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Urinary Tract Stones & Kidney Stones treatment under Dr. Soumyan Dey:
- Patients are assessed by history and symptoms
- Attention is first given to address issue of pain, infection, inability to pass urine if any and restoration and maintenance of renal function.
- Various tests are run to see
- if stone is the cause of presenting symptoms
- if stone has caused any loss of renal function, or if it can cause any loss of renal function in future
- Size of stone, hardness of stone (CT Hounsefield units), location of stone are assessed
- Etiology or cause of renal stone formation is evaluated to determine prevention strategies
- Serum creatinine, urine for pH and routine examination, USG of kidney, ureter and bladder (KUB), CBC, RBS are the initial tests done
- PLAIN CT SCAN KUB, and sometimes CT UROGRAPHY or X RAY Urography and DTPA/ EC Renogram are also done sometimes.
- Serum PTH, VIT D3 are ordered.
- THEN WE ANSWERE THIS QUESTION: Do we require to actively treat this stone endoscopically or follow a WAIT AND WATCH policy with regular clinical follow up
- Various operative methods are explained to patient and decision to perform a procedure is taken after a thorough discussion
What are the Symptoms of renal stone?
- Severe pain in abdomen radiating from loin to groin.
- Nausea with vomiting
- Sometimes strangury, which implies a severe pain in perineum at end of voiding
- Inability to pass urine, occurs when a stone gets stuck in the outflow tract of bladder
- Sometimes signs of renal failure in bilateral stones, like swelling of face and foot and decrease in urine output
How is Renal / Kidney Stone Diagnosed?
Once patients present with symptoms as described above, a PLAIN CT SCAN abdomen or when a CT scan is unavailable, an Ultrasonography abdomen confirms presence of stone and absence of other pathology
Non-surgical TREATMENT FOR URETERIC STONE (MET) and when they are PRUDENT for URETERAL stones?
- MEDICAL EXPULSIVE THERAPY (MET) is prudent most of the time for small ureteric stones
- MET has a greatest success rate for ureteric Stones 5 mm or lesser
- MET may still have a fair success rate for distal ureteric stones upto 10 mm.
THE CORNERSTONE OF MET is prescription of a medicine: ALPHA BLOCKER DRUG like TAMSULOSIN.
- To continue on MET, PATIENT SHOULD BE PAIN FREE with paracetamol, free of infection, free of bilateral Ureteral obstruction, should have normal renal function or creatinine levels.
Surgical treatment for kidney stone and when they are required for URETERIC stones?
We inject a radio opaque dye or contrast into the kidney. This visualizes each and every calyces (chambers) of the kidney under the C-arm. The endoscope is passed to each of the calyces to check if any residual stone is left anywhere. At the end of the procedure there should be no fragments more than 2mm. When we have confirmed this the kidney specialist puts in a stent and the procedure is over.
- URETROSCOPY is done to visualize the ureteric stone; the stone is then fragmented and cleared with laser. Post URS sometimes a DJ stent may be inserted which will be removed after a few days.
- Laparoscopic URETERILITHOTOMY may be required for large stones 2 cm.
Which surgical method is chosen for renal stone removal?
- For stones more than 2 cm, Miniperc will be prudent
- For stones 1 to 2 cm, RIRS is the preferred treatment, however for a lower pole renal calculus with unfavorable anatomy, sometimes a MINIPERC may be required
- For stones less than 1 cm
- RIRS is the preferred modality to achieve clearance in a single sitting.
- ESWL can be used in treatment of upper, mid pole and renal pelvis stones, and sometimes even for inferior pole stones. If stones clearance is incomplete, secondary procedure like RIRS OR MINIPERC may be required.
Surgical methods for renal stone removal?
MINIPERC, ULTRAMINIPERC OR PCNLThese methods involves perctaneous access/ placement of a tube from the back then through the abdominal wall into the kidney, to visualize the stone and then the stones are fragmented and dusted with laser and cleared.
RIRSThe pelvicalyceal system/interior/lumen of kidney is visualized through an flexible ureterosrenoscopy, then the stones which are identified are fragmented and dusted with laser and cleared. The goal of holmium lithotripsy is to reduce stones to small fragments 2 mm or less. If the stone is large , the kidney is filled with dust and debris making visualization of fragments difficult, in such a situation a DJ Stent is placed and the stone is managed in a staged fashion in a second sitting after 2 weeks.
ESWLCan be done for stones less than 1cm , when they are in a favorable location in kidney ( non Lower pole) , and HU less than 1000
PNLRarely Laparoscopic assisted PNL may be required especially in the setting of PU junction obstruction.
- Patient is admitted on the morning of surgery, observed overnight after surgery and discharged the next day after an URS, RIRS, MINIPERC.
- After PCNL ,patient is observed for one more night before discharge
- Before discharge, an X RAY is taken to document stone clearance
- Urine may be pinkish for a few days
- Sometimes antibiotics may be required for a longer duration after the surgery
- If a stent is inserted ,stent dysuria is experience by few patient despite a generous use of ant cholinergic medication, which persists till the stent removal
- We usually insert a threaded stent after the procedure, so that we don’t admit the pt again for a stent removal. Also it avoids discomfort due to placement of a stent
- But sometimes , a stent has to be placed for a longer duration of around two weeks and patient has to come for a few hours day care admission for cystoscopy and stent removal under anesthesia
- Rarely there may be failure to clear all stones in the first surgery due to infection or unfavorable intrarenal anatomy require a second endoscopy
- Pain due obstruction to urine outflow from kidney
- Damage to renal function , evidenced by worsening hydronephrosis from mild to moderate to severe hydronephrosis
- Persistent and recurrent urinary tract infection
- Stone in bladder or urethra can cause painfull retention of urine
- Renal failure when both kidneys are affected with a long term obstruction
- Low fluid intake
- Obesity , diabetes and metabolic syndrome
- Urinary tract infections
- Mild pain
- Discomfort due STENT
- Bloody urine
- No method can guarantee 100% stone clearance, very very rarely small stone fragments may persist after a surgery
- Rarely injury to ureter
- Rarely bleeding from PCN tract which may require further treatment.
- Calcium containing stones:
- Calcium oxalate 60%,
- Hydroxyapatite 20%
- Brushite 2%
- Non calcium containing stones:
- Uric acid 7%
- Struvite 7%
- Rarely Cystine, Triamterene, Silica