Clinical Condition

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Kidney Stones

SOME FACTS ABOUT UROLITHIASIS (Stone disease):

Kidney Stone disease is the most painful urological disorder. Humans have been suffering from this disorder for centuries. Scientists have found evidence of kidney stones in a 7,000-year-old Egyptian mummy. The incidence of urolithiasis, or stone disease, has increased in the last 25 yrs. The reason for the change is of the dietary and climate changes in our population. Kidney stones are most common in middle-aged people and are 3 times more common in men than in women. Urbanization, stress at work, travellers bad food habits seems to the increase in the incidence of stone diseases of late.

The Urinary Tract-

The urinary tract consists of the kidneys, ureters, bladder, and urethra.

The kidneys are two bean-shaped organs located one on each side of the vertebral column in both loins. They are responsible for maintaining fluid and electrolyte balance by removing extra water and wastes from the blood and converting it to urine. Ureters are the narrow tubes that carry urine from the kidneys to the bladder in the lower abdomen. The bladder has elastic walls that expand to store urine. Urine is emptied through the urethra to outside the body.

What are kidney stones and how they are formed?

Kidney stones are gravel-like collections of crystalline mineral material formed within the kidney or urinary tract. Kidney stones often result from a combination of factors, rather than a single, well-defined cause. Normally, urine contains many dissolved substances. At times, some materials may become concentrated in the urine and form solid crystals. These crystals can lead to the development of stones when materials continue to build up around them.

In simple words it is the crystals formed due to precipitation of certain chemical components, which are in excess in the body. It can also happen due to deficiency of certain components. If the body fluid or urine has excess of stone formers like calcium, phosphorous, uric acid, oxalates etc and deficiency of stone inhibitors like potassium, magnesium and citrate to mention a few, might cause stone formation in the genitourinary tract. In addition if the body water content is inadequate as in hot conditions, one might land up with stone formation.

Certain conditions can also increase the risk of kidney stones such as obstruction to urinary passage like in prostate enlargement or stricture disease, hyperparathyroidism (an endocrine disorder that results in more calcium in urine), cystinuria (formation of cystine stones), hyperoxaluria (excessive urinary excretion of oxalate), hypercalciuria, (a surplus of calcium in the urine), hyperuricosuria, (excess uric acid), obesity, chronic diarrhea and gastric bypass surgery.

Where else the stone can be found in genitourinary tract’?

Ureter -The tubes which drain the urine to the bladder, urinary bladder where the urine is stored and sometimes in prostate.

What age group suffers from this ?

There is no age bar; all Age groups suffer from this disease starting from a child to old age. But commonly in the middle age group.

How one comes to know that he has a stone disease or what are the symptom manifestations?

It depends upon where the stone is located –

If the stone is in the kidney: Dullaching continuous pain in either of the loins or repeated urinary tract infections or sometimes intermittent hematuria – blood in the urine- in an young adult.

If the stone is in the ureter: Stones usually at least 3 mm can cause obstruction of the ureter. Ureteral obstruction cause hydronephrosis (distension and dilation of the renal pelvis and calyces), as well as spasm of the ureter. This leads to pain, most commonly felt in the flank (the area between the ribs and hip), lower abdomen and groin (a condition called renal colic). Renal colic can be associated with nausea, vomiting, sweating, urinary urgency, blood in the urine and painful urination. Renal colic is often described as one of the strongest pain sensations known. It typically comes in waves lasting from minutes to hours, beginning in the flank or lower back and often radiating to the groin or genitals. It is caused by peristaltic contractions of the ureter as it attempts to expel the stone.

some times patient presents with Lithuria : passing repeated episodes of Gravels or stones while pasing urine.

Sometimes they are asymptomatic especially when it is present in the kidney. Even large kidney stone like stag horn stone which occupies more than 80% of the kidney may not produce any symptoms and they come to light when undergoing evaluation for some other diseases.

How it is diagnosed ?

lt is diagnosed on the basis of clinical findings, X- ray abdomen, and Ultrasonography and urine examination. Some times advanced tests like spiral CT, contrast CT may be required

What are the predisposing factors for the stone formation’?

Generally Hot climatic conditions suffer mostly from this disease . For ex- It is more common among northern part of India and the west. In Karnataka south canara and north suffer more compared to south although we don’t have authentic records and statistics.

Any congenital anomaly of the kidney like birth defects like PUJ obstruction and horse shoe kidney etc .,.will have more predisposition to form stones .

If there is stasis of urine in the urinary system like in chronic BPH conditions or any obstruction along the urinary tract

Some metabolic disorder with some parathyroid hormone changes might well produce bilateral kidney stones.

Family history of the stone disease

By your above explanation of the causes does it mean that once the stone is formed, is it going to form again even after its complete removal ?

Yes, stone recurrence is very common.

If not treated there are 20-3 0% chance that it recurred within 2 years, 50 % chance with in 5 years and 65 % chance in 10 years.

If treated appropriately with diet modifications to reduce the stone formers in the body this can be reduced to more than 60 % although 100% cure is impossible to achieve.

What are the complications of stone disease’ ?

Repeated infection / pyelonephritis etc

Obstruction and further leads to temporary kidney failure with rise in serum creatinine .

If obstruction is repeated and if not treated timely and if associated with other systemic diseases might leads to permanent renal failure needing dialysis and renal transplant.

Renal failure i.e chronic kidney diseases

There is a very good Indian study to suggest that if the stone is present in non functioning kidney for more than 7 years it might cause cancer either squamous cell or TCC

Does everybody with stone disease should undergo a Surgical treatment ?

No, ,

There are 4 different groups of patient who undergo treatment either surgical or medical treatment

Surgically active group: These are the group who has stones causing obstruction, blood in the urine, repeated infection and delayed functioning of the kidneys. These patients may require early surgical intervention to prevent complications

Metabolically active group: Stone found in early age group., These with repeated Lithuria i.e. passing stones in urine repeatedly in the past 2 years, or having asymptomatic small passable stones in both kidney’s. These patients are mostly asymptomatic or produce symptoms which may not require active surgical intervention. These should undergo complete stone , blood and urinary metabolic evaluation to find out the cause and to be treated. Most of these require medical treatment.

Metabolically dormant group can be observed on medical treatment

Fourth group falls in between

What are the treatment options for those with stone disease of the urinary system ?

Watchful waiting/ MET ;( Medical expulsion therapy) for small passable stones ; where in patient is asked to take certain medicines which will push the stone out of the ureter

ESWL – shock wave lithotripsy for the moderate sized soft stone :

Endoscopic removal for the stones in the lower ureter

Flexible ureteroscopy and laser disintegration for the stones in the complex kidney system and inaccessible system.

PCNL for the large stones of the kidney

with the addition of laparoscopy one can tackle complex pelvic stones via laparoscopic surgery

open surgery in selected cases

Any simple measures to prevent stone formation or recurrence ?

Should undergo screening for those with family history of stone diseas

Diet and life style modification as prescribed by the treating physician after metabolic evaluation.

long term medical management

with the addition of laparoscopy one can tackle complex pelvic stones via laparoscopic surger

Timely surgical intervention

What are the major concerns of this disease and what are the future plans ?

The major concern of this disease is its recurrence and its ability to destroy the kidney if neglected.

In this, our future plan is to make the general public awareness programme in the form of kidney stone awareness ,screening and treatment camp.

Trying to make the Stone clinic registry at Columbia Asia so that one can have complete statistics of stone belt and its demography and mass screening can be taken at an early stage.

DIET AND LIFESTYLE MODIFICATION

Those who are suffering from the stone disease can avoid / restrict some of the diet given below –

AVOID :

Oxalate stone formers should avoid : Palak, Tomato seeds, Black grapes, cucumber , cashew nuts, Amla , chikoo.

n this, our future plan is to make the general public awareness programme in the form of kidney stone awareness ,screening and treatment camp.

Uric acid/Purine stone former should avoid : Cauliflower, pumpkin, mushroom, brinjal, Red meat, Fish,Milk products

General precautions / diet advised :

Avoid excess of table salt

Avoid excess of animal protein

Maintain 2.5 litres of urine output : One needs to adjust the Water intake depending on the season to get the desired urine output

2 ounces of milk can be taken in a day

One glass of Lemonade per day without salt

Surgical treatment of stones include:

Shock Wave Lithotripsy (ESWL)

Ureteroscopy (URS)

Retrograde lntra renal Surgery (RIRS)

Percutaneous nephrolithotomy (PCNL)

Laparoscopic & Open Surgery

ESWL:

Extracorporeal shock wave lithotripsy (ESWL): Here the stone is fragmented in to small particles using a lithotriptor via the shockwave delivered from outside the body. Small stones in the kidney and upper ureter can be effectively tackled by this method. The main advantage is that the procedure can be done on an outpatient setting.

Semi rigid Ureteroscopy

This is an endoscopic method where in miniature (6 Fr) scope is passed through the urethra and the stones are fragmented and removed under direct vision. This method is used commonly for the removal of the stones when they are present in the mid and lower ureter and some times for the large upper ureteric stones. In this method stone is directly visualized and broken with pneumatic or ultrasonic lithotripsy or using LASER. The main advantage is complete stone clearance in a single stay.

Most of the ureteric stones can be tackled effectively by this method.

RIRS:

Retrograde lntra Renal Surgery: This is an advanced endoscopic technique of fragmenting the stone in situ using a flexible ureteroscope & LASER. Here the stone is approached whichever calyx it is present within the kidney and the stone is disintegrated using LASER under direct vision. Most of the complex small stones in the kidney can be tackled by this method. It is one of the current most favored approaches for the stone treatment.

Surgeons at Columbiaasia have done over >1200 RIRS and have standardised the procedure for kidney stones . This procedure in minimally invasive and 90 % of the kidney stones can be treated effectively be it simple or complicated. Also it is blood less , no shock waves , min radiation. This is a preffered procedure for those with multiple stones and stones in both kidneys. Here the fibre optic scope (shown above) is passed thorugh the urethra under anaesthesia into the bladder and all the way up into the kidney. Stones / disease to be treated are performed under vision using laser energy . it has the advantage of tackling minor calification if any (which are not picked by Ct scan ) so that future recurrance is prevented.

Percutaneous Nephrolithotomy (PCNL):

Here the kidney is directly punctured through the skin and a tract is made to approach the stone. Then the endoscope (Nephroscope) is used to visualize the stone and is fragmented by the available energy sources and Laser. This method is useful in large stone bulk within the kidney. Patient needs to stay in the hospital for 4-5 days.

Mini perc ; Here the procedure is same as above , however the hole created is small and sthe stone crushed using LASER. This is suitable for single stone in the kidney.

Columbia Asia achievemen

> 5000 laser surgeries till date

>3500 stone surgeries by LASER

>1200 RIRS (laser treatment for kidney stones and other diseases)

>500 laser surgeries for prostate enlargement

>500 laparoscopic procedure for various cancers of the kidney, prostate and urinary bladder

CARE OFFERED FOR KIDNEYS

Various urological diseases can affect kidneys. Commonest of them are stone and infections. We provide emergency care in acute pain because of stones and infections. We are equipped with state of art diagnostic and therapeutic modalities at our centre to manage renal stones.

We manage most of the ureteric and kidney stones with endourological procedures. We have rigid as well as flexible endoscopic instruments by which we can access any stones in the urinary tract and can break them with the help of LASER.

We are performing various reconstructive procedures laparoscopically on kidneys, commonest is laparoscopic pyeloplasty. We also correct other abnormalities in the urinary tract like ureteric obstruction laparoscopically.

Kidney cancer is rare compared to prostate cancer. However there is only one curative treatment available for kidney cancer and that is complete surgical excision. We specialise in laparoscopic removal of kidney cancer to giv best survival advantage.

For details about the condition and procedures, refer to our section on clinical condition.