Articles tagged with: Kidney Stones

10
January
2015

Rapid Access Kidney Stone Service

Rapid Access Kidney Stone Service

Kidney stones are a common problem in Australia and can be very painful. Patients with severe pain may need to be seen urgently by a urologist. One option is to present to an emergency department, where the condition can be diagnosed with a consultation and CT scan, and then referral if necessary to a urologist.

From early 2015 we will be offering a rapid access stone assessment service based in the rooms at Calvary Hospital in North Adelaide. You will need a referral from your GP, and can then be seen the same day, with a CT scan organised at Radiology SA (in the same building as our office). CT usually needed to confirm the diagnosis, and show the size and location of the stone.

If necessary, you can be admitted directly to Calvary North Adelaide Hospital, and have the necessary treatment undertaken. Often, it is enough to be admitted with pain killing drugs, anti-inflammatories, and a tablet called an alpha-blocker – many kidney stones will pass on their own with this treatment and this may be sufficient to relieve your kidney stone pain. If the stone is larger or there are complications such as infection, you can have your surgery at the same time.

The aim of this rapid access kidney stone service is to shorten the time from presentation to definitive treatment.


Categories: Updates, Kidney Stones

07
January
2015

Kidney stone infection and surgery

Kidney stone infection and surgery

Patients with kidney stones that need surgical treatment are at risk of urinary tract infection, and sometimes sepsis. Stones often have bacteria attached to them, and these bacteria can be hard to eliminate. A recent study from Tel Aviv University looked at post-operative infection in patients undergoing percutaneous nephrolithotomy (PCNL). Stone samples retrieved during surgery were sent for culture, to see if there were bacteria associated with the kidney stones.

Urinary sepsis (an infection that spreads from urine into the bloodstream and causes a patient to be unwell) occurred in 31% of patients who had a positive stone culture, compared to 5.9% of those patients who had a negative stone culture. E coli (gram negative bacteria) and Enterococcus sp. (gram positive bacteria) were the most common organisms found.

The problem is that it takes a number of days for the culture to come back, and the patient will have developed sepsis by that time. However, what it does highlight is that doing a urine culture 1 to 2 weeks before PCNL surgery can help the situation. If the urine culture is positive, the patient should have a course of antibiotics for 7 days to try to sterilise the urine, and then intravenous antibiotics at the time of surgery. If the urine is sterile pre-operatively, then intravenous antibiotics at the time of surgery are sufficient.

Two other interesting points were raised. First, that resistance to ciprofloxacin and norfloxacin was high, and this is something that is of concern. These antibiotics may be overused in the general population, causing resistance. This is something we are also seeing in patients who need a prostate biopsy for a raised PSA.

Second, we know that some patients cannot reach a point where the urine is sterile (free of bacteria) if they have stones, because the stones themselves are colonised with bacteria, and antibiotics cannot get into stones. These patients pose a specific problem and are at higher risk of infection.

Reference - Ohad Shoshany et al. Percutaneous nephrolithotomy for infection stones: what is the risk for postoperative sepsis? A retrospective cohort study. Urolithiasis (online) 01 Jan 2015

You can read more about kidney stone surgery and the risk of infection by following this link to an article by Michael Wong.


Categories: Updates, Kidney Stones

07
April
2014

Infectious Complications of Kidney Stone Surgery

Infectious Complications of Kidney Stone Surgery

Our latest Guest Blog is by Dr Michael Wong, Director of the Singapore Urology, Fertility and Gynaecology Centre. He is a US Fellowship Trained Urologist, and previous President of the Singapore Urology Association. Michael gives an up to date and comprehensive account of Infective Complications in the Surgical Management of Urinary Stones.


Infective Complications in the Surgical Management of Urinary Stones


Introduction

Despite the significant advancements in the surgical management of urinary stones, morbidity and even mortality are still being reported. Krambeck reported in the Journal of Urology in 2013 that deaths still occur after surgery, particularly in the elderly population as their immunity is lower and there could be delay in diagnosis due to lack of classical symptoms. The importance of appropriate antibiotic prophylaxis and assessment of risk factors prior to treatment cannot be underestimated.


Infective Issues with Percutaneous Nephrolithotomy (PCNL)

PCNL is most appropriate for large renal stones. One of the feared complications of PCNL is urosepsis. A common composition for staghorn stones is struvite,5 which results from the presence of urea-splitting organisms, and non-struvite stones may also harbor bacteria. There is therefore an increased risk for sepsis during the procedure. Further, PCNL utilizes large volumes of irrigation relative to ureteroscopy, which may increase the risk of sepsis.

The practice of prophylaxis for PCNL is not for debate. David Tolley reported that the rate of UTI reduces 3 fold when using prophylaxis for PCNL. Recently, the CROES group reported a series of 162 patients from multiple institutions who underwent PCNL without pre-operative antibiotics and matched them to patients who did receive antibiotics6 All patients had negative pre-operative urine cultures and matching was based on infectious risk factors such as diabetes, nephrostomy tubes and staghorn stones. They found that antibiotic prophylaxis led to fewer fevers (2.5% vs. 7.4%) and other complications (1.9% vs. 22%) and higher stone free rate (86.3% vs. 74%). The explanation for this finding may be that stones themselves may harbor bacteria that may not manifest in a voided urine culture.

ESWL -

Techniques to culture stones were described over 40 years ago. In a study examining infection rates in patients undergoing PCNL, 35% of patients had positive stone cultures, compared with 21% of upper tract and 11% of bladder urine cultures. Stone manipulation and lithotripsy can result in the release of bacteria and contamination of urine with possible systemic transudation resulting in sepsis or systemic inflammatory response syndrome (SIRS). Stone cultures have been shown to be a better predictor of sepsis and SIRS than voided cultures. Mariappan showed a positive stone culture to have over 80% sensitivity and a positive predictive value of 70% in predicting SIRS.7 Overall, positive stone cultures increased the risk of SIRS 4-fold. Along with bacteria, stones contain endotoxins that can potentially result in a systemic immune response clinically similar to sepsis.

The greatest limitation of stone cultures is that they are only available after a procedure with some days to allow bacteria culture and so cannot influence immediate peri-operative treatment. The utility of obtaining stone cultures in clinical practice is to guide antibiotic choice in the event of sepsis following ureteroscopy or PCNL rather than predicting it. Having said this, it is reassuring to routinely collect stone cultures intraoperatively from patients undergoing PCNL.


Understanding the Risk factors for Urosepsis during PCNL

Many groups have reviewed their experience with PCNL in an attempt to identify risk factors for post-operative fever, sepsis or SIRS. A positive pre-operative urine culture was associated with increased infectious risk (OR 2.2 -16.7), as were positive pelvic urine (OR 10.2 – 24.1) and stone cultures (4.88 – 25.6). Other factors such as female sex, hydroureteronephrosis, pre-operative nephrostomy tube, large or complex stone burden, and diabetes have all been associated with an increased risk of post-operative fever or sepsis.

Korets and colleagues showed that an increased number of access tracts increased the risk of SIRS (HR 4.8) when controlling for patient sex, stone culture and composition, while several other groups have found increased operative time to be a risk factor for fever. Dogan also showed volume of irrigation fluid required was a significant predictor. These three factors are likely all surrogates for stone size and complexity, resulting in a prolonged procedure.


Infective Issues with Ureteroscopy

A 2003 RCT by Knopf et al. that included 113 patients found a single prophylactic oral dose of fluoroquinolone prior to ureteroscopy reduced the incidence of post-operative bacteriuria (1.8% vs. 12.5%, p=0.02). There were, however, no incidences of symptomatic UTI. This study guided the AUA Best Practice Policy in recommending antibiotic prophylaxis prior to ureteroscopy for the management of stone disease.3 The guideline committee states that the potential risk of bacteriuria is 30% and UTI ranges from 4% - 25% without prophylaxis. There is no difference in efficacy between oral fluoroquinolone and intravenous cefazolin.

A Korean group reviewed their experience of infectious complications following ureteroscopy and identified several risk factors.4 They noted an overall UTI rate of 3.8%. Furthermore, they found hydronephrosis, bacteriuria, and an indwelling ureteral stent or nephrostomy tube was associated with an increased risk of post-procedural fever. Administration of antibiotics after the procedure was not as effective as pre-procedural prophylaxis.

flexi scope

Eswara and colleagues retrospectively reviewed their experience with stone cultures in patients undergoing ureteroscopy (n=274) or PCNL (n=54). They found that while pre-operative urine cultures were only positive at some point in 7% of patients, stone cultures were positive in 29%. Their overall sepsis rate was about 3-4% for all patents. In patients with positive stone cultures, the sepsis rate was significantly higher at 8% compared to only 1% in those who had negative stone cultures. Ultimately, urine cultures had a sensitivity of 11% versus 64% in stone cultures and there was a concordance of 64% between the stone culture pathogen and the one causes sepsis compared to only 9% of pre-operative urine cultures. Despite the correlation of stone cultures and post-operative infection, their utilization in guiding clinical practice is limited in that it takes several days following the removal of the stone for cultures to results. They are most helpful following the development of UTI to help guide antibiotic choice.

Unfortunately we do not have a study showing the use of ureteric stent post URS reduces UTI as upper tract decompression using a stent would also play a part in reducing UTI.


Infective Issues in Extra-Corporeal Shock Wave Lithotripsy (ESWL)

In general, the incidence of urinary tract infection occurring after uncomplicated ESWL is less than 1%, rising to 2.7% for staghorn calculi. This risk of sepsis increases in the presence of bacteriuria prior to ESWL especially if there is distal obstruction.

Until recently, the practice of giving prophylactic antibiotics was controversial in patients undergoing ESWL with negative urine cultures. It has been reported that bacteriuria can develop in 5-6% of patients undergoing ESWL even in the presence of sterile urine prior to the procedure and the risk of clinical UTI can be seen in 2-3% subsequently.

The European Association of Urology guidelines on urological infections (updated in 2010) do not recommend prophylactic antibiotics in ESWL unless there are risk factors like ureteral stents, urinary catheters, nephrostomy tubes or infective stones1. More recently, in a meta-analysis reported in the Journal of Urology in 2012 covering 9 randomized trials of 1364 patients undergoing ESWL for urinary stones with sterile urine cultures2, Lu et al reported no significant differences between the prophylactic group and the control group in terms of symptoms, rate of fever, rate of positive urine culture and the incidence of urinary tract infection. They suggested that antibiotic prophylaxis is not necessary for ESWL in low risk patients.

PCNL

The American Urological Association guidelines3 were recently updated in Jan 2014 and currently do not recommend antibiotic prophylaxis for patients undergoing ESWL with negative urine culture. In the light of more recent publications, prophylactic antibiotics are recommended only in high risk stone groups with infective stones, recent instrumentation, nephrostomy tubes, positive urine cultures and a history of recent UTI or sepsis. In addition, special considerations should also be given to high risk patient groups which the AUA defines as advanced age, anatomical anomalies of the urinary tract, poor nutritional status, chronic smokers, chronic steroid users, immunodeficiency, externalized catheters and prolong hospitalisation.

In general, ESWL should only be performed if the urine is sterile and when there is no distal obstruction to minimise infective complication. Currently, prophylactic antibiotics should be considered only in high risk patients.


Conclusion

The current guidelines and practice patterns pertaining to stone surgery have evolved based on emerging clinical data. These recommendations in conjunction with patients’ individual risk factors and culture data should help guide ongoing practice patterns.


References

1. Wolf, J. S., Jr., Bennett, C.J., Dmochowski, R.R. et al. : Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol, 179:1379,2008.

2. Grabe, M., Bjerklund-Johansen, T.E., Botto, H. et al.: Guidelines on Urological infections. European Association of Urology:79,2010.

3. Lu, Y., Tianyong, F., Ping, H. et al.: Antibiotic prophylaxis for shock wave lithotripsy in patients with sterile urine before treatment may be unnecessary: a systematic review and meta-analysis. J Urol, 188:441,2012.

4. Sohn, D. W., Kim, S. W., Hong, C. G. et al.: Risk factors of infectious complication after ureteroscopic procedures of the upper urinary tract. J Infect Chemother, 2013

5. Segura, J. W., Preminger, G. M., Assimos, D. G. et al.: Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. The American Urological Association Nephrolithiasis Clinical Guidelines Panel. J Urol, 151: 1648, 1994

6. Gravas, S., Montanari, E., Geavlete, P. et al.: Postoperative infection rates in low risk patients undergoing percutaneous nephrolithotomy with and without antibiotic prophylaxis: a matched case control study. J Urol, 188: 843, 2012

7. Mariappan, P., Loong, C. W.: Midstream urine culture and sensitivity test is a poor predictor of infected urine proximal to the obstructing ureteral stone or infected stones: a prospective clinical study. J Urol, 171: 2142, 2004


You can read more about Michael Wong by clicking this link

Categories: Updates, Other

28
November
2013

Percutaneous Stone Surgery in the Supine Position

Percutaneous Stone Surgery in the Supine Position

This week’s Guest Post is by Denby Steele, an Adelaide Urologist, an expert in the management of complex kidney stone disease and pioneer of supine PCNL in Australia

"Marberger, Clayman and Whickam, in different parts of the world, were instrumental with the development of percutaneous stone surgery in the late 1970’s and early 1980’s, and for many years this has been performed in the prone position. Extracorporeal shock lithotripsy in the early 1990’s and flexible ureteroscopic laser lithotripsy in the later 1990’s have provided less invasive alternatives for upper tract stone surgery but percutaneous surgery still offers an excellent minimally invasive option, particularly for larger stones.

"Traditionally, percutaneous stone surgery has been performed in the prone position but since the first description of this in the supine position by Valdivia et al in the Journal of Urology in 1998, there have been pockets of interest and increasing expertise in surgery in this position.

"My series of 322 cases published in the Journal of Endourology in 2007 is still the second largest published series, but there are increasing reports from around the world and numerous reviewers and commentators have highlighted the advantages of surgery in this position. Randomised trials have proven the safety, efficacy and time saving.

The supine position for Percutaneous Stone Surgery (PCNL) by urologist Denby Steel

"The supine position was presumably neglected because of fear of colonic injury, but it has been shown radiologically that the colon floats further away from the kidney in the supine position, exposing a greater area for safe percutaneous puncture. With the patient tilted over a 3 litre bag under the flank it is possible to puncture even more posteriorly than some prior prone punctures. There have been no reports of colonic perforation in the supine position in the literature.

"There has been debate about which position is best, but this will depend on the sex of the patient, body habitus, whether concomitant rigid lower tract instrumentation is required, stone burden and position of the colon relative to the kidney. I recommend a 3 litre (1 litre in small patients) saline bag under the ipsilateral flank, a pillow under the ipsilateral leg for males, and lithotomy position for females or males requiring a rigid cystoscopy or ureteroscopy. The ipsilateral arm is always brought across the chest. The flank and perineum are prepared and draped together for a single stage procedure starting with flexible cystoscopy and ureteric catheterisation over a glide wire. The image intensifier is angled back 5 – 10 degrees to allow for the patient tilt. Kidney puncture, tract dilatation and stone surgery are then performed in the standard fashion. I tend to leave a ureteric stent afterwards and drain the bladder but do not leave a nephrostomy tube.

"The supine position is very attractive to nursing staff, anaesthetists and surgeons, and offers the following advantages:

  • Reduced manual handling with no position change
  • No dangerous prone position
  • No patient shoulder strain
  • Single set up and draping
  • Easy concomitant rigid cystoscopy and ureteroscopy
  • Comfortable surgery in the sitting position
  • Reduced radiation to the surgeon as hands not under the image intensifier
  • Increased safety as it is easy to pass a wire through the puncture and out the urethra
  • Stone fragments will spontaneously exit the obliquely placed sheath
  • Reduced operating theatre time
Urologist Denby Steel performing Percutaneous Stone Surgery (PCNL) using the supine position.

"I have performed percutaneous surgery in the supine position in all 680 cases since 1999 and regularly lecture and run workshops in Australia and overseas to promote and teach this simple and improved technique."

Denby Steele is a Urologist in private practice in North Adelaide South Australia, a Senior Visiting Urologist at the Royal Adelaide Hospital, the inaugural Chairman of the Endourology Special Advisory Group of the Urological Society of Australian and New Zealand, the immediate past Chairman of the SA & NT branch of the Urological Society of Australian and New Zealand and an examiner in Urology for the Royal Australian College of Surgeons.

Categories: Other

19
November
2013

Aerospace Medicine and Urology

Aerospace Medicine and Urology

This week’s Guest Post is by Dr. Gordon Cable, a specialist in Aerospace Medicine, based in Adelaide. He discusses what this specialty involves and its relevance to Urology. He also talks about some of the big names at NASA he has met.


Gordon, can you explain what Aerospace Medicine involves?

Aerospace medicine is a specialty area of medicine that deals with the determination and maintenance of the health, safety and performance of all those who fly in the atmosphere or in space. It is an important specialty because those environments are so hostile to the anatomy, physiology and psychology of humans adapted to an earth-bound existence.


What sort of Urological problems do you encounter, and how do these affect pilots?

Pilots can of course develop any urological problem, just like any other member of the community, but the problem is how those conditions interact with the hostile aviation environment, and most importantly, how they affect a pilot’s performance and safety. Another important consideration is how any treatments for urological conditions might affect pilot performance, whether they be surgical or medications. The aerospace industry is still very heavily gender biased towards males, so mens’ health issues such as testicular cancer in younger males, prostatic hypertrophy and cancer in older males are common problems. Asymptomatic haematuria is a common finding at routine aviation medicals, which must be investigated thoroughly because the biggest showstopper of them all is the potential for renal calculus disease.


Kidney stones are a particular concern. Can you explain how the management of kidney stones in pilots differs from those in the general population?

The primary concern with renal calculi in pilots is the risk of sudden acute incapacitation due to renal colic. The presence of any calculi in the renal tract is bad news for pilots. Generally unrestricted medical certification is not possible, even if there is parenchymal calcification. When stones are present, even if asymptomatic, definitive treatment and proof of stone clearance is required before a pilot will be allowed to fly unrestricted. After an episode of renal colic, the risk of recurrence is also quite concerning, so careful management of stone-forming risk factors is particularly important, as is regular follow-up. Low-dose CT scanning is the preferred method of screening over ultrasound. Dehydration is common in many types of aviation operations, and some pilots are even known to intentionally dehydrate prior to flight so they don’t get caught short in the aircraft! This does not bode well for renal calculus risk.


What are the key areas of research in Aerospace Medicine?

Current hot topics and areas of ongoing work include fatigue management, especially as long haul flying now becomes commonplace with extended range aircraft. Aviation has always been a 24-hour a day industry, and combating the effects of shift work, long hours of “vigilant boredom”, and circadian dysrhythmia across multiple time zones are critical in maintaining pilot performance. The “ageing pilot” is an area of increasing interest with more and more pilots flying into their senior years beyond 60 years of age.

Cardiovascular risk, and determining the subtle effects of altered cognition are important areas of inquiry. Looking beyond earth, commercial space tourism is coming to a Spaceport near you – will you be fit to become an astronaut? This is a big question facing our specialty, and medically risk-managing a large cohort of the general public venturing into the near-vacuum microgravity conditions of suborbital flight is a topic we need to grapple with. Finally, maintaining the health of astronauts for long duration space flight will be essential if we ever intend to land humans on Mars, or travel beyond that on exploration class deep space missions to asteroids and beyond. Here radiation protection and the psychological aspects of isolation are important concerns.


You must have met some interesting people in your work. Who are the standouts?

Gordon Cable with Navy CAPT (Ret) Jim Lovell, Mission Commander of the famous but ill-fated Apollo 13.
Gordon with Navy CAPT (Ret) Jim Lovell, Mission Commander of the famous but ill-fated Apollo 13.

Attending international conferences in the field always affords the opportunity to meet some really interesting people, even some boyhood heros! I think the highlights have to be the NASA astronauts and flight surgeons I have met over the years. Last year I had the privilege to meet Jim Lovell, commander of the Apollo 13 mission, and Dr Charles “Chuck” Berry, NASA flight surgeon for the same mission. Previously I have met CAPT (Dr) Joe Kerwin, former USN Flight Surgeon and first US physician to fly in space as science-pilot aboard Skylab 2. Dr Story Musgrave, who flew on 6 Space Shuttle missions, attended one of our Australian conferences some years ago and in many ways was the most impressive individual I have ever met – physician, scientist, military and civilian pilot, astronaut – not sure how one can achieve so much in one lifetime!



Gordon Cable: Biography

A graduate of the University of Sydney, Gordon is a specialist in aerospace medicine, and a designated aviation medical examiner for CASA and CAD Hong Kong. His professional affiliations include:

  • Fellow of the Australasian College of Aerospace Medicine
  • Clinical Senior Lecturer, Discipline of Public Health, University of Adelaide
  • Past President/Honorary Member of the Australasian Society of Aerospace Medicine
  • Member of the International Academy of Aviation and Space Medicine
  • Fellow of the Aerospace Medical Association
  • Fellow of the Royal Aeronautical Society

Gordon is a Senior Aviation Medical Officer for the ADF, and has been a consultant to the RAAF Institute of Aviation Medicine since 1996. He has worked part time as a medical officer for CASA's aviation medicine section in aeromedical certification and complex case management. He holds a Postgraduate Diploma in Aviation Medicine from the University of Otago (NZ), and a Graduate Diploma of Occupational Health and Safety Management from the University of Adelaide. The author of many scientific publications, his professional interests include:

  • Altitude physiology of hypoxia and hypobaric decompression illness
  • Hypoxia awareness training of military and civilian aircrew
  • Postgraduate education in aerospace medicine for medical professionals

In his civilian clinical practice Gordon takes a particular interest in the management and certification of complex aeromedical cases, and education of aircrew in health, safety and performance issues.


Categories: Other

12
November
2013

Kidney stones - prevention and treatment

Kidney stones - prevention and treatment

Matthew Bultitude is a consultant urological surgeon practising at Guy's and St. Thomas' Hospital in London. He has a subspecialist interest in stone disease, and in this article he answers questions about the common problem of kidney stones.


Matt, how did you become interested in urological stone disease?

I was fortunate to work as a junior doctor in the stone unit at Guy's and St. Thomas' Hospital and following on from that I was offered a research position which I gladly took up. I undertook a number of clinical projects during that period including an MSc thesis assessing the safety of flexible ureteroscopy. I really enjoyed the challenges that stone disease creates and this has carried on throughout my career.


Do you see an increasing rate of stone disease in the UK, and what is the cause of this?

There is no doubt that there has been a steady increase in the number of stone cases in the western world and the UK is no exception. The lifetime risk may now be as high as 12% (American data) and although more common in men, they are becoming increasingly prevalent in women. This is essentially due to a combination of increasing obesity with poor diets (high in animal protein, fizzy drinks, processed foods, salt etc) and low fluid intake.


What have been the major developments in surgery for stone disease in the last few years?

I remember (as a boy with a urological father) when the first public lithotripter arrived in the UK (St. Thomas' Hospital) in the 1980's. This revolutionised stone treatment and continues to be a common treatment. What has changed over the last decade has been the development of smaller (diameter) and more robust instruments allowing us to pass telescopes up the urinary tract to the kidney to treat stones (flexible ureteroscopy). For large stones percutaneous surgery (PCNL) remains the standard and recent developments have seen some interesting changes to how this is done with smaller and smaller instruments and also in new surgical positions with many surgeons now choosing the supine position (so lying on side) rather than prone (lying on front).


Does shock wave therapy have an ongoing role in stone management?

There is no doubt that shock wave lithotripsy has been on the decline but in my opinion it is still a useful treatment for many patients. Choosing the correct stone for this treatment is important and as it works better in a thin patient with a smaller stone, rather than trying it in everyone. However I increasingly find patients prefer the more definitive choice of surgery with ureteroscopy to fragment the stone with a laser as although it is more invasive, the outcomes are more predictable.


Calcium oxalate stones are the most common kind of kidney stones. What is your advice to someone who has had a stone like this, to prevent future stone formation?

I often give quite detailed advice about stone prevention, although the summary of this is a normal healthy diet with lots of fluid (which is what we should all be doing!). In principal we should aim for a diet with:

- Enough fluid to produce at least 2 litres of urine per day. The actual amount will be different for everyone but usually a minimum of 2.5 litres in per day is required. This is the most important advice.

- Limited animal protein (meat and fish)

- Low salt

- Plenty of fruit and vegetables

- High fibre

- A normal calcium intake - so cutting back is often the wrong thing to do.

For calcium oxalate stone formers there are some foods high in oxalate and limiting intake of these may also help.


What developments do you see on the horizon for kidney stone treatment?

I think surgery will continue to improve with better quality and smaller instruments becoming available. Shockwave lithotripsy will probably continue to decline (as discussed above). What would be a game changer is the development of effective medication that could reduce the chance of stones growing in urine although I suspect we are many years away from this!


You can read more about Matt Bultitude by following these links to the Guy's and St. Thomas' Hospital website and the London Bridge Hospital website.

Click here for a link to his personal website.

You can also follow Matt Bultitude on twitter


Categories: Kidney Stones

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