Category: Clinical Stones: Outcomes
Introduction & Objective :
Following External Shockwave Lithotripsy (ESWL), Flexible Ureterorenoscopy (fURS) or Percutaneous Nephrolithotomy (PCNL) some patients will have small residual stone fragments, often termed Clinically Insignificant Renal Fragments (CIRFs). Small renal stones may also be identified either incidentally or following an episode of acute ureteric colic. There is currently little evidence to guide the longer term management of small renal stones and it is likely that there is significant heterogeneity in national and international urology practice. Therefore our aim was to sample current endourological management of small renal stones in the UK.
A bespoke questionnaire based on 5 clinical scenarios of a patient with a single renal stone ((i) incidental stone, (ii)stone after resolved ureteric colic, (iii)CIRF after ESWL, (iv)CIRF after fURS (v)CIRF after PCNL) was given to the 114 delegates at the Endourology Section meeting of the British Association of Urological Surgeons in September 2017. Questions related to; timing and length of follow up, additional treatment and imaging modality used. There were 41 responders (36%). Of 36 who provided occupation, 34 were consultants and there was a wide geographical spread of represented urological centres. 76% stated that over half of their workload was endoluminal endourology.
Urologists were more likely to immediately discharge patients with a single incidental stone or renal stone after resolved ureteric colic (22% and 18% respectively) compared to CIRF’s after treatment (ESWL 2.8%/fURS 11%/PCNL 5.4%). There was heterogeneity in length and interval of follow up (table 1). Follow up imaging modality also varied (xray: 50-62%, USS: 28-38%, CT: 16-24%). Increasing stone size when under surveillance or a younger patient age increased the likelihood of longer surveillance or intervention.
Whilst appreciating the bluntness and lack of validation to our questionnaire, it is apparent that there is indeed significant variation in the management of small renal stones amongst consultant endourologists in the UK. Outpatient review appointments for renal stones constitute a significant workload and financial burden on urology units. Further work is clearly required to identify optimal discharge patterns, follow up protocols and guidelines.
Alistair Rogers– Newcastle upon Tyne, England, United Kingdom
Ben Grey– Consutlant Urological Surgeon, Manchester, England, United Kingdom
Hannah Doyle– BAUS events manager, London, England, United Kingdom
Oliver Wiseman– Urologist, Cambridge University Hospitals, Urology, Cambridge, United Kingdom, CAMBRIDGE, England, United Kingdom
Daron Smith– Consultant Urological Surgeon, Stone and Endourology Unit, Institute of Urology, University College London Hospitals NHS Foundation Trust, London, England, United Kingdom
Cambridge University Hospitals, Urology, Cambridge, United Kingdom
CAMBRIDGE, England, United Kingdom
Oliver is a Consultant Urologist based at Cambridge University Teaching Hospitaks NHS Trust Cambridge, UK. He specialises in the treatment of kidney stones, their metabolic management and in the devlopment of patient reported outcomes for stone disease. He runs a number of training courses teaching stone surgery, and has been invited to operate and lecture nationally and internationally on stone disease.
He qualified in Cambridge and following basic surgical training, he underwent specialist training in urology in London, including at Guys Hospital and UCLH ("The Institute of Urology"). He has published widely including articles relating to the management of patients with renal stone disease.
He is a trustee of BAUS, honorary treasurer elect of BAUS, a member of the BAUS Section of Endourology Committee, and on the Endourological Society Awards and Medals Committee. He is training program director for Urology for the East of England.
Consultant Urological Surgeon
Stone and Endourology Unit, Institute of Urology, University College London Hospitals NHS Foundation Trust
London, England, United Kingdom
Daron Smith is a consultant urological surgeon at the Institute of Urology at University College Hospital. His practice is "endoluminal endourology" and encompasses the comprehensive management of Urinary Tract Stone disease, and includes the endourological management of ureteric obstruction, ureteric injuries, and the endoscopic diagnosis and management of upper tract TCC. He is the vice-chairman of the BAUS Section of Endourology, having been its Secretary from 2015-17 and a committee member since 2013, is the Consulting Editor on stone disease for the BJUI and the deputy editor of the Journal of Endoluminal Endourology