Urologist Justin Ahn, MD, answers crucial questions on preventing and managing kidney stone disease – a condition affecting 10% of the U.S population, with young patients increasingly at risk. He presents keys to diagnosis, including imaging tips, and a thorough update on the many high-tech procedures available, describing how to make treatment decisions based on factors ranging from stone numbers and size to the patient’s health issues and lifestyle preferences.
So hi everyone, my name is Justin and I'm the new urologist uh with UCSF just finished my fellowship in july and I'll be back in the be practicing full time in the Peninsula Redwood City SAN mateo area. Um my specialization is in kidney stones and laparoscopy um, Bph surgery, but I'll be just basically doing general urology as well. Um, so this is meant to be a review updates sort of in kidney stone management and treatment and then just a little info about myself as I mentioned before. Um, so without further ado um, a lot of you already started participating this in this questionnaire. So if you are just logging in, um, I'm gonna have some a couple of questions just to keep just for sort of um viewer engagement during a couple of questions throughout my talk And so you'll be willing to be able to participate. You just have to go to this link. Right, sorry, get out your phone, text the message just not 6642. This number 22333. Um, a lot of you already had a chance to respond and I thought this is a good way to sort of break the ice with this talk um, to give you a sense of the relevance of kidney stones. Um, so actually, even here within this population we have a fair number of you have actually had kidney stones and most of you know, a lot of you have had a close friend or family member that have had kidney stones. Um, so thank you for doing that and we'll have some more questions as we go. Um So You got 10% of the us population over their lifetime is expected to have kidney stones. Um there's an increasing prevalence over the past 15 years. Um and uh and then we talk about its people think of kidney stones is just a one time event, but it's really a chronic disease. There's a 50% chance of recurrence of kidney stones in the first five years and it jumps up to probably closer to 80 and 10 years. Um It's a huge cost burden on the healthcare system. If you uh this was database and look at the most costly diseases uh for in urology and kidney stones is number two. Uh surpassing prostate cancer, Bph, other urethral issue, urinary tract issues. Um This equates to basically a lot of money, um potential morbidity, mortality and a lot of visits to you and to er s and things like that. Um So um life, the epidemiology is much more common in men than women. Uh caucasian more than other ethnicities all ages are affected. You know, we're seeing a higher prevalence in Children, especially older, like young older teenagers, younger adults with the kind of recording with the obesity and metabolic syndrome epidemic. Um It seemed more in the Southern and the hotter environments. So you can just call it the stone Belt, basically the Deep South, but basically, anywhere that it's hot and dry, hot and arid. Um we're going to see more kidney stones just because we think of dehydration as part of the play occupational exposures if they work in really hot environments. Um And we also tend to see a spike in kidney stones towards the end of the summer, early fall because of because of the weather conditions. And you can see here the bay Area is not spared. Um in this heat map, you know, in terms of being close to basically on the border of um high risk, high risk area for stones. Mhm. Um Common risk factors we talked about with patients are poor fluid intake, high oxalate are so bad diet, basically metabolic syndrome, diabetes, recurrent urinary tract infections play a significant role with infection type stone specifically Struve fight um sedentary lifestyle, especially if you're a wheelchair about or immobilized. You just resort lots of your bones, resort lots of calcium uh and anatomical abnormalities of the upper urinary track. So if you have um you know, some congenital abnormality or your public junction obstruction or things like that are abnormal anatomy, inflammatory bowel disease is not to be discounted can lead to significant acidosis. The body which in turn can have significant impacts on the urinary tract um Crohn's and ulcerative colitis. Um And um this is also not to discount the strong family disposition, all of genetic predisposition to when, you know, patients always ask me what's the most common type of stone, it's always by far most common If you're betting a if you're betting on it, it's going to be most likely a calcium oxalate stone, uric acid, Struve fight infection, stones. Those are all tend to be less common. Um, so, um, symptoms, you know, you think about the classic renal colic pain, you know, they can't find a comfortable position, they're riding around as opposed to a peritoneal abdomen where they're they're fine. If they sit still, you know, if they go over a speed bump or, you know, you push on their belly, it's really tender. But renal colic is, you can't, you're not comfortable at all in any position and it's just waves of pain, you know, described as as painful and more painful than childbirth. Uh, the pain is so severe, it causes nausea, vomiting blood in the urine, sometimes seeing microscopic or gross blood. Um, and then, um, you know, the class. The symptoms can range when you're passing a kidney stone. Um, you know, a single thing of flank pain, but it does tend to radiate around to the front. Has the stone migrates into the distal ureter, just because of the referred nerve pathways. And occasionally we'll see, I'll diagnose a patient with kidney stones, uh, with someone who has a groin or even I've seen men in labial or sorry, in women in labial pain or men with testicular pain, a deep groin pain that can be also from a distal stone. That's that's passing always important to ask about medical history, medications like we talked about A medical history from the prior slide. A strong family history always pretends a higher risk for recurrence. And um and I it's seen in about 40% of patients will have some family predisposition. Um um in terms of initial diagnostics, you know everyone gets your analysis red blood cells, you know you're always looking for microscopic or gross but you're not always going to see a positive red blood cells. So if you have high enough clinical suspicion don't discount a negative are you know blood or R. B. C. S. For you know that is not having not being inside of kidney stones. Um white blood cells or leukocyte estuaries essentially. That's just showing inflammation. It can be suggestive of infection especially with higher like if the white blood cell count is more than 100 range if it's like in the you know low fifties or you know in the low tens it tends to be just more related to inflammation. That literally the these the stone irritating the urinary tract nitrites in the analysis. I definitely look forward because that will tend to indicate there is some form of grand neg negative bacteria in the air and that is causing that chemical reaction. And then finally um I look at your NPH because that does pretend certain stone types higher ph like in the seven range or above. It tends to be calcium phosphate or Struve fight infection. Stones really low urine ph can be pretend uric acid stones. Um and then serum labs, the things we care about really are what is your renal function doing? You know what is currently in terms of G. F. Are creating and also what is your house it compared to your baseline? Do you have any underlying CKD and not much renal reserve? Are you solid? You know, are you, were you born with a solitary kidney? Those are important considerations. And then finally do you have any evidence of uranium or asked based abnormalities, electrode abnormalities such as your or your e mia signs that would warrant urgent intervention and then concerns about infection. You know, fever chills. I was checking a white blood cell count. But sometimes the response for the Lucas, ketosis can be delayed. And so the next step, you know, probably one of the most important for us is imaging. And I wanted to comment on each of those studies individually. K. U. B. Your plane filled abdominal X. Straight pros. It's really cheap. It's easy to obtain. You know, if you come to UCSF you don't need an appointment even um just walk in. But the cons is it's not very sensitive and you can see here that this huge strides stone is not trivial and you can see it pretty clearly. But you know here you can see a small like probably once 1.5 centimeter renal stone as well. Um But not all stones are radio opaque as we may have remembered from our medical trivia. Uric acid stones tend to our tend to be the classic ones we can't see on X ray. Um A lot of stones can be mixed composition too. So they're not purely uric acid or purely calcium oxalate. Um You also don't get any sense of functional enemy. So you can't access for obstruction hydra necrosis, which is one of the important things we want to factor in. So really K. U. B. X rays reserved for follow up patients with known radio opaque stone disease. You know, they get a CT scan with a scout that shows a scout X ray that shows a radio opaque stone. Then we'll just follow them with X rays. Um It also is used for assessing candidacy for specifically shockwave linda tripp see treatment because we use X ray targeting is the main way for main method for treating those stones renal ultrasound has become much more in vogue I think with consciousness about radiation exposure, um cumulative radiation exposure. And the nice thing is it can access we can assess basic brain anatomy. We can assess um for obstruction hydra necrosis limitations are you can't see the ureter basically the from the proximal ureter down the destroyer is sort of this black box that you can't really see. Um without a ct scan um missed the renal ultrasound. Gonna miss small stones, you know if there are one or two millimeters in size, it can also over call stone size frequently. And so you can see here that the classic what we to trying to measure is the actual shadow behind these stones is very indicative of the actual renal stone versus you know, you can see your brighter spots, psychogenic that don't have that shadow behind the stone. And same thing here, you can see a stone that's coming into the distal ureter. And here's the bladder. And you can see once again, there's this kind of shadow called the shadow sign behind the stone. Some sometimes we'll measure the shadow and that gives us a more accurate sense of the size. All that to say is that ultrasound? Sometimes radiologists can sometimes over call the size of stones by a couple of millimeters. Um It's also limited in obese patients. So obviously the more obese you are the limited, more limited ability for sound waves to penetrate and get a good diagnostic image. Um, so really the utility for ultrasound we see now that we're using is for screening for patients. So, if you have a, you know, if you have a patient you, you know, you want to just check out their kidneys in or you know, maybe a lower suspicion they have a stone. It's great. Just a screening measure. It also can allow you to assess the bladder prostate size. If you ask for, if you ask for it And also bladder emptying post word residual. Um Since they do the bladder and kidneys but with any ultrasounds nowadays. Um It's also great for surveillance. So patient with known kidney stones or a patient who's had stones and now we're just looking for recurrence. Um You'd like to get ultrasounds annually once a year and that will. Um So that's a great another tool, right? And also pediatrics, kids and also pregnancy is really our go to. Um So the next question for everyone is what radiation dosage is considered low dose for a cT scan uh for C. T. QB. So the classic no contrast cT scan you obtained for patients with kidney stones. Um You know, just to give you a reference plane. X ray is one millisievert standard CT scan. Um Non loan on low dose would be 10 to 15 millisieverts. And then a CT scan with contrast is probably closer to 15 to 20. So, I'll give you all about maybe 30 seconds to I'll put in your answers. Um And still working. So we see um appreciate everyone's participation and uh you will not be you will not be graded on this but don't worry, there's no credit for this, appreciate the engagement. All right. So um uh So it looks like everyone actually most of you picked the right answer. Um So looking at C. T. Scan, the answer was less than formula seabirds. Um there. Um So let's talk about C. T. Scan for a second and we can go back to that. Um the gold ct remains the gold standard has the best sensitivity over 90% sensitivity and specificity for detecting stones. It gives you detailed kidney and ureter oral anatomy unlike ultrasound. And it also allows us to assess stone density. Which is really important because for us surgical planning wise we want to know if it's a really hard stone or a really brittle soft stone. And that can also help. We can even sometimes predict what type of stone we're going to treat you based on the household units when we look at a CT scan. Um The cons is the radiation and that's why I bring up, you know, there's been a lot of concerns about cumulative radiation. And so we have moved towards doing low dose cT scans at UCSF. And we actually and so less than four million seabirds or even three is considered now the gold standard. If you order just a standard cT scan of the no loud contrast, you can be up to eight or 10 or it can be up to 10 or 15 minutes seabirds. Um So almost double or triple the dose. So I always make a habit when I order scan cT scans specifically for stones, I always say assess just for kidney stones, low dose protocol. Um And so that helps to prompt the radiologist that hey I don't need a, you know, I'm not looking for a small, you know, mass and in the colon. I'm just because you know, that we don't need that greater resolution to pick up kidney stones and it can significantly lower the cumulative dose A lot of these kidney stone patients get. Uh, in one, I think one study found that in with one kidney stone episode, the average patient just in a year can get up to three or four CT scans. Um, so it is significant. Um, and we actually did a study looking at how well low dose CT scans have been updated, uptake have been taken up at academic institutions here and several on the west coast. And it was only about 2030% of the time that patients get for kidney stone patients get a low dose scam or one that met that criteria. So we're really trying to push this and encourage the radiologists do as well. Um, you, so utility for CT scan is really for those first times don't work up patients. We want to get a big picture view of their anatomy. We also want to assess, uh, if they, if they had, if they were passing a stone, is it clear of the ureter, especially if, you know, if they didn't pass it or they, they don't have a stone in hand or they are not sure if they pass, they may be having some residual symptoms. We're going to get that CT scan to confirm because we don't want to make, we want to make sure that stone is not stuck there in perpetuity. It's also if you want to assess for other intra abdominal or public pathology, right? They come into the er er dog wants to rule out appendicitis, you know, diverticulitis, other things like that. Um But they usually can pick up with low dose scans to be honest, but that's that's the radiologist call. And then finally, for any patient, we're taking a surgery most of the time we want to have some pharmacy damaging. But like I said, if someone's had a cT image within the past year and I think an ultrasound is just fine for more updated imaging, there's no need to give them more radiation. Um So we talked about stone passage and the three places that it tends to get hung up, hung up is here at the urinal pelvic junction is the first road road block here at the as the ureter crosses the iliac vessels. Uh And then here finally at the urinal vesicles junction, because that's such tunnel through the wall of the muscular wall of the bladder. Um So once it makes its bladder that the stone is home free. And even studies have found that the more distal, the more distal the stone is at the time of the imaging, the more likely the chances of successful passage. So if you find someone who has a stone has already made it down here by the time they get their imaging, they're more likely to pass it. Which makes sense, I think. Um, so this is a rough decision making tree for what I'm thinking about whenever I see a stone and what hopefully you're thinking about as well. Um, so if someone has a kidney stone 1st, 1st of all I'm asking, is it in the ureter, the kidney, if it's in the kidney and now we have to decide if we're going to observe it based on size, location symptoms or treat. Um, if it's in the ureter now are asking, we have to make sure that stone gets out of there either by treatment or buy passage. So now based on size symptom and patient factors, we decide either one of these um, patient factors can be everything from how frail or morbid morbid risk of morbidity is they have, but I've also had patients who are, you know, didn't want to spend the time trying to pass a stone. Maybe they had a they live down in the middle of nowhere and couldn't afford to be near an er, or they were traveling and wanted to make sure that they were safe to be in an airplane and we're going to do to divert the flight. Um, so it's important to get that social history component. Um, let's talk about medical expulsion therapy. So really indicated for stones less than 10 millimeters uh, in, in patients who have well controlled symptoms right. They're tolerating the pain or discomfort with some Tylenol. Ibuprofen or Medicaid oral medications. They're hydrating. They have good renal functional reserve. Um You know they may have a mild bumping their creatinine but you know they're not know where they're nowhere. They have two healthy kidneys and you know they're nowhere near like you know fulminate Urania uh and also no evidence of infection. So I'm talking about is infection. Can is we'll talk about later. Is probably one of the biggest concerns emergencies we have in neurology for stones. Um Symptom control uh uh insides in Thailand or great toward all works is one of the probably one of the best medications that it's everything. It's what you know it's the only thing that er docs give and it has the best relief. So if you can give patient P. O. Or I am or even an I. V. Injection of it when they're having acute colic uh you will really help them out always just making being cognizant of their renal function because if they are not to give sort of chronic long term doses of it especially if they already have an A. K. I. Um narcotics. You know we try to limit those as much as we can. Uh anti medics as needed. Um This chart here shows why we why these white hat we have these numbers You can see that if the stone is less than five. There's over a 50% chance of it likely passing once it gets into the 67 millimeter range. Now your chances are significant going um tipping lower. Um and so that's where that's really why we use that as sort of a cut off for intervention. Um we say 5 to 6 millimeters. That's really the cut off where you should consider seeing a neurologist to consider treatment. Um um in terms of Flomax, you know, there's been a debate back and forth right now, the established dogma for urologists is that Flomax? Yes, it's relatively low risk and it doesn't have really much side effects. Maybe some mild hypertension. Um but it's the best, the most benefit that they've seen for it is in distal stones in the distal ureter. And also for a larger stone. So above, you know, six million above 56 mm in size. Um if you want to give it to patients with proximal stones or less than five, you know, I think It's not gonna hurt. And it's a relatively cheap medication. So um you know, if you asked 10 urologists in room five will tell you, yes, I will tell, you know. Uh and then finally, four weeks for trial of passage of the stone. Um I really don't. We always worry about chronic obstruction or stones getting lodged in the ureter, it causes this bad inflammatory response that can lead to your stricture disease. Um Long term issues and also affect renal function. We think that After about 4-6 weeks of unobstructed or partial obstruction even that you start to lose never Franz permanently. So we really want to get these patients evaluated counseled and also set up in case they don't pass their stones in that 4-6 week period. Um so next question for you guys is, what is the chance of an asymptomatic renal stone? So renal stone, not your edelstone under five millimeters requiring intervention over a five year period once diagnosed. So this is actually just a recent study that came out in 2020 by actually a Japanese group. Um but I think um same results. So To give you 30 10, 20 seconds for people to respond. Mm hmm. Okay, mm hmm. Good. Um so a common question I get asked by patients is doc my stone is, you know, is like that 54 millimeter. You know, what are the chances that this is going to cause problems in the future? You know, am I really safe to watch to keep it just to observe the stone and not treated. Um so, um, so the debt, the answer for that question was about 20%. Uh and um that was uh, you know, there's been a, there's a lot of the studies in the past are variable, depends on methods and there's some uh, you know, a lot of patients end up getting treatment anyway, even though because they're just nervous. They don't have hard indications. Um, but overall it tends to be about for under five millimeters. You're looking about a 20% chance of some sort of intervention or needing the stone treated um, above five millimeters that jumps up to probably 50% over five years. So I think that helps just to kind of frame things for patients. Um, you know, we really save the observation of stones for those that are asymptomatic. They're not causing any obstruction or blockage. So they're usually in the kidney, not in the ureter. Um, and, you know, and the patient's reliable. They know they're nearby to health care. They have access to healthcare. Um, right. I would not, you know, I would be much more proactive with someone who lived, you know, in the middle of nowhere or it was homeless or, you know, um, low socioeconomic status. Um, urinary tract decompression. Um, we think about really the hard indications for urgent decompression are having an irritable stone. And either infection compromised kidney function, which can also mean that they have a solitary kidney or intolerable symptoms. So nausea, vomiting pain, basically that's refractory oral medications, um, have some of the sickest patients I've seen with with acute kidney stones have been young, healthy patients. Again, their twenties or thirties who have some who have a urine infection with an obstructing stone. The problem is that the the because of the obstruction, you have all this trapped urine and then bacteria can get up into that system. And now you basically have you have it by definition and abscess because of trapped bacteria that then causes just under pressure and basically sees the bloodstream and causes a really horrible stepsister factory mia. So it's really important that patients are within signs of infection or that are risk for infection like HIV diabetes, very frail elderly. That we lean more towards some sort of intervention for them rather than conservative observation or trial of passage. Um The main they come in decompression comes in two flavors urinal stenting or an atrocity tubes. Um, they're both plastic and they're both temporizing. You know, we eventually do have to treat the stones. Um, so these are just what they look like. Um as you may have all likely familiar with, um just little pieces of plastic that can assure drainage of the kidney. Um, so next question is, how long can a typical plastic urethral stent or in a frost? Me to be left inside tube in the body? Yeah. Before needing to be removed or exchanged. Mm hmm. And I wanted to comment that when I talk about infection, I'm talking about, they don't necessarily have to have fevers and chills. If they have a positive your analysis with bacteria and nitrates. That's usually someone I'm not feeling as comfortable sending home or I want to make sure their home on antibiotics and they're reliable and they're gonna come right back to the hospital if they have symptoms, um infection is not just fevers, chills and classic, you know, piling arthritis symptoms. It can just be having some positive traits Questionable you a and, you know, being at risk for infection. So thanks everyone for responding. And uh 46% of you gotta. Right. So the answer is three months is the average that we can leave stones safe stents safely. Um for patients that help relieve chronic tubes in place, we can stretch that out. The reason that we don't leave tubes in for too long is this exact problem, basically, basically, n crusting calcifications that form on the stents. Um and so we start with about three months for the first interval changes. Some patients tend to form encrusted more fat more quickly on their stents, like uh immobilized wheelchair bound uh spinal cord injured patients. Um This is just a ct scan showing basically, this is a really bad case where essentially, you can't even see the curl this tent because it's the entire kidney has now formed this stone or um filling the entire kidney dialysis, and then there's also simultaneous to bladder stones um that I'm also formed from it. So this is kind of worst case scenario you can and really certain bad circumstances lead to, basically, I was having to remove the kidney. Um So don't forget about the stents. We do have, there are some, you know, for patients who do, well at three months, we will start to space them out for every four or five months. Um We even have metal stents or certain states. We can leave it up to a year for those chronic obstruction patients, like those um chronic hydro like in a really bad abdominal cancer patient. Um um So let's talk about treatments first and then we'll talk about the three. Just a brief overview, extra shockwave with the trips. He has been around for a long time. It's still a great morality. In my opinion. It's 2 to 3000 shocks. Ultrasound waves takes about 45 to 50 minutes. It's under general anesthesia done as an outpatient. It's nice. It's not invasive. You don't have to stick any cameras anywhere inside. Um It has the lowest complication rates. Um You know, um And um this is just a picture of what it used to look like. It's in this big bathtub. Um This is probably more accurate what the machine looks like. I can tell you that the patients are usually not this good looking and they also probably don't look this comfortable because it literally feels like you're getting hit by a four by four, you know, 1000 times, which is um so you're pretty sore. And that's why in the US at least we put patients to sleep for it. Um The cons of treatment are fragments are not necessarily, you have fragments have to pass on their own spontaneously. So there's an increased risk. You may need multiple treatments to fully clear out of stone. It's not great if you have more than two or three stones because you have to divide the shop, You can only shock the kidney so much you have to divide the shock some months multiple stones. Uh, it's not great in obese patients because the sound waves can't penetrate. All that tissue is great for skinny patients. Uh, and finally, it's contraindicated in pregnancy. We don't want to shock the baby. Um, the ideal patient for shockwave is really the single, you know, under 10 million, you know, maybe 10 millimeter or less stone. That's radio opaque because we used X ray targeting. Usually rarely ultrasound targeting in the kidney or upper mid kidney or approximately order by the way. The reason I say, upper mid kidneys, because the lower collects of the of the kidney tends to be an area where the fragments just pull and collect. They have to go up and over to pass. Um, so, you know, patient wants to ride a rollercoaster lay lay upside down for a couple of days. They can do that. Um, but lower chances of passage for lower pole stones. Um, or, you know, moving your generosity is the tried and true and is probably now the most common treatment for kidney stones surgically. Um, we use the home, we use a laser, we use a basket. We use this very small scope called the ureter scope. And we go in and we break the stone up into a bunch of pieces and we pull all the fragments and flush them out as best we can. Outpatient general anesthetic usually takes 1 to 2 hours. We do go through the natural world peace because there's no incisions, which is nice. It is both diagnostic and therapeutic. So we can visualize the year new tracks. We can also do biopsies. We can also see if confirm if they're actually stones or not. It was a false positive. The cons are as the stone size goes up. Um, you're the chances of being completely stone free after these procedures starts to go down. Um, and because we break the stone up in dementia fragments, you can't always get every single fragment out and we know that we're leaving behind residual fragments is potential notices for future stone regrowth. Uh and it's always, it's never fun to tell a patient. We didn't get all the stones, you still have some left over. Um, so risk. Also your instrument in the ureter. The ureter is a very fragile organ, writes five. It's about five in width and it's it's very easy to injure. So, repeat instrumentation can be a risk for strictures or injury to the injury. And finally, infection risk. Um, and finally, urinal stents, which we frequently will leave after temporary for five, you know, five days a couple of days or up to one or two weeks are a significant, significant source of morbidity, pain, urgency frequency, um material for patients after this. Um We call it the necessary evil and endo urology and in my field because it's assuring the kidney drains, but it causes a lot of a lot of discomfort for the patient. So the ideal patient figuras copy is really less than 10 in size in the ureter or the kidney or multiple small kidney stones. Um So now we get to the bigger guns, perpetrators, natural autonomy. This is going through a direct puncture through the back where we dilute we obtain access into the kidney with a needle and then we dilate up about an eight millimeter tracked. Used to be even a 30 french or closer to 10 or 12 millimeter tracked. In the past. We are have gotten smaller and then what having a bigger access track allows us to do is to put in is to use um more advanced, basically ultrasonic or ballistic drills that can basically break up the stones really quickly, large volumes and then suck out all the fragments at the same time. Um So it's a much more efficient and faster stone clearance rate. Great for those patients with much larger stone volumes. Um Otherwise we'd be doing your garage copy for for for days or weeks. Um repeat repeat treatments. Um It also avoids urinary instrumentation. So patients who have abnormal anatomy and the it's great. The cons or it's a little more invasive. It is a puncture through the back, directly into the most vascular organ by you know by weight I think. Um So bleeding risk is not insignificant. Um The patients spend a night in the hospital at least they usually we have temporary to frost me tube and it can be annoying because they have urine leaking out there back. Um And then we talked about risk. There is always small risk of lung or colon injury and then always small risk of bleeding. So the ideal patient for this is really those large stones, complete staghorn stones where you just gotta clear a lot of stone efficiently. Um So that being said um we are at UCSF trying to you know think of always moving the ball and being more advanced. Um And so this is I always think of this skip from one by Will Ferrell from SNL it's like this really tiny cell phone as we, you know, we're making a commentary on how small technology is becoming. Um But anyway we are that is the name of the game with your with with our field with endo urology we're trying to be less invasive and make everything smaller, less smaller incisions, smaller punctures. And so that's what mini or micro pc. Now it's almost considered a separate type of procedure. But essentially we're going through the back but with much smaller tracks. So 12 or 16 french which is like a 4 to 5 millimeter hole instead of an eight or one centimeter hole. Which can make a difference because it's you still get all the benefits of the pc. Nl where you get to get large volumes stone removal. Um But you have less risk of morbidity, shorter hospitalizations, quicker recovery times. Uh And also we don't have to leave tubes in these patients as often. Um So really this kind of helps to bridge the gap between those 10 and 30 millimeter stones. Um So we don't have, you know, poor stone free rates. Um But you know, we don't have the morbidity with the more aggressive piece of the larger piece and regular P. C. N. L. And this is just a photo highlighting um The one of the, one of the miniature per cutaneous you can see here. Um It's very fulfilling for us when we get these stones out of there just have these collection devices. But you can see here the difference in the track size, just relatively from conventional PCL versus the many that we now are able to offer patients. And then finally we're also using more ultrasound. We're trying to go less radiation less floral. Um So we are uh dr key here is really pioneered when my my fellowship mentor, it was really a pioneering ultrasound treatment. Ultrasound inter operative ultrasound use forgetting not only access but also the visualization the kidney and also for putting in a prostitute's ourselves if interventional radiology is not available. Um so we're actually able to go use do cases basically with minimal floral or even without any floral for a lot of these PCL cases and some your ferocity cases um like pregnant patients or kids. Um so other surgical approaches, these are more rare. Um laproscopic robotic removal is usually done in the simultaneous sense of if someone has a congenital abnormality, like a urinal public junction obstruction where we have to go in and do a reconstruction repair. These patients commonly also have kidney stones were removed. It will cut into the collecting system, move the stone and then also do the reconstruction of the obstruction Knaperek to me is the last really resort. We, you know, we try to avoid if we can. It's really for those patients with that have lost the renal function based on an arena graham nuclear medicine radiogram study. Uh and they're also symptomatic. They're having pain there, having infections. Um and really what this is all the this usually as a result of what we call silent hydrogen fibrosis. Basically the patients develop some form of mild obstruction. They may have some temporary flank pain or symptoms, but after a while the the pain seems to go away and the patient doesn't feel it anymore. So they have this chronic obstructive process where the stone is causing obstruction. They have hydro necrosis and they're not symptomatic from it. So they never seek treatment or they just discounted. Um and so this is why we talk about, you know, only really about waiting 4 to 6 weeks for patients to get their treatment. Don't sit on a on a urinal stone or you know, obstructing stone for you know, 2 to 3 months because this is our worst nightmare really of patients coming in and they already have a dead kidney. Um Um so let's um so just moving it now. This is you're asking, okay, this is how we treat manage stones. How can we prevent stones? So they don't have to do any of this in the first place. So we do uh metabolic evaluations um which we talk about. The goal really is still the gold standard is getting a 24 hour urine collection. We personally UCSF used the little link company which gives you patients all done by the male. Uh this and you send the patient doesn't have to bring their jug of urine into the lab to send a little alarm clock back to this lab in Chicago through the shipping. Um and it gives us this nice report card of kind of where they stand in terms of their kidney stone risk. Um So it's really nice. You can kind of custom time. We I tell patients to do at least one or 21 if not two of these first before we really make any changes to their diet or hydration or even medications because then it would abnormally affect their, you know, there was some observation bias where they know they're being obsessed and you know, we really want to assess what is their underlying predispositions. It's not perfect, but it's the best we have. Um Finally, a basic metabolic metabolic panel assessing for any signs of acidosis also. Um um serum calcium. If you think uh as a screening measures were looking out for primary hyperthyroidism, which is a great reversible cause of kidneys of hyper calc area or kidney stones. Um and para thyroidectomy essentially will cure someone cure someone from getting any more kidney stones. Not very common, but it was good to screen for it. Um And so if elevated calcium, we get api th and then finally, if any suspicions for uric acid stones, checking a serum uric acid. Um to see also if any, or if they have any history of gout. Um for uric acid type stones, interestingly, uric acid stones don't necessarily always correlate with high serum levels. It is mainly dependent on your nph, which I'll get to my next slide. Um So, diet wise, people always ask what should I be doing? So I tell everyone, drink 2 to 3 liters of fluid a day you really want. You know, patients, patients are like, okay, what is that? How many glasses? Well, just drink enough until, you know, basically don't make yourself happen to treatment and then drink enough so that your urine looks really clear or light colored. Don't you know, we don't want to really um uh concentrated, looking like orange or dark yellow. Try to limit your salt intake. Um You know very hard to do with an american diet. But we know that sodium uh increases calcium passage into the urinary tract. It drags calcium into there. So if if they have hyper calc area, I'm telling you really cut back on their sodium um limit your animal protein intake. Any sort of animal protein. You know my patients are like yeah doc I cut back on steak and I'm just having fish now and I'm like it's really any analytics. So eggs, chicken, eggs, um fish, um You know dairy products. Um The all these are really that's just causing more of an acid arctic state. Which is not great for kidney stones. Um We tell patients, you know, even increase your fruits and vegetables. That's all great. Great alkaline sources. Um and citrusy is a great way to do that. We dr stoller here, published on orange juice, but also, you know, lemon juice. Um And there are we also prescribed medications for that too. Um A lot of patients stay here. I have calcium, oxalate stones, I should be taking, I should be cutting back on my calcium. And we've actually studies have actually shown that if you limit your calcium, you're actually going to hurt yourself because because of the calcium oxalate interplay in the intestines. If you limit your calcium then more calcium. More oxalate will be absorbed into your from the G. I. Tract. If you have calcium with uh and with your oxalate sources at the time of your meals you actually it stays bound in the gut and is excreted, excreted in the gut. Um So that's a common misconception that patients have and I always I tell everyone you need and there's a way guidelines you want to maintain a sort of a normal dietary calcium intake, have a one or two servings of yogurt a day or you know, a glass of milk. Um Don't limit yourself. And with patients who have actual hyper axillary area um I'll advise them to take some calcium, dairy or calcium source with their meals, especially if they have been taking a lot of oxalate type rich foods. Um So sometimes or have them take a Tums tablet, even for if they don't have a calcium source, it's one or two tablets a day. Um patients always ask me doc, I looked up what a low oxalate diet is and everything in the world has Oxley, you know, are you basically telling me to not eat anything? No, it's really avoiding those obsolete dense foods um that are out there and this link that you know will be in the slide show, you can look at later really points to what the more dense Oxley foods are um you know a lot of written, a lot of great fruits and vegetables have Oxlade and patients should necessarily cutting those out. Um um, So, last question I think below what your nPH to uric acid stones typically form. So it's it's in the name that your urine ph should be Hasidic. But um have a have a point to make because with this question someone shows e and then change their mind and their fingers slipped. Okay, so yeah, most people hit it on the, hit the nail on the head. It is 5.5. And so I wanted to briefly talk about medications for in the home stretch here, medications for kidney stones. So, we talk about prevention. If they have high positive curia, low citrate in the urine, we want to boost that. So we give them potassium citrate or some alkaline source like sodium bicarb. You have to keep an eye on, we have to keep an eye on their potassium levels. Usually one or two weeks after they started. We do sometimes have to titrate. We will get usually repeat 24 hour urine collections on medications to sort of track their progress. Um And then if they're hyper calc erIC right, we make sure they don't have any uh, you know, hyper parathyroid, we will go to is our weak thighs, I'd type diuretics. Um if you know, for a patient that you're managing on with hyper with hypertension. That's great. We can coordinate um you know, adam I tore cartilage and hydrochlorothiazide, those are all great for reducing calcium excretion in the urine. Uric acid stones are the one stone that can be, you know, that can be treated. Patients ask me doc, is there anything I can take to dissolve my stones? Um There has been like a supplement called Shonka Pietro. That has been shown to have some benefited prevention. But really uric acid stones are the one that we can dissolve because they only form in acidic urine environment. So ph less than 5.5. Um if you give potassium citrate and alcohol, eyes, the urine, those stones will dissolve over like weeks to months on that. And then patients who have your goats and stones were usually keeping them on some sort of maintenance therapy chronically to prevent the stones from coming back. Or unless they can reverse the underlying predisposition the underlying elevated uric uric acid levels. Um elop urinals indicated if their serum uric acid elevated, not if, but if it's normal, I don't give it. Um And um yeah, it's it's really if you should suspect that if the urine ph is really consistently less than 5.5, so they have one urine ph levels below 5.5, I don't really think too much. But if they're like, if you look back at the history and every year in ph has always been, You know, less than 5.5 and I'm more suspicious and we can also tell by the CT scans based on how dense the stones are. They gonna be. Very non dense stones, very light, very brittle. The other thing that can't be discounted is avoiding carbonic anhydrous inhibitors. I it's not every it's not uncommon that I see patients come in with kidney stones and they are on to pyramid Topamax mosquitoes. All media mocks cynicism, um not the eye drops, but the oral medications and these all result in a metabolic acidosis that will result in um um, in kidney stones because it introduces a hypo secretarial, low century levels in the urine and can also lead to bone absorption because of the acidosis. Um, so, it's really important that if, you know, there are all these medications for different reasons. So, I think it's a it's kind of a risk, risk benefit balance or would you rather have kidney stones or rather have, you know, the other issue. But something to keep an eye out on the med in the med list. So takeaways inclusion really consider ultrasound for screening or surveillance really annually. Any kidney stones. Any patient with chronic or recurrent kidney stones should really get the screening once a year with ultrasound. I think limits see to radiation. Always request a low dose when able if you're ordering for kidney stones, patients should pass retreat. Ural stones within 4 to 6 weeks. Don't wait any longer obstructing stones with infection, compromised kidney function or intractable symptoms should come to the er uh And then finally as you've seen really a heart I tell patients a heart healthy diet and good hydration or ability the best stone prevention diet. But let's do the 24 hour urine to see if there's any really any really specific outliers that we can work on. Um So with that that's my talk and just a brief shameless pitch for myself. So this is our new clinic down in san mateo Redwood city area. It's just uh there's Ortho E. N. T. And myself. I'll be down here full time um Money through Wednesday's there's free parking. Um And it's a one stop shop. There's a grocery store, coffee store, Starbucks, lots of things to do. Um And right now my available is great. So I can see people same week. Um Really and we're really trying to make access easy to get in. Um So we have a separate phone line. I see a lot of patients who work who live in the city and also commute down to the South Bay. So that's stopping here on their way is no problem at all. And we're doing a lot of virtual visits of course as well. Um So um yeah that being said uh And this is a non exhaustive list of, you know basically are designed to be a general urology clinic here, we will offer all the common general urology procedures like vasectomy, prostate biopsies test Oscar peas. um, testosterone sexual function, things like that, your dynamics. Um, And then, uh, finally that uh, thank you everyone, mm hmm.
