Kidney Stones/ Ureteric Stones

Kidney stones are formed when an imbalance occurs in various chemicals that are present in the urine. The most commonly involved chemicals are calcium, oxalate, citric acid, uric acid and cysteine. When there is an abnormal composition of urine such as with certain medical conditions, some of these chemicals can precipitate and form crystals, that later result in the formation of stones. In addition, certain medications can also contribute to the formation of kidney stones.

You are at increased risk of developing recurrent kidney stones if:

• You don’t drink enough of water.
• You eat a high protein, low fiber diet high in sodium and sugar. Too much sodium in your diet means that the amount of calcium your kidneys has to filter, increases your risk of kidney stones.
• You have had recurrent kidney or urinary infections
• Only one of your kidney works
• You are inactive or bed bound.
• Family or personal history of kidney stones increases your risk of developing stones.
• If you already had one or more kidney stones, you’re at increased risk of developing another.
• Being obese.High body mass index (BMI) and weight gain have been linked to an increased risk of kidney stones.
• Medical conditions.Diseases and conditions that may increase your risk of kidney stones include renal tubular acidosis, cystinuria and hyperparathyroidism.

Calcium stones are the most common stones and occur in about 80 per cent of patients with kidney stone disease. Among calcium stones, the most common form of stones found are calcium oxalate stones followed by calcium phosphate stones. Other important stones are those composed of other chemicals like uric acid, struvite (magnesium ammonium phosphate) and cysteine stones.

High calcium levels in urine and high oxalate levels in the urine can cause formation of calcium stones. Patients who do not drink enough water are also at risk of developing calcium stones.

Recurrent urinary tract infections with certain bacteria, for example, proteus or klebsiella, create an environment in the upper urinary tract that is favourable for the formation of a fast growing stone composed of magnesium ammonium phosphate.

Some patients have a genetic abnormality that causes them to excrete excessive cysteine in the urine leading to the formation of cysteine stones.

Pain due to kidney stones can vary in intensity and is usually present in the flank or lower abdomen. The pain may be associated with nausea and vomiting and may be more intense when passing urine.

Another common presentation of kidney stones is the appearance of blood in the urine. Other symptoms include frequent and painful urination and fever.

Some general precautions for a patient diagnosed with kidney stone disease are:

• Increase your daily fluid intake (water intake should exceed two litres per day)-if you already have renal failure you need to check with your doctor about how much water you can have.
• Lower the content of animal protein in your diet (reduce meat intake)
• Lower daily salt intake (2000 mg sodium restriction per day)
• Lower intake of high oxalate content foods (example: spinach, beets and chocolate)
• Limit coffee, tea and cola intake
• Do not take excess of Vitamin D supplements. Take them only as prescribed.
• Reduce your daily sugar intake
• Lemon and cranberry juice are considered safe

If there is blockage of urine flow, it may result in infections which can damage your kidneys. There is a 20% chance of recurrence in 5 years.

Most kidney stones will be small enough (< 4 mm in diameter) to be passed out in your urine. These also cause pain that lasts a couple of days and disappears when the stone has passed out.

Medication: If you have severe pain, you will be given a painkiller as well as medication for the nausea and vomiting.
You should drink enough water to make your urine colourless to help the stone to pass out.

Admission to hospital: You may be admitted to hospital if you have severe pain and if you are at increased risk for any reason such as if you have only one kidney, you are vomiting too much and cannot keep any fluids down or if you are have other medical problems or are advanced in age.

Stones that do not pass on their own are treated by a procedure.

ESWL (Extracorporeal Shockwave Lithotripsy): uses X-rays (high-energy radiation) or ultrasound (high-frequency sound waves) to locate the kidney stone. A machine then sends shock waves of energy to the stone through the skin to break it into smaller pieces so it can be passed in your urine. This non-invasive procedure is safe and easy to practice and has quickly gained popularity instead of surgery. The procedure is performed under sedation as it can be uncomfortable. After the lithotripsy, all the tiny particles of the stones get removed by the kidney through the urine.
However, before undergoing the procedure, you should consult your doctor about your current physical condition and any medication or supplements you may be taking.

Endoscopy: For those stones that cannot be removed with ESWL, there are procedures that are performed through endoscopy (passing a lighted tube to visualize and perform surgery through natural body passages). These are fairly simple procedures and patients can often go home the same day.

Laser treatment uses a machine called the Holmium Laser to break down the stone and is used in combination with endoscopy.

Ureterorenoscopy: This surgery involves passing a long, thin telescope called an ureteroscope through your urethra (the tube through which urine passes through out of the body) and into your bladder. It is then passed up into your ureter up to where the stone is lodged. Ureterorenoscopy is also sometimes known as retrograde intrarenal surgery (RIRS).
The surgeon may either try to remove the stone using another instrument or laser energy may be used to break the stone up into small pieces so that it can be passed naturally out in your urine. Your surgeon may place a plastic tube called a stent inside you temporarily, to allow the stone fragments to drain into the bladder.
Ureterorenoscopy is performed under general anaesthesia.

Percutaneous Nephrolithotomy or PCNL, is a procedure to remove medium-sized or larger kidney stones from the patient’s urinary tract by means of a nephroscope that is passed into the kidney through a track created in the patient’s back. The term “percutaneous” means that the procedure is done through the skin. Nephrolithotomy is a term formed from two Greek words that mean “kidney” and “removing stones by cutting.”

The nephroscope is an instrument with a fiber optic light source and two additional channels for viewing the inside of the kidney and washing out the area. The surgeon may use a device with a basket on the end to grasp and remove smaller kidney stones directly. Larger stones are broken up with an ultrasonic or electrohydraulic probe, or a holmium laser lithotriptor. The holmium laser can be used on all types of stones.

Postoperatively, you will have a urinary catheter to drain the urine through the bladder and a nephrostomy tube is placed in the incision in the back to carry fluid from the kidney into a drainage bag.
After surgery, you may experience some discomfort due to the presence of the drainage tube. You will be have an x-ray to evaluate the position of the stent and catheter. Your doctor will observe your progress and decide on how long the stent should remain. The catheter is generally removed after 24 hours. The nephrostomy tube is usually removed while you are still in hospital but may sometimes be left in after you are discharged.

Obstruction of the ureteropelvic junction (UPJ) –where the ureter meets the kidney, may be caused by congenital abnormalities such as a horseshoe kidney, fibrous scarring due to stones or a previous operation, a blood vessel that crosses it causing it to kink or a stone that gets impacted in the upper part of ureter. The build-up of pressure behind the obstruction can cause damage to kidney tissue, deterioration of kidney function and kidney failure. It causes symptoms such as pain, infection or high blood pressure. Laparoscopic Pyeloplasty is the procedure of choice to relieve all these symptoms.

After a general anaesthetic has been given, a telescope is placed through the urethra into the bladder. A little tube (stent) is placed in the ureter, which is the tube that connects the kidney to the bladder.
Through small incisions in the side of the abdomen, just below the ribs, the narrow part of the junction between the renal pelvis and the ureter is excised. A new ‘join’ between the kidney and ureter is constructed. The ‘stent’ placed internally between the kidney and the bladder remains at the end of the operation and is removed about 6 weeks after surgery. This is done under local anaesthesia.

This is rare and usually done for a very large stone or if there is an abnormal kidney or ureter.

Laparoscopic surgery or minimally invasive surgery is an alternative to open surgery by which a laparoscope (a lighted tube) is passed into the abdomen through which surgery is performed.

The term ‘nephrectomy’ means removal of a kidney. Kidney removal may be recommended for cancer or if the kidney is damaged by infection or stones etc. A kidney may be removed either using an ‘open’ surgical approach or using ‘keyhole’ (laparoscopic) surgery. Open surgery to remove a kidney involves making a large cut on the side of the abdomen. This is associated with some pain of the incision –though every attempt is made to keep you pain free with mediations. It also involves a hospital stay of 7-10 days and would need some time for recovery.

A thin tube with a light and camera on the end (a laparoscope) and surgical instruments is passed through three or four, ½ -1 cm incisions. The camera sends pictures to a TV screen so that the surgeon can see the kidney and surrounding tissue. One of the incisions will be enlarged to enable the kidney to pass through once it has been disconnected from the surrounding tissues and blood vessels.

A laparoscopic nephrectomy is performed under general anaesthesia. The laparoscopic method of kidney removal has been shown to cause less blood loss and fewer complications than the open method as well as needing a shorter time to recover. The open surgical approach to kidney removal is now used only for complicated cases.

Preparing yourself in advance can reduce your anxiety before undergoing surgery.
You should inform your doctor if you are taking any medication and follow instructions about discontinuing them.
You should stop taking drugs such as aspirin, ibuprofen, and naproxen 2weeks prior to surgery. Many of these medications may contribute to unwanted bleeding during the surgery.
If you have symptoms such as burning sensation, blood in the urine, urinary frequency and urgency or fever 2 weeks prior to the surgery, inform your doctor.
You may be asked to take a laxative a day before surgery to prevent the risk of constipation during the recovery period.
You should take nothing by mouth for at least 8 hours before (from midnight the night before) surgery and have only a light dinner.

You should contact your doctor if you have fever of 38°C (100.4°F) or higher with shivering or chills and if the pain gets worse, particularly if it is a sudden, severe pain.

Complications of treatment of kidney stone are:

• Infection
• Blockage of the ureter by the fragments of stone
• Injury to the ureter or bladder
• Bleeding