SERVICES

Stones

History and milestones of the urinary calculus disease.

Mankind has been affected by urinary stones since centuries, and has been the silent cause of renal failure. Even in the 4th century BC, Hippocrates (father of modern medicine) notes the presences of the renal stone together with renal abscess and he wrote in his Hippocratic oath "… I will not cut, even for stone, but leave such procedures to the practitioners of the craft." The speciality of urology has been recognized ever since. And the surgeons who treat urinary stones and other urinary diseases are called Urologist.

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Incidence

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Urinary stone constitute one of the commonest diseases in our country and pain due to kidney stones is known as worse than that of labour pain. In , approximately 5 -7 million patients suffer from stone disease and at least 1/1000 of n population needs hospitalization due to kidney stone disease.

Thus, the disease is as widespread as it is old, particularly in countries with dry, hot climate. These "stone belt regions" of the world are located in countries of Middle East, North Africa, the Mediterranean Regions, North Western state of and Southern State of USA and areas around the great lakes.

In , the "stones belt" occupies parts of Maharashtra, Gujarat, Punjab, Haryana, Delhi and Rajasthan. In these regions, the disease is so prevalent that most of the members of a family will suffer from kidney stones sometime in their lives. Surgery for removal of urinary stones forms one of the commonest operations in hospitals in these regions.

The kidneys are solid; bean shaped, reddish brown-paired structure, which lie behind the abdominal cavity one on either side of the vertebral column. This kidney acts like the filter organ, which removes the waste products from the blood, which forms urine.

About 180 litres of blood, which run through these nephrons (functional unit of the kidney), are reduced to urine by the process of filtration, reabsorbtion, and secretion by the nephrons. The urine enters the pelvis of the kidney where it collects and continues down the ureters to the bladder. In the urinary bladder urine is temporarily stored and is finally eliminated from the body. Human being on an average excrete about 1 to 1.5 litres of urine per day.

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Stone formation

Kidney can be formed any where in the urinary system, like kidney, ureter, and bladder. The process by which the stone formation occurs is Supersaturation of urine. Here is simple example illustration the formation of the stone.

Supersatuaration theory

Imagine a glass of water containing little salt .If you add some more salt, it dissolves. When you add more and more salt, a stage is reached when the water is no longer able to dissolve the salt added to it. This is because the solution is supersaturated with the salt. Above this point, any little amount of salt added to the solution will start precipitating. This is exactly the mechanism by which kidney stones form except that the solution is urine and the chemical composition of the salt is different.

Natural History

Virtually all stones are formed in the kidneys, initially as small particles. These particles grow within the kidney to varying sizes, often filling up the whole kidney as a branched stone (the staghorn calculus). Sometimes they move out of the kidney when relatively small, and then migrate down the ureter into the bladder. Some stones less than 5 mm in size pass out spontaneously, but occasionally they migrate down the ureter & they may block the ureter causing obstruction to the flow of urine. This results in pain, which may be very severe (ureteric colic). Nausea and vomiting can also be associated with the colic pain. Some stones reach the bladder, and lodge there, growing larger and larger. Rarely they block the urethra causing a painful retention of urine

Types of stone

There are various types of urinary stones, but the most common ones are

• Calcium oxalate.
• Uric acid.
• Struvite.
• Cystine stones

Symptoms

Kidney stones in the kidney or ureter do not cause any symptoms until and unless they obstruct the urinary passage. The nature and the location of the pain can vary from person to person depending upon the size of the stone, the position of the stone within the urinary tract, and the damage it causes to the urinary system. "It should be however remembered that the size of the stone does not interrelate with the severity of the pain."

Stones can be diagnosed with following symptoms:

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• Incidental diagnosis on routine health checkups.
• Dull aching pain in the back
• Acute colic.
  Classical pain is described as pain from loin to groin, accompanied by nausea, vomiting and gaseous distension.
• Urinary tract infection.
• Increased frequency of urine
• Pain and or burning while passing urine.
• Passage of blood in urine (Haematuria) which can be gross or detected in the Urine test.

Investigations

A through physical examination is very important to understand the site and nature of the pain. It would also give the doctor an idea as to whether the pain is likely due to a stone within the urinary system or due to other reason.

To diagnose stone formation:

1. Urine routine which will show:
   • Crystals in urine.
   • Blood cells in urine
   • Pus cells in urine.
2. Urine Culture colony count & sensitivity test to rule out the urinary tract infection and to select the best antibiotic that will treat the infection if present.
3. X-Ray KUB
   • To detect size and site of stone
4. Ultrasonograpy of kidney, ureter, and bladder.
   • To show the size of the kidney & swelling (Hydronephrosis) of the kidney in obstructive uropathy. It will also show ureters if they are dilated. However, it does not give information about the function of the kidney.
   • Will also screen other abdominal organ for any pathology.

1.Blood test to look for normal functions of the kidneys

• Serum Createnine.
• Serum Blood Urea.
• Serum Electrolytes.

2.Intravenous Urography. This is the specialized test were series of X- ray are taken after injecting the special medicine, a dye  - Contrast, which has radiopaque property. The kidneys excrete these contrasts and kidneys are out lined on X rays and serial films are taken. This is a very useful test. It gives lot of information including size and shape of kidneys, function of kidney – comparative and individual, presence of obstructive uropathy, delineates the anatomy of kidney, ureter & bladder etc.

1. Test to find out the cause of the urinary stone disease.

   Metabolic tests may have to be done to look for any defects in your body, which may be responsible for kidney stone formation. This is very important, as it is not only sufficient to treat for the kidney stone but to find out why kidney stone has been formed. The recurrence of kidney stone formation can be prevented. Therefore, an appropriate treatment can be given so that one does not form kidney stones again.

   • Serum Calcium
   • Serum Phosphorus.
   • Serum Uric acid
   • 24 hour urinary calcium / 24 hrs urinary uric acid
   • Stone analysis of the retrieved calculus.

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   Treatment

   It has been said that "once a kidney stone former, always a kidney stone former". Once a kidney stone has been diagnosed, the choice is between expectant treatment and more aggressive forms of treatment, such as transurethral, percutaneous, or opens surgeries or the relatively new extra corporeal modalities. Although some kidney stones may pass spontaneously and unless complicating conditions arise, surgical intervention may not be necessary. Thus, identification of kidney stones that are likely to pass is of utmost importance.

   The primary decision is whether to apply surgical treatment or wait. Removal of kidney stones by any methodology is necessary when there is evidence of:

   1. Significant obstruction
   2. Progressive deterioration of the kidney
   3. Irreversible infection of the kidney (Refractory pyelonephritis)
   4. Unremitting pain
   5. Stone obstruction an infected kidney requires emergency intervention

   Various general and specific medical measures are used to treat the kidney stone disease. A significant percentage of patients will at sometimes or the other require intervention for the recovery of the urinary stone.

   1.Conservative-Management
   
   Most kidney stones of small size pass spontaneously in the urine without any need for intervention. The probability of a kidney stone passing down spontaneously will depend upon the size of a stone, its location, shape etc. Such patients are treated symptomatically with:

   • Anti-biotic to control infection.
   • Analgesics to give relief from the pain
   • Oral Hydrotherapy. The patient is generally instructed to maintain a high fluid intake ranging from 2 to 3.5 litres/day so that they can produce at least 2-2.5 liters of urine in 24 hours.
   • If the colic is severe and associated with the nausea, vomiting, fever then such patients are treated with Intravenous saline to produce adequate amount of urine so that kidney stone can be flushed out.
   • Endoscopic procedure is carried out like DJ Stenting, Ureteroscopy in some cases where the urinary stone causes severe obstruction and infection.

   2 Principal Therapeutic Procedures Are:

   • ESWL (Lithotripsy)
   • Ureteroscopy (URS)
   • Percutaneous Nephrolithotomy (PCNL)
   • Open surgery.

   Extra Corporeal Shock Wave Lithotripsy (ESWL)

   For many centuries, surgery was the only option in treating stones that would not pass spontaneously. About 22 years ago the German aeronautics company Dornier, through groundbreaking research, developed the means for focusing external energy to treat Kidney stones and pulverize them to small fragments that are voided naturally with the urine.

   This was a major advancement, perhaps one of the most significant medical advancements of the last century. Over the last 20 years lithotripter applications for renal stone therapy have been perfected, and these days Lithotripsy is performed as an out patient procedure in a painless fashion.

   • All the kidney stone with size of up to 1.5 -2 cms can be treated with the Lithotripsy.
   • Non impacted upper ureteric stone can be also treated with Lithotripsy

   For this treatment the patient lies on a special couch. X-ray and/or ultrasound are used to target the kidney stone, and by a computerized system the kidney stone is placed at the focal point of the energy source of the lithotripter. Having realized the stone, the shock waves are delivered through a remote control, which leads to fragmentation of kidney stone into fine particles.

   Treatment usually lasts about 45 minutes.
   

   Post lithotripsy

   After the procedure is complete, the patient is kept under observation for an hour then he is allowed to return home. He is asked to take plenty of liquid orally to maintain his urinary output to 2-2.5 litres per 24 hrs. He may require some antibiotics and some painkiller. It takes few to several weeks for final stone fragments to pass out through urine. The patient may experience some burning sensation and blood in urine for few days. The patient is generally advised to do routine urine test with X- ray KUB for 7-10 days.

   The patient rests for a while and then is allowed to return home. Sometimes a "stent" is placed in the ureter if it is anticipated that the stone fragments may block the ureter after Lithotripsy. Repeat sessions of Lithotripsy may be required, usually not earlier than 3-5 days.

   However, all urologists realize that Lithotripsy is sadly not an answer to many of the stones seen in day-to-day practice. The reason is that for stones that are more than 2 cms in size, branched stones and various other complicated situations Lithotripsy is either not effective or is slow to work with patients needing multiple procedures and hospital visits. In these patients, other options should be considered. In an average practice in , where patients present with advanced and neglected disease, at least 40% of kidney stones fall into this category. These larger stones are removed by a new technique called Percutaneous Nephrolithotomy or PCNL.

   
   

   Percutaneous Nephrolithotripsy (PCNL)

   In this technique the stone is removed by making a small tunnel into the kidney from the back. A fine needle is used to puncture the renal collecting system with the aid of X-ray and/or Ultrasonograpy, and a guide wire is led into the kidney through the needle. This tract is dilated over the guide wire and a Nephroscope (kidney telescope) is inserted into the pelvis of the kidney. The stones are visualized, fragmented using Swiss Lithoclast and extracted using fine forceps, allowing the kidney to become free of stones at the end of the operation, in the vast majority patients. This is of course an operation, needing full general anesthesia, average 90 minutes of operation time, 3 -4 day hospitalization, and an occasional need for blood transfusion. Patient returns to light work in 5-7 days time. Nevertheless the operation is safe, for both the patients and the kidney. This operation has really reduced the need for open surgery (cutting surgery), which is now reserved for exceptional indications
   

   This technique is used to treat kidney stones of:

   • Large than 2.5 cms,
   • Staghorn calculus,
   • Calyceal diverticular calculus.
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   Ureteroscopic Stone Removal

   All the ureteric stone can be treated with this endoscopic technique.

   • Upper ureteric
   • Middle ureteric
   • Lower ureteric
     
     

   Technique:

   Ureteroscopy is highly successful procedure for the retrieval of stone in the ureter. It is passed through the normal urinary opening through the bladder into the ureter.

   It involves the passage of an instrument namely Ureteroscope through normal urinary passage. The instrument is as thick as a pen and is about 40 cm long. The Ureterorenoscope is advanced under vision through the normal urinary passage under anesthesia. The Ureterorenoscope is advanced on the side of the ureteric stone and up to the ureteric stone. Once the ureteric stone is localized, various options are available. If the ureteric stone is small, it can be picked up by the forceps & pulled out. But, if the ureteric stone is larger, the ureteric stone can be broken into tiny fragments using Swiss lithoclast or ultrasound or even a combination of both as in Swiss Lithoclast master. A variety of other instruments can be passed in through the scope, which can be used to break the stones and remove them. Patients have to be admitted in the hospital for a few

   days (2-3 days) for this procedure and it has to be done under anesthesia. Double J stent is usually kept post procedure to drain the kidney.

   It is a very safe procedure in experienced hands and Ureterorenscopy can treat almost all the ureteric stones.

   Therapeutic status of ESWL, PCNL, URS:

   These techniques are not competitive with one another but are greatly complimentary to each other. Though ESWL is the ideal treatment for urinary calculi but in selected cases a combination of the above treatment modalities are much better off. Kidney stones up to 2-2.5 cms can be treated by introduction of Double - J stent and multiple sessions of ESWL therapy. However, kidney stones larger than 2.5 cms or partial or complete stag horn will do better with a combination of PCNL and ESWL. PCNL can be used to debulk the kidney stone mass and can be followed up with lithotripsy for residual fragments, if any are left behind. Impaction of stone fragments in lower ureter after lithotripsy may need URS. With the advancement of medical science and availability of these modalities, open surgery for the stone shall be rarely necessary. However, in certain selected cases, open surgery still remains the best modality of treatment.
   

   Open surgery

   With the advent of new technologies to treat kidney stone disease, the need for open surgery has been drastically reduced. However, in some cases it might be required. The type of open surgery will depend upon the site and size of the stone within the urinary tract.
   

   Interesting facts about urinary system.

   1. The Human bladder can stretch to hold about 250-350 ml of urine. 2.All the blood in our body passes 400 times through each kidney every day. Each kidney is made of numerous (about 1 million) called tubules known as nephrons, which are the functional unit of the kidneys. About 180 litres of blood, which run through these nephrons, are reduced to urine by the process of filtration, reabsorbtion, and secretion by the nephrons.