy

– Open LithotomyOpen Lithotomy

Medical ManagementMedical Management 63% of adult men with a single stone 63% of adult men with a single stone

episode will form further stonesepisode will form further stones Patients with a single stone have the same Patients with a single stone have the same

incidence and severity of metabolic incidence and severity of metabolic derangements as recurrent stone formersderangements as recurrent stone formers

A metabolic cause can be found in A metabolic cause can be found in approximately 97% of those evaluatedapproximately 97% of those evaluated

Cost and inconvenience of metabolic Cost and inconvenience of metabolic evaluation must be balanced against risk of evaluation must be balanced against risk of further stonesfurther stones

Medical ManagementMedical Management

Therefore one solution is to reserve Therefore one solution is to reserve fullfull evaluation for high risk patientsevaluation for high risk patients– Middle aged Caucasian men with a family history Middle aged Caucasian men with a family history

of stonesof stones– Patients with chronic diarrhoeal states, Patients with chronic diarrhoeal states,

pathological fractures, osteoporosis, gout, UTIspathological fractures, osteoporosis, gout, UTIs– Any patient with cystine, uric acid, or struvite Any patient with cystine, uric acid, or struvite

(infection) stones(infection) stones– All childrenAll children

Medical ManagementMedical Management

Low risk patients should have evaluation of Low risk patients should have evaluation of – Serum calcium, uric acid and phosphateSerum calcium, uric acid and phosphate– 24 hour urine pH, oxalate, phosphate, uric acid 24 hour urine pH, oxalate, phosphate, uric acid

and calciumand calcium– Single urine sample for cystineSingle urine sample for cystine

ConclusionsConclusions

The Investigation and modern management The Investigation and modern management of urinary stones, though challenging, has of urinary stones, though challenging, has been transformed by recent technological been transformed by recent technological advancesadvances

ESWL remains the initial treatment for ESWL remains the initial treatment for most stonesmost stones

Overall success rates for stone treatments Overall success rates for stone treatments are very goodare very good

ConclusionsConclusions

The management of stones in pregnancy The management of stones in pregnancy remains a challenge to the Urologistremains a challenge to the Urologist

Limited metabolic evaluation is worthwhile Limited metabolic evaluation is worthwhile in the majority of patientsin the majority of patients