Management Of Ureteric Stones: An update BY Ahmed A. Shokeir, MD, PhD, FEBU Professor of Urology From Urology & Nephrology Center, Mansoura - Egypt Shokeir A.A. Management Of Ureteric Stones: An update Update of diagnosis Update of treatment Special situations Children Pregnancy Shokeir A.A. Management Of Ureteric Stones: An update Update of Diagnosis Shokeir A.A. Diagnosis Of Ureteric Stones Traditional Methods: History and clinical examination KUB Gray-scale US IVP Recent Methods (revolution) Doppler US (RI, ureteric jets) Noncontrast CT Others less common method: MRI Renogram Shokeir A.A. Clinical Diagnosis of Ureteric Stones Renal Colic History Colicky pain from the loin to the groin Haematuria Gastro-intestinal symptoms Site of referral: Upper ureter Mid ureter Lower ureter Shokeir A.A. Accuracy of Clinical Diagnosis Haddad et al (Radiology, 1992) Riyadh Armed Forces Hospital Sensitivity: Specificity: Overall accuracy: Shokeir A.A. 73% 46% 70% Diagnosis of Ureteric Stones Clinical Scoring System Eskelinen et al, (Euro Urol. 1998) The most significant predictors of acute renal colic are: 1. Acute abdominal pain with short duration ( 12 h) 2. loin or renal tenderness 3. Haematuria (RBC > 10 /HPF) Shokeir A.A. Diagnosis of Ureteric Stones KUB Of limited value (sensitivity 45- 59%). Limitations: Superimposed bowel and bone Non- opaque calculi Vascular calcifications (phleboli) Not sufficient alone to diagnose stone disease. Shokeir A.A. Diagnosis of Ureteric Stones Ultrsonography (US) Advantages: Non- invasive Quick Portable Repeatable Relatively inexpensive No ionizig radiation No contrast material Attractive in pregnancy Attractive in renal impairment Shokeir A.A. Diagnosis of Ureteric Stones US Conventional (gray scale US): Direct role: visualization of stones Indirect role: pyelocaliectasis Doppler US: Resistive index Ureteric jets Shokeir A.A. Diagnosis of Ureteric Stones Gray- Scale US Direct Role : (Visualization) Pelvis &calyx PUJ Difficult TRUS &TVUS Shokeir A.A. Diagnosis of Ureteric Stones Gray- Scale US Indirect Role: (Pyelocaliectasis) False negative: 20- 30 % False positive: Pyelonephritis. VUR Residual dilatation. Overdistention of the bladder. Shokeir A.A. Diagnosis Of Ureteric Stones Doppler US RI Definition: (Peak sys. Velocity – Peak diast. Velocity) / Peak syst. velocity Relation to obstruction: RI Values diagnostic of obstruction: Chronic: RI 0.70 Acute: Shokeir A.A. RI 0.04 DUS in Renal Colic Role of RI British journal of urology (1997). 80.195-200 Review Resistive index in obstructive uropathy A.A SHOKEIR, A. P. PROVOOST† and R. I. M. NIJMAN __________________________________________________________________________________________________ BJU International (1999).84.249-251. Resistive index in renal colic: the effect of nonsteroidal antiinflammatory drugs A.A SHOKEIR M . ABDULMAABOOD. Y. FARAGE and H. MUTABAGANI ____________________________________________________________________ BJU International (1999).83. 378- 382 Resistive index in renal colic:a prospective study A.A SHOKEIR and M . ABDULMAABOOD Shokeir A.A. Diagnosis Of Ureteric Stones RI In Pregnant Women Shokeir et al, Urology, 2000 RI is a sensitive and specific test that can replace IVP in the diagnosis of acute unilateral ureteric obstruction in pregnant women Shokeir A.A. DUS in Renal Colic: Role of RI Shokeir A.A. Diagnosis Of Ureteric Stones Doppler US Ureteric Jets Patent ureter: normal jet Complete obstruction: no jet Partial obstruction: low level jet that is asymmetric to the other ureter Shokeir A.A. DUS In Renal Colic: Ureteric jets Shokeir A.A. Diagnosis Of Ureteric Stones Doppler US Ureteric Jets Disadvantages: No objective parameters for measurement. Time consuming. Current Indications: Pregnancy Shokeir A.A. Diagnosis Of Ureteric Stones Role of Noncontrast CT (NCCT) Smith et al “Radiology 1995” Sensitivity: 98% Specificity: 100% Shokeir A.A. Diagnosis Of Ureteric Stones NCCT Advantages No contrast Visualize small radiolucent stones that may not be seen in IVP Very fast (5 min) Can identify other urinary and non urinary abnormalities to direct further imaging and management Shokeir A.A. Diagnosis Of Ureteric Stones NCCT Interpretation Regardless of composition, all stones are visible on NCCT Secondary NCCT signs of ureteric obstruction are: Ureteric and renal dilatation Stranding of the perinephric fat Perinepheric collection Soft tissue ring sign Pale-kidney sign Shokeir A.A. NCCT Shokeir A.A. NCCT Shokeir A.A. NCCT Shokeir A.A. Diagnosis Of Ureteric Stones NCCT Potential Pitfalls Pelvic phleboli: can mimic ureteric stones. Gonadal vein: can be confused with a dilated ureter. Shokeir A.A. NCCT Shokeir A.A. Diagnosis Of Ureteric Stones NCCT Disadvantages No evaluation of renal function. No evaluation of urothelium. Expensive. High radiation limiting its use in pregnancy. Not universaly available. Shokeir A.A. Diagnosis Of Ureteric Stones NCCT VS RI Shokeir et al, J Urol, 2001 Patients and Methods 109 patients with acute flank pain Subjected to: NCCT DUS: IVP: RI 0.04 gold standard Shokeir A.A. Diagnosis Of Ureteric Stones NCCT CT VS RI Shokeir et al, J Urol, 2001 Results NCCT RI Sensitivity: 98% 92% Specificity: Overall accuracy: 100% 99% 100% 96% Shokeir A.A. Diagnosis Of Ureteric Stones Noncontrast CT VS RI Shokeir et al, J Urol, 2001 Conclusion Both NCCT and RI are sensitive and specific in the diagnosis of acute ureteric obstruction.They can replace IVP particularly in situations where IVP is undesirable. Shokeir A.A. Diagnosis Of Ureteric Stones Role of IVP Previous gold standard Current indications: IVP is no longer the primary investigation in patients with suspected renal colic, however, it is still indispensable if endoscopic or open intervention is decided. Shokeir A.A. Other Methods of Diagnosis of RenalColic MRI Provides anatomical and functional information (alternative to IVP). No ionizing radiation (pregnancy , adolesence, children). No nephrotoxic contrast. Promising results. Studies are few. Limitations : Shokeir A.A. Expensive. Not universally available. IVP MRI Shokeir A.A. Other Methods of Diagnosis of Renal Colic Renogram Provides anatomical, functional urodynamic data of each kidney It has not gained much popularity Limitations: and Expensive Using radioisotopes and ionizing radiation The results depend upon differential variables Shokeir A.A. Flank pain Clinical evaluation Suggestive of stone disease Nonsuggestive of stone disease KUB , US & DUS Stone present Stone absent Stone present NCCT Stone absent Plan treatment Shokeir A.A. Further work-up assuming stone disease is absent Management Of Ureteric Stones: An update Update of Treatment Shokeir A.A. Factors Affecting Treatment of Ureteric Stones Stone Urinary tract Patient Hospital Doctor Shokeir A.A. Ureteric Divisions Upper Middle Lower Proximal Distal Shokeir A.A. Methods Of Treatment Conservative ESWL Ureteroscopy PCNL Laparoscopy Open surgery Shokeir A.A. Conservative Management Chance Of Spontaneous Passage < 5mm 5-10 mm Proximal Distal Shokeir A.A. 29-98% 71-98% 10-53% 25-53% Conservative Management Prediction Of Spontaneous Passage More likely Small Distal Right side Less likely Big Proximal Left side Shokeir A.A. Conservative Management Average Time To Spontaneous Passage mm ≤2 days 8 ≤3 4-6 12 22 > 2 months → No spontaneous passage Shokeir A.A. Conservative Management Renal Function General trend Short-lived, partial obst. → no long-term irreversible damage. Holm-Nielsen et al 1981 Obst. > 4 week → irreversible damage in 1/3 patients Irving et al 2000 Renogram after 1 month → loss of at least 5% of renal function in 52% of patients Shokeir A.A. Lines Of Conservative Management 1. Pain relief. 2. Watchful waiting. 3. Role of antispasmodics. 4. Role of hydration. Shokeir A.A. Lines Of Conservative Management 1- Pain Relief Traditional: Morphine and pethidine Recent: NSAIDs Other methods: Intranasal desmopressin Acupuncture Shokeir A.A. Lines Of Conservative Management 1- Pain Relief NSAIDs In Renal Colic Mechanism of action Arachidonic acid COX xxx NSAIDs PGs Intrapelvic pressure RBF Diuresis Shokeir A.A. Lines Of Conservative Management 1- Pain Relief NSAIDs In Renal Colic Advantages Provide the same degree of pain relief as narcotics. Avoid the complications of narcotics (addiction, respiratory depression, mental changes, constipation). Shokeir A.A. Lines Of Conservative Management 1- Pain Relief NSAIDs In Renal Colic Disadvantages Decrease RBF by 35% Consider renal function Shokeir A.A. Lines Of Conservative Management 1- Pain Relief NSAIDs In Renal Colic Routes of administration IV, IM, Rectal, Oral, Sublingual. IV indomethacin is more effective than IM diclofenac. Rectal route is less effective than parentral route. Oral diclofenac prophylaxis prevents new episodes of renal colic. Sublingual piroxicam is as effective as parentral diclofenac. Shokeir A.A. Lines Of Conservative Management 1- Pain Relief NSAIDs In Renal Colic Types of COX Cox- 1: Present in all cells. Constitutively expressed. Its inhibition gives the gastric and renal side effects. Cox- 2: Present in certain cells only. Responsible for inflammation. Its inhibition provides therapeutic effect. Shokeir A.A. Lines Of Conservative Management 1- Pain Relief Intranasal desmopressin (minirin) (El Sherif et al, J Urol. 1995 “Qatar”) It causes significant decrease in renal colic. Mechanism is uncertain: ?antidiuretic ?relaxation of smooth muscle ?central analgesic effect It needs further studies Shokeir A.A. Lines Of Conservative Management 1- Pain Relief Acupuncture (Lee et al, J Urol, 1992) Common in China. As effective as conventional analgesics. Mechanism is uncertain ? Increased level of endogenous opiates which may modify sensory afferent impulses. Shokeir A.A. Lines Of Conservatives Management 2- Watchful waiting KUB + Us → every 2 weeks. Intervention → 4-6 weeks. Shokeir A.A. Lines Of Conservative Management 3- Role of Antispasmodics Not recommended. Ureteric peristalsis needs to be encouraged and not discouraged. Shokeir A.A. Lines Of Conservative Management 4- Role of Hydration Conventional teaching → push fluids?? Not logical: Diuresis + obstruction → ↑ ↑pressure →: ↓ ↓ peristalsis → no stone passage. ↑ ↑ pain. Shokeir A.A. When To Stop Conservatives Management 1. 2. 3. 4. 5. Infection (fever, tachycardia, leukocytosis). Intractable pain > 72 hours. Stasis of the stone (4-6 weeks). Renal functional impairment. Socioeconomic reasons. 6. Patient’s desire. Shokeir A.A. Methods Of Treatment Conservative ESWL Ureteroscopy PCNL Laparoscopy Open surgery Shokeir A.A. ESWL Success Rate (%) Proximal ureter ESWL In situ ESWL ESWL, with push-back ESWL, with ureteric stent ESWL, overall ≤ 1 cm 87 77 83 84 > 1 cm 76 65 76 72 Distal ureter ≤ 1 cm > 1 cm 85 76 No data No data 83 68 85 74 Shokeir A.A. ESWL Role Of Stent General consensus Does not improve the results (↓ motility). Indications Solitary kidney. Severe degree of obstruction. Shokeir A.A. ESWL Overall Experience Advantages Effective Non- invasive Anaesthesia – independent First line treatment in most cases Disadvantages Time consuming (several sessions + symptoms) Operator- dependent Machine- dependent Shokeir A.A. Methods Of Treatment Conservative ESWL Ureteroscopy PCNL Laparoscopy Open surgery Shokeir A.A. Ureteroscopy Technical Advances Types: rigid, semirigid, flexible 4 - 9.8 F. Dilatation: 1/5 with 7.5 F. Anesthesia: ?? sedoanalgesia with small instruments. Hospital stay: ?? day-care setting. Shokeir A.A. Ureteroscopy Ureteric Stenting Routine stenting Not necessary Disadvantages ↑ ↑ operative time. ↑ ↑ symptoms (flank pain, LUTS). ↓ ↓ quality of life. Indications Difficult cases Prolonged procedures Shokeir A.A. Ureteroscopy Methods Of Stone Extraction Mechanical: Dormia, Forceps. Intracoporeal lithotripters US Preumatic (lithoclast) EHL Ho: YAG laser Shokeir A.A. Ultrasound Mechanism: piezoelectrically generated fragmentation. US waves evoke mechanical stone Probe: rigid, reusable. Ureteroscope: rigid, semirigid. Stone-free rate: 70 – 97%. Safety: heat effects possible when irrigation speed is too low. Disadvantage: not flexible. Shokeir A.A. Pneumatic Mechanism: compressed air-driven propelling metal projectile in handpiece evokes mechanical stone fragmentation. Probe: rigid and recently flexible, allow suction. Ureteroscope: rigid, semirigid, flexible. Stone-free rate: > 90%. Safety: mechanical perforation by direct contact. Disadvantage: stone migration, needs fixation of the stone by basket. Shokeir A.A. Electrohydraulic Mechanism: electric spark produces a plasma bubble and hydraulic shockwaves. Probe : flexible, life 30 sec. Ureteroscope: rigid, semirigid, flexible. Stone-free rate: > 90%. Safety: perforation by plasma bubble and heat effects possible. Disadvantage: higher risk of ureteral injury. Shokeir A.A. Ho: YAG laser [state of the art] Mechanism: photothermal effect Probe : flexible , reusable. Ureteroscope: rigid, semirigid, flexible. Stone-free rate: - 97% in single session. - 100% in staged sessions. Safety: - Heat effects possible. - Minimal tissue penetraction (0.5-1.0 mm). Disadvantage: cost Shokeir A.A. Ureteroscopy Overall Experience Success rate: > 90% Complications: Short-term: < 5%. Long-term: None. Shokeir A.A. ESWL Vs Ureteroscopy Ureteroscopy Stone-free rate Time of treatment Complication rate Anesthesia Cost Shokeir A.A. ESWL Lower Longer Low Usually No Lower Higher Shorter Low Usually Yes Higher Methods Of Treatment Conservative ESWL Ureteroscopy PCNL Laparoscopy Open surgery Shokeir A.A. Laparoscopic Ureterolithotomy Centers capable of laparoscopy are also the same centers that show excellent results for less invasive modalities. This, together with the learning curve associated with laparoscopy, is likely to restrict the overall expansion of this approach. Shokeir A.A. Open Ureterolithotomy Rarely indicated manouever. Indicated in as a primary Complications of other methods of stone removal Associated pathology e.g. ureteric stricture. Shokeir A.A. Management Of Ureteric Stones: An update Special situations Children Pregnancy Shokeir A.A. Ureteric Stones In Children Special Considerations Larger stones will pass easily through the ureter. Stenting prior to ESWL is not recommended. ESWL is not recommended in girls (damage of ovarian germ cells). ESWL requires anesthesia more frequently. Shokeir A.A. Ureteric Stones In Children Treatment Options Spontaneous passage is more frequent. 4 F pediatric ureteroscopes + laser→ safe & easy ureteroscopy As ESWL requires anethesia, the need to ensure success after one intervention favours ureteroscopy Shokeir A.A. Stones In Pregnancy Physiological Considerations Factors promoting stone formation Hypercalciuria Hyperuricosuria Factors inhibiting stone formation ↑ ↑ Urinary citrate ↑ ↑ Urinary magnesium Physiological respiratory alkalosis→ alkaline urine Net result Balance between opposing factors. The incidence of stones in pregnancy is not significantly different from that in nonpregnant women. Shokeir A.A. Stones In Pregnancy Physiological Consideration The physiological dilatation of the upper urinary tract particularly on the right side may provoke diagnostic confusion. Shokeir A.A. Stones In Pregnancy Diagnosis 1. Gray-scale US Not reliable because of physiological dilatation. 2. Doppler US Δ RI is of great help. 3. Three-shot IVP ? Radiation exposure? 4. Ureteroscopy Combines diagnostic accuracy and therapeutic potential. Shokeir A.A. Stones In Pregnancy Management Treatment Of Renal Colic: Opiates are the safest analgesics. NSAIDs should be avoided. Shokeir A.A. Stones In Pregnancy Management Most ureteric stones will pass spontaneously. Active management: ESWL is contraindicated. PCN and JJ stents→ encrustation (hyper calciuria) → change at 12-week interval. Ureteroscopy is the best. Shokeir A.A. Stones In Pregnancy Management Ureteroscope Shokeir, BJU, 1998 Rigid ureteroscopy is a safe and reliable method in the diagnosis and treatment of ureteric calculi during pregnancy Shokeir A.A. Harvest I IVP is no longer the primary investigation in patients with suspected renal colic, however, it is still indispensable if endscopic or open intervention is decided. KUB and US with Doppler assistance are the procedures of choice in patients with history of stone disease. Shokeir A.A. Harvest II NCCT is the investigation of choice in patients with no history of stone disease or those with atypical symptoms. DUS is of particular importance in pregnant women with suspected renal colic. Shokeir A.A. Harvest III NSAIDs are as effective as pethidine and morphine in the relief of pain, however, clinicians should be aware of renal function. 80 % of ureteric stones causing renal colic will pass under conservative treatment. If intervention is decided ESWL ureteroscopy are the treatment of choice. Shokeir A.A. or Shokeir A.A.