1. Another unfortunate stone former!

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

3. 1. Pain Renal Ureteric Vesical Testicular Referred

4. Renal Pain and Ureteric Colic

5. Pain Testicular Referred

6. Painful Scrotal Swelling

7. Diagnosis

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

9. That’s an easy diagnosis!

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

11. Which of these is haematuria?

12. 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

13. Risks Lifetime Risk 12% Male 6% Female Peak 40-60 yrs 3/1000 per year Seasonal variation

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

15. 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

16. 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

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

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

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

23. 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

24. AUA /EAU Ureteral Stone Guidelines Panel

25. AUA /EAU Ureteral Stone Guideline Panel

26. 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

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

30. Ureteroscopic Stone Fragmentation

31. Flexible Ureterorenoscope Allows intrarenal visualisation, biopsies and stone fragmentation

32. Flexible ureterorenoscope to renal pelvis

33. Light Amplification by Stimulated Emission of Radiation

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

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

40. 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)

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

42. Prevention Fluid intake or monitoring urine output Dietary advice

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