What is a kidney stone?
Your kidneys main function is to remove excess water and waste products from your blood and make urine.
A kidney stone forms when certain minerals separate out from the urine and form crystals in your kidney that gradually gets larger in size with passage of time.
Most kidney stones when very small in size travel through the urinary tract without being noticed or causing any significant pain. Sometimes they might get stuck in your ureters or urinary bladder or urethra and can cause problems.
What are they made up of ?
They are mostly made up of calcium oxalates. Other types are uric acid, struvite ( a.k.a infection stones) , phosphates, cystine and medications induced and other less common types.
Why do they form ?
Most of the time an exact cause cannot be identified, and there is not a single cause which leads to stone formation. In general it occurs mostly in people who consume less fluids, or due to dehydration in hot climates. It can also occur in people who consume lots of nuts, chocolates, berries, or coffee etc as they have high content of oxalates. Risk also increases in those who are consume excess of salt or high animal proteins, take dietary supplements like vitamin C, or laxatives or antacids. People who are overweight, or have chronic diarrhoea, or underwent some previous gastric by pass surgery also are at increased risk of developing kidney stones. People who have a family member who had kidney stone earlier are also at slightly higher chances of developing stones.
Why do they form ?
Most of the time an exact cause cannot be identified, and there is not a single cause which leads to stone formation. In general it occurs mostly in people who consume less fluids, or due to dehydration in hot climates. It can also occur in people who consume lots of nuts, chocolates, berries, or coffee etc as they have high content of oxalates. Risk also increases in those who are consume excess of salt or high animal proteins, take dietary supplements like vitamin C, or laxatives or antacids. People who are overweight, or have chronic diarrhoea, or underwent some previous gastric by pass surgery also are at increased risk of developing kidney stones. People who have a family member who had kidney stone earlier are also at slightly higher chances of developing stones.
Can kidney stones recur again even after treatment ?
Yes kidney stones are notorious to recur. Even if someone has taken treatment or passed out stones in urine on their own or underwent some surgical procedure for removal of stones, they can still recur. Almost 50% patients develop stones again in next 10 years who had earlier formed stones. Sometimes in less than 5% of cases, in a condition known as hyperparathyroidism the parathyroid gland can secrete excess hormones which can increase risk of stone recurrence. Treatment of this condition can generally halt the recurrence.
What are the symptoms ?
A kidney stone usually will not cause symptoms until it moves around within your kidney and passes into your ureters. If it becomes lodged in the ureters, it may block the flow of urine and cause the kidney to swell and the ureter to spasm, which can be very painful. At that point, you may experience severe sharp pain in the sides and back, below the ribs which might radiate to lower abdomen or groin area, or burning sensation while passing urine. Other symptoms might be blood in urine or foul smelling or cloudy urine or passing urine very frequently. In severe cases fever with or without chills or excessive vomiting also might occur. Sometimes if stones get obstructed in your urethra there may be even complete inability to pass urine.
What tests are necessary for diagnose and treatment ?
Once you visit your urologist, certain blood tests like CBC, KFT, serum calcium, phosphate, uric acid, blood sugars levels, viral markers and coagulation profile are performed. Urine routine tests and urine culture sensitivity are also done to look for any urinary tract infection. An ultrasound or Plain CT scan of your kidneys, ureter, bladder region ( NCCT KUB) are generally required to locate the stone and know its size, hardness, number and swelling in kidneys etc so that accordingly treatment can be planned.
In people who need some surgical procedure additional tests like chest x ray, ECG etc may be needed for anesthesia fitness as deemed necessary by the anaesthetists.
In people who have repeated stone formation some additional tests like serum parathromone levels and 24 hr urine analysis for calcium, uric acid , oxalates, phosphates, citrates, magnesium etc and Arterial blood gas analysis. These tests are usually done 3-4 weeks after all stones have passed out or have been removed surgically.
What are the treatment options ?
Pain killers are usually prescribed initially only to relieve pain, however until and unless the patient passes the stone spontaneously or gets it removed by an urologist the pain likely to recur. For very small ureteric stones sometimes a special medicine (Alpha blockers) is prescribed for 1-2 weeks if the urologist feels so that it shall pass out and safe to be given depending on the clinical situation.
However if the ureteric stone size is large or causing significant discomfort and depending upon the blood , urine and CT/ultrasound test reports and location, number, hardness of stone, presence or absence of kidney swelling and other factors, either ESWL, URS, PCNL, RIRS, CLT might be advised. If there is any evidence of severe infection on blood or urine tests or clinically then antibiotics either in tablet form or injectable may be prescribed with or without PCN/Double J stenting.
ESWL (Extracorporeal shock wave lithotripsy)
ESWL is a non-invasive treatment (no external cut or endoscopy needed) generally carried out under local anesthesia on a day care basis for kidney stones <1.5 cm which are not very hard and some upper ureteric stones( < 1 cm).
It involves the administration of a series of external shock waves which are generated by a machine called as lithotripter to the targeted stone. These shockwaves break the stone into small fragments which are passed out through urine for several weeks.
Generally 1-2 sessions lasting for an hour with an interval of 1 week may be required depending upon the hardness of stone and location. While these fragments pass out, patients may experience some burning and frequency of urination or mild bleeding in urine intermittently, for which pain killers along with increased hydration may be needed. Follow up with plain X ray KUB is generally done to check for clearance. Residual stones may need additional endoscopic procedures.
We can identify some patients who will be unlikely to experience a successful outcome following ESWL, whereas we may predict that other patients will be more likely to clear their stones. Patients who are on blood thinners, pregnancy or Chronic Kidney Disease are generally not good candidates for this procedure. Sometimes the fragments get blocked in ureter and can cause fever or sepsis necessitating emergency Double J stenting/ PCN placement.
URS (Ureteroscopy)
Ureteroscopy is a minimally invasive technique (endoscopic technique, no external cut) involving the passage of a very thin semirigid endoscope through the urethra & bladder into the ureters upto the place where the stone is located.
The stone is then either grabbed and removed with forceps intact if small, or else it is fragmented and removed or it is dusted and made into a sand like particles which pass out with urine in few days. Ureteroscopy is typically performed under general anesthesia, and the procedure usually lasts from 30 to 60 minutes.
Sometimes if the stone is stuck very hard or there is pus inside or the ureter is very tight not allowing the insertion of the endoscope then only Double J stent is done and the definitive procedure is performed after 7-10 days.
This is done to reduce complications, like ureteric injury, sepsis etc. keeping patient safety in mind. Staged Ureteroscopy usually does not need DJ stent insertion at the time of stone removal. However final decision for stenting is done at the time of ureteroscopy.
Discharge is usually done the next day if there is no fever. Patients who are on Double J stent experience some loin pain. Frequency, urgency, slight burning urination or slight blood at end of urination. These symptoms are however temporary and resolve after stent removal.
Patient have to get readmitted on a day care basis after 10-14 days to get the stent removed under local anesthesia which again is an endoscopic procedure of 5 min duration.
P.C.N.L (Percutaneous Nephrolithotomy)
Percutaneous means through the skin. P.C.N.L. involves making a small keyhole size (0.5-1 cm) cut on your back and creating a small tract with the help of guide wire and small dilators into the kidney.
The endoscope is then passed and the stone visualised and broken with either laser or other device known as lithotripter.
All the pieces are removed under vision and confirmed under X ray for any residual stones on operation table, followed by placement of a tube in your back which extends from kidney to outside through your back to drain the urine and dust.
A thin tube known as Double J stent is also placed at the end of procedure which extends from kidney to urine bladder. The Urologist may decide intraoperatively not to place a Nephrostomy Tube (Tubeless PCNL) on a case to case basis.
A Foleys catheter is also placed to drain your urine. Depending on the location and number of stones, surgery can take anywhere from 1 to 2 hours to complete and usually involves a one to two days hospital stay. Complicated stones may need development of more than one tracts and placement of more than one nephrostomy tubes.
In case of large stone load or complex stones repeat PCNL may be needed before a patient is completely stone free. There is always some risk of bleeding , infection, adjacent organ injury however all of them can be safely managed most of times. The nephrostomy tube and urine catheter are removed and discharged by day 2 after surgery. You may have a burning sensation when passing urine after the catheter is removed. This if required can be relieved with medication or increased intake of water.
The Double J stent is removed after 2 weeks on a day care basis using an flexible endoscope and patient is discharged the same day.
RIRS ( Retrograde Intrarenal Surgery)
This is a minimally invasive procedure which utilises special equipment known as a flexible ureteroscope to access all portions inside the kidney.
Its typically used for stones which are < 1.5 cm , or to remove some residual stones after a previous surgery or ESWL, or for stones which are not visible on plain x ray or for patients who are on blood thinners and due to some reason cannot be stopped.
This procedure is generally performed under General Anesthesia.
This procedure is generally a two staged procedure in which first sitting involves placement of only double J stent so that the ureters can dilate and next sitting performed after 7-10 days involves the actual process of breaking and removing the stone which may or may not need stenting again depending on the operative findings and surgeon decision.
Discharge is usually done on the next day if its an uneventful recovery. If the stent is placed in second sitting it is then removed after 2 weeks as a day care procedure. In some conditions in patients whose ureter is very wide , even single sitting RIRS is also possible however it depends on case to case basis.
CPE+CLT/ PCCLT ( Cystoscopy+Cystolithotripsy/ Percutaneous cystolithotripsy)
These are minimally invasive treatment options for bladder stones. Depending on the size and number of stones, either the endoscopy is done from the natural passage i.e urethra and the stone is broken with laser/lithoclast if the size of stone is < 2-3 cm.
However for larger size stones a small puncture is done just above your pubes and the tract dilated till bladder followed by endoscopic removal of the stone.
Double J stent/PCN (Percutaneous Nephrostomy)
Double J stents are soft silastic tubes placed endoscopically which extends from your kidney to urine bladder and cannot be seen from outside.
Their sole purpose is to decompress the urinary system, reduce the swelling and inflammation, drain any pus and reduce infection and also helps in passage of small dust after surgery.
Sometimes they are placed solely to dilate the ureter and make it more capacious so that later on our instruments can be accommodated easily to perform safe surgery.
Stents are known to cause some discomfort as long as they are inside he body like, frequency of urination, urgency, flank pain, some blood drops at end of urination, mild burning sensation while passing urine.
These symptoms resolve once the stent is removed. Depending on need they are generally removed after 10-14 days again through a endoscope which needs a day care admission and involves a 5 min procedure, generally done under Local anaesthesia followed by discharge 2-3 hrs later.
PCN/nephrostomy tube is a special tube which extends from kidney to outside from the back. The purpose of these tubes are to drain any infection/urine from kidney directly to an external collection bag.These tubes also cause some discomfort as long as they are present, however once all stones are removed and /or infection settles, they are removed the pain resolves.
Both these tubes serves as emergency rescue tubes in cases of fever or severe infection/sepsis which can generally be placed under local anesthesia under Ultrasound guidance or may require placement in OT under Fluoroscopic guidance. They function by draining the urinary system effectively of all pus and infected material and hasten the recovery of the patient following which the stone surgery may be planned later.
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Dr Anantkumar Urologist
Best Robotic Surgeon In Delhi
Location: Max Supper Speciality Hospital (A Unit of Devi Devki Foundation) 2, Press Enclave Road Saket, New Delhi – 110017
Email: dranantkumar57@gmail.com