Another unfortunate stone former!

Rajiv Puri Consultant Urologist Nuffield Healthcare Leeds Hospital & The Yorkshire Clinic

1. Pain Renal Ureteric Vesical Testicular Referred

Renal Pain and Ureteric Colic

Pain Testicular Referred

Painful Scrotal Swelling

Diagnosis

Differential Diagnosis Musculoskeletal Appendicitis Cholecystitis Diverticulitis Testicular torsion Gynaecological problems Leaking aortic aneurysm >60 years Pyelopnephritis

That’s an easy diagnosis!

LUTS Storage * Frequency - dysuria * Nocturia * Urgency * Urge incontinence * Feeling of incomplete bladder emptying

Which of these is haematuria?

Who forms stones? People who live in warm climate People who work in warm climate Obese Metabolic disorders Previous stone formers 30-40% Those who drink less – so produce less urine -1L vs >2L

Risks Lifetime Risk 12% Male 6% Female Peak yrs 3/1000 per year Seasonal variation

Urinary Tract Stones 90% radio-opaque (except urate & cystine) Male - usually metabolic Female - may be associated with infection CUPOX

Management Absolute indications for emergency referral to A&E Unsure about diagnosis Poor pain control Significant fever >37.5 C with renal pain Single kidney/transplanted kidney/ poor renal function/bilateral stones Delay in investigation or urology referral Travel / Occupation

Investigate and Treat in community Usually recurrent stone formers Urine dipstick and MSU Heamaturia Rule out UTI Blood Tests U&E/FBC ? S Ca, Uric Acid

Treat in community Pain Relief NSAID – Diclofenac Opiods – Not Pethidine as associated with higher incidence of vomiting

Medical Expulsive Therapy MET or Expectant managament Alpha blockers – Tamsulosin Side effects Warning for females in child bearing age Nifedipine

Imaging Which Non Contrast CT Scan KUB and USS How soon Within a week See Urologist within 2 weeks How often

Which stones will pass and how soon ? < 5mm – 80% will pass, specially in lower ureter 5-10 mm depends on location - 47% > 10 mm unlikely to pass spontaneously Six weeks is a reasonable time for stones to pass, if still there requires intervention/ expert care

AUA /EAU Ureteral Stone Guidelines Panel

AUA /EAU Ureteral Stone Guideline Panel

Management Absolute indications for emergency referral to A&E or Urology Department Poor pain control Significant fever >37.5 C with renal pain Delay in urology referral Non progression of stone

“If the only tool you have is a hammer... then you tend to see every problem as a nail” A. Maslow

Ureteroscopic Stone Fragmentation

Flexible Ureterorenoscope Allows intrarenal visualisation, biopsies and stone fragmentation

Flexible ureterorenoscope to renal pelvis

Light Amplification by Stimulated Emission of Radiation

Extracorporeal Shock Wave Lithotripsy (ESWL) Now Storz Modulith electromagnetic membrane no GA mobile

Percutaneous Renal Stone Surgery Make a track via loinInspect, fragment and remove stone pieces

PCNL: Disadvantages compared to open surgery staged procedures often required increased level of endoscopic skill learning curve complications (rare) = catastrophic expen££e (capital for equipment, video, laser, special scopes, etc)

Laparoscopy/ Robotic Larger Stones >15 mm Failed URS / ESWL

Prevention Fluid intake or monitoring urine output Dietary advice

How do you find a urologist? Choose and Book Through GPWSI service NHS referral