Part 2
By Dr Vineeth Naja, MS (Gen Surgery) MCh (Urology)
(Consulting Urologist and Andrologist)
This is the second part in our discussion on kidney stones. This week we will look at the management of kidney stones and attempt to explain the steps involved in the various procedures that are available here.
Treatment
When tests show there is a kidney stone, the next step is to determine treatment. The patient should be admitted to the emergency room if they have severe vomiting, fever, or symptoms of infection.
Treatment for severe attacks
Strong opioid painkillers are often required for a severe kidney stone attack. However, doctors will usually not give such drugs until they confirm the presence of a kidney stone on an x-ray.
Watchful waiting
In about 85% of patients, the kidney stones are small enough that they pass through normal urination, usually within 2-3 days. In some cases, a stone may take weeks to months to pass, although pain usually goes away before that.
The patient should drink plenty of water (two to three quarts a day) to help move the stone along, and take painkillers as needed. The doctor usually provides a collection kit with a filtre and asks the patient to save any passed stones for testing.
If the stone has not passed in 2-3 days, or pain persists and/or there is morbidity the patient will need additional treatments. In some severe cases, hospitalization may be necessary.
Other treatments
Surgery is usually needed if the stone is too large to pass on its own, if there are signs that the stone is growing, or if the stone is blocking the urine flow and causing urinary tract infection or kidney damage.
Stone removal procedures:
■ Minimal invasive procedures
● Extracorporeal shock wave lithotripsy (ESWL)
● Percutaneous nephrolithotomy(PCNL)
● Ureteroscopy(URS)
● Cystolithotripsy(CLT)
■ Standard open stone surgery(OSS)
Extracorporeal shock wave lithotripsy(ESWL)
Extracorporeal shock wave lithotripsy (ESWL) is a technique that uses sound waves (ultrasound) to break up simple stones in the kidney or upper urinary tract. (‘Extracorporeal’ means ‘outside the body,’ and ‘lithotripsy’ means stone-breaking). The procedure generally does not work for stones larger than 3 centimetres in diameter (which is slightly over an inch). There are several variations of ESWL. The following is a typical procedure:
● Most ESWL procedures use some anaesthesia, although they are often done on an outpatient basis.
● The patient lies on a soft cushion with a water balloon beneath.
● The procedure uses ultrasound to generate shock waves that travel through the skin and body tissues until they hit the dense stones. (The doctor pinpoints the stone during treatment by using x-rays.)
● The shock waves crush the stones into tiny sand-like pieces that usually pass easily through the urinary tract.
● The shattered stone fragments may cause discomfort as they pass through the urinary tract. If so, the doctor may insert a small tube called a stent through the bladder into the ureter to help the fragments pass.
ESWL has a 50-90% success rate, depending on the location of the stone and the surgeon’s technique and experience. Recovery time is short. Most people can resume normal activities in a few days.
Complications may include:
Blood in the urine, the most common complication, may last for a few days after treatment. To reduce the chances of bleeding, doctors usually tell patients to avoid taking aspirin and other NSAIDs, which can promote bleeding, for 7-10 days before the treatment.
Bruising and minor discomfort due to the shock waves are common on the back or abdomen.
Sometimes the stone does not completely break up with one treatment, and additional treatments may be required. Inability to pass stone fragments may also be a particular problem in patients who have cysts or other kidney problems.
The advantages of ESWL include the fact there is no need to make a cut, there is no wound, no healing time, no admission to/stay in hospital or OPD procedure.
Percutaneous nephrolithotomy(PCNL)
Percutaneous nephrolithotomy may also be used for the treatment of kidney stones when the patient is not a candidate for ESWL (such as if the stone is very large, in an inaccessible location, or is a cystine stone).
It is more effective than ESWL for patients with severe obesity, and appears to be safe for the very elderly and the very young. Success rates are nearly 98% for kidney stones and 88% for ureteral stones. They may vary by the technique used and the specific patients. A typical procedure is as follows:
■ The surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney.
■ The surgeon then inserts an instrument called a nephroscope through the tunnel.
■ The stone is located and removed. If it is large, it is destroyed using ultrasound, lasers, or other devices. The surgeon then removes the fragments.
An advantage of percutaneous nephrolithotomy over ESWL is that the surgeon is able to remove the stone fragments directly, instead of relying on their natural passage from the kidney. Generally, patients stay in the hospital for 3 or 4 days and may need a small device called a nephrostomy tube left in the kidney for 1 day’s duration for smooth healing.
Complications: Complication rates are about 3%. Major complications occur in about 1% of patients. These complications may include scarring of the tissue, but studies indicate that this scarring does not impair kidney function, even if the patient needs repeat surgery. There is also a risk for blood loss during and after the procedure, which sometimes can be significant. Because the procedure uses large volumes of fluid, fluid overload is a potential problem, particularly in children or patients with heart disease. Infection may result in some patients. Other complications may include a collapsed lung and injuries to areas outside the kidney (but within the operative area), such as the abdomen or chest.
By PCNL a urologist may remove a complex stone without making an 8-10 cm cut in the body which takes at least 2 weeks to heal.
Next week, we will conclude our discussion on kidney stones.
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