the modern management of stone disease

7/28/2019 The Modern Management of Stone Disease

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The Modern Management of Urinary

Stone Disease

Mr C Dawson

Consultant Urologist

Edith Cavell Hospital



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



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



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



Lithotrity

First performed by Jean Civiale - 1823

Sir Henry Thompson



Modern Management of Urinary

Stone Disease



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



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



Differential Diagnosis of renal

colic

Gastro-enteritis

Acute appendicitis

Diverticulitis

Salpingitis

Cholecystitis

Pyelonephritis

Ruptured Aortic Aneurysm



Initial Investigations

Dipstick testing of urine - confirms

haematuria in about 90% of patients.

Absence of haematuria should suggest other

possible diagnoses KUB +/- IVU



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



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



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



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



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



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



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



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




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




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



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



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



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



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



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



Conclusions

The management of stones in pregnancy

remains a challenge to the Urologist

Limited metabolic evaluation is worthwhile

in the majority of patients

the modern management of stone disease

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