George Fowlis

BSc(Hons)Yale FRCS(Eng) MD FRCS(Urol) FEBU

Consultant Urological Surgeon
Independent Practice, London UK
Š Most painful urological disorder.
Š ↑ incidence in renal stone disease.
Š ↓Age of onset of symptomatic stones
Š Peak incidence: 30s-40s(previously 40s-50s)
Š 1.6 male : 1 female. (3 :1 in 1975).
Š Life-time risk
ƒ 10% in UK, 15% in USA, 20% in SA,
Š Recurrence rate
• 10% at 1yr, 35% at 3yrs & 50% at 5yrs
Š Asymptomatic stones
Š Treatment of symptomatic renal, ureteric &
bladder stones
Š Acute ureteric colic
Š Rigid & flexible ureterorenoscopy
Š Bladder procedures
Š Advances in stone management
Š New endourological management options
Š 77% of untreated asymptomatic stones will
lead to complications, a quarter will require
surgery due to persistent severe pain or kidney
blockage

J Endourol 2004 Aug; 18(6):534-9

Š ESWL

Š Flexible ureterorenoscopy & laser stone

removal (FURS)

Š Percutaneous nephrolithotomy (PCNL)

Š Dornier studied effects of
shock waves on tissue 1969
Š Dornier HM3 Lithotriptor
1980
Š FDA approval 1984
Š Non-invasive first line Rx for
stones < 2cm
Š Overall stone-free rates were
76% (RP), 69% (UC), 68%
(MC) and 59% (LC)
Š 2nd and 3rd generation
lithotriptors more user-
friendly
Š Efficacy not surpassed HM3
Š Higher stone recurrence rate
in ESWL compared to PCNL
Š ESWL 22% and PCNL 4% at 1
year
Š ESWL success can be
predicted by stone
density measured on
non-contrast CT
KUB

Š CT Hounsfield unit
> 1000 suggest very
hard stone and
ESWL failure
Š 1964 Marshall 3mm fibrescope passed
transurethrally via a 26F cystoscope into ureter
Š 1971 Takagi 2mm flexible ureterosocpe 75cm
long & 2.5 cm angulating tip
Š Modern day digital fibreoptic imaging bundle,
working channels and dual-direction active
deflection
Š Holmium laser
Š Tipless baskets
Š Access sheaths
Š Visualisation of
intra-renal collecting
system
Š Laser disintegration
of kidney stones
Š Laser widening of
pelvi-ureteric
junction obstruction
Š Laser treatment of
upper tract TCC
Š 19th century, not acceptable to operate directly
on kidneys
Š Conservative measures include ostrich egg
shell & scorpion oil
Š 1879 Heinecke Pyelolithotomy
Š 1881 Nephrolithotomy
Š 1976 Fernstrom Percutaneous access
Š 1980 Wickham & Kellett, Alken PCNL
Š Treatment of large kidney
stones, dilated PC system
Š Lower pole renal stones
Š Calyceal diverticulum
Š PUJ or ureteric obstruction
Š Ileal conduit, neobladder
Š Stone-free in single op
Š Large upper ureteric stones
Š Encrusted stent
Š Large prostate, rapid
encruster
Š Size (mm) ESWL PCNL p value

Š 0-10 67% 100% 0.017

Š 11-20 21% 92% 0.0001
Š 21-30 14% 100% 0.033
Š Overall 35% 96% <0.001
Š Encrusted Double-J stent
Š Combined
Cystolitholapaxy,
laser ureterolithotomy
and PCNL
Š Swiss Lithoclast Master
reduced operating time
by half
Š Analgesia - Diclofenac 100 mg pr and/or
Pethidine and antiemetic
Š Alpha-blocker eg. Tamsulosin 400 µg od
?increases spontaneous stone passage rate by
29% (Medical Expulsion Therapy – MET)
Š Primary endoscopic laser ureterolithotomy
Š Emergency stenting and stent symptoms
Š Increasing use of CT
for diagnosis of
acute ureteric colic

Š CT useful in
planning for
treatment of
complex stone cases
Š Non-contrast CT KUB
Š Rapid diagnosis
Š No side effects of contrast
Š Abdominal abnormalities
Š Overall for stones in Proximal Ureter,
no significant difference b/t ESWL & URS

Š Proximal Stones <10mm, ESWL↑

Š Proximal Stones >10mm, URS sig↑

Š Distal Stones, URS↑ ≤10mm & >10mm(sig)

Š Mid Stones, ns between ESWL & URS (sig)

Š 1912 Hugh Hampton Young
Rigid cystoscope into
dilated
ureter
Š 1960 Invention of Rod-lens
system
Š 1977 Goodman 9.5Fr
paediatric cystoscope into
distal ureter in women
Š 1979 Wolf 23cm, 13 to 16 Fr
Š Traditionally open Š Images
cystolithotomy +/-
retropubic
prostatectomy
Š Cystolitholapaxy
+/- TURP
Š Lasertripsy
Š Bladder irritation
Š Urinary frequency
Š Painful micturition
Š Haematuria
Š Loin pain
Š Dipstick urine will
show WBC and RBC
Š Encrustation
Š Fibreoptics, digital cameras
and chip-on-tip
Š Imaging 3-D CT urogram
Š Smaller rigid ureteroscopes
4.5 Fr
Š Flexible ureterorenoscopes
Š Stone cone and nitinol
baskets
Š Holmium lasers
Š Rapid imaging & diagnosis CT or IVU
Š Multiple modalities to treat kidney stones
Š ESWL, Laser ureterolithotomy, Flexible renoscopy &
lasering, Percutaneous nephrolithotomy, Nephrostomy
tube insertion
Š Ability to respond to urgent / emergency cases
Š MDT approach
Š Prevention
Š Asymptomatic kidney stones should be treated
Š Alpha-blocker increase spontaneous stone
passage rate by 29%
Š Stone density can be measured by Hounsfield
unit (HU) on CT
Š HU > 1000 very hard stone and ESWL failure
Š Paediatric stone management
Š Renal sparing ureterorenoscopy to laser
remove TCC in ureter & collecting system
Š Ureteroscopic laser widening of PUJ
obstruction
Š Rendezvous procedure to manage ureteric
injuries and avoid open repair
Š Endoscopic laser removal of TVT bladder
erosion
Š Stone is merely a symptom of underlying
disease
Š Surgical intervention treat stones but do not
solve underlying disease or prevent stone
recurrences
Š MDT approach
Š Endoscopic laser vapourisation of upper tract
TCC
Š Endoscopic laser widening of PUJ obstruction
Š Flexible renoscopy and laser widening of
calyceal diverticulum & stone removal
Š Laser removal of eroded TVT into bladder
Š Rendezvous procedure for ureteric injuries
Š Nephroureterectom
y for upper tract
TCC
Š Endoscopic laser
treatment effective
and safe for low
grade TCC
Š Renal sparing
Air in kidney
 fistula

Air in ureter
Contrast in sigmoid

Leak in vagina