Dr. S. K. Pal is an eminent endourologist and is a renowned urological surgeon in Delhi. He has innovative skills and aggressive procedural expertise in various techniques of standard and mini PCNL, RIRS, and URS. Dr. Pal has earned the reputation of an international authority on kidney stone disease. He is sought after for his innovative approach to treating common kidney and renal stones. Dr. Pal is proficient with modern technologies and has trained numerous specialists in the field. He has excelled in both upper and lower endocrinology. He was also elected as National Convener of Endocrinology by Urological Society of India. Here, he has shared the most frequently asked questions about Urinary Stones. Read on to know about latest technological developments in the field.
1. Where are the kidneys situated in our body & what comprises of the urinary system?
We have two kidneys, normally situated in the loins. These filter & clean our blood continuously and the waste products are passed out of the body through our urine. The urine passes through a 25 to 30 cms long tube called the ureters, which bring the urine down into the urinary bladder, situated in the lowermost, front part of our abdomen.
2. What causes stone formation in the urinary system?
Several waste products and chemicals are excreted in the urine in a soluble form. The capacity of an individual’s urine to dissolve various chemicals and substances is varying, and sometimes, reaches to its maximum dissolving capacity. When this happens, any further excretion leads to the formation of crystals of the chemical/substance. In the long run, these crystals stick to each other and form a stone. Thus, this tendency to form stones in the urinary system is subject to individual health.
Most of the time, these patients continue to form stones repeatedly, while other members of their family consuming the same diet may not face such complications. Oftentimes, this tendency to form stones is also hereditary.
3. How to prevent stone formation?
There are several medicines available which prevent the formation of crystals & prevent aggregation of formed crystals so that a larger lumpy stone is prevented in the early stages itself. However, the best way to prevent stones is to increase your water intake. This way even if a 2 or 3 mm stone is formed, it will be washed away with the urine.
4. What are the symptoms of a kidney stone?
A common symptom is severe pain on the affected side and the loin, lasting for 2 to 4 hours and often accompanied by nausea and vomiting. At times, a reddish-bloody tinge of the urine is noticeable along with an increased desire to pass urine very frequently. This episode of pain and discomfort usually lasts only for 1-2 days and then the patient becomes pain-free till another similar episode is repeated after a few days or months.
5. How can we be sure about stone formation?
Nowadays, an ultrasound of the abdomen is available everywhere and although this helps in detecting stones, it is not the only preferred choice. An ultrasound has its limitations as it may not detect stones in the ureter very accurately. Unless the ureter is large, obvious & dilated due to a long-standing stone, it is difficult for the ultrasound to detect the same. Another limitation is that the ultrasound cannot accurately measure the size of the stones.
A good way to detect stones is a kidney x-ray. Approximately 90% of urinary stones can be detected in an X-ray of kidney ureter & bladder region (X-ray KUB), taken on an empty stomach with thorough bowel preparation. Most comprehensive details of stones can be obtained by doing a non-contrast C.T. scan of the kidney, ureter & bladder region (NCCT of KUB). It does not need bowel preparation or necessarily an empty stomach to perform. In case assessments of kidney function or finer details of anatomy are required, contrast-enhanced CT scan or CT Urography can be done.
6. Do all stones need operation/surgery for their removal?
Not necessarily, stones up to 4 to 5 mm size do not need any active intervention, unless they start causing obstruction to the flow of urine from whole or a part of the kidney & thus endanger the function of the kidney. Mostly these stones are passed out along with urine. But, the patients who have been suggested this line of treatment must remain under the supervision of their urologist on and off. They should not assume that the stone has been passed out, just because they do not have any pain or other symptoms because not all stones necessarily cause pain all the time. They must get frequent checkups and tests done till it is confirmed that the stone has been passed out on its own.
7. What are the treatment options available for small stones in the kidneys?
If the size of the stone is less than 1.5 cms, the kidney is functioning well, and producing lots of urine- then the stone can be broken into several small particles within the kidney itself from outside the body with the help of a machine called Lithotriptor. This technique is called ESWL or Lithotripsy. These stone particles are then gradually passed out of the body, with the flow of urine in next few days. However, it is required for the patient to come for a review on a weekly basis till all the stone particles have been cleared from his/her urinary system.
8. What happens during a surgery?
Any size or any number of stones can be removed from the kidneys with a technique called PCNL or keyhole surgery. More than 90% stones need only one incision of 8mm, but some may require two or very rarely, varied incisions in different size of 5-8 mm incisions. This is to ensure complete clearance of stones. In this technique, a patient is admitted for 1 to 2 days in the hospital & after anesthetizing to the lower portion of the body, a telescope is passed inside the kidney right up to the stone. The stone is fragmented into several small particles by using the laser, pneumatic or ultrasound energy & then all the stone particles are removed from the kidney. Thus patient is rendered stone-free right at that moment & then kidney is washed thoroughly from inside with the jet of saline (sterile liquid) so as to achieve a complete clearance of stone burden including fine dust of stones. This procedure is done under double control. A visual control with the telescope inside the kidneys displays every portion of the kidney on a large TV screen in operation theatre & a continuous X-ray monitoring on the table shows the presence or movement of the stones within the urinary system on another screen. This is the only technique with double control & hence gives most confident and complete clearance of stones from the kidneys, tubeless PCNL which causes minimal or no pain after the operation has also been a routine. All these new developments are extremely helpful in reducing bleeding and post-operative pain, so as to make this procedure amazingly patient-friendly.
9. Can stones in both the kidneys be removed at the same time?
Yes, that is possible. Unless the patient is deemed medically unfit for a prolonged operation or for anesthesia, both the kidneys can be operated upon at the same time. However, if there are any such complications, then the second kidney can be operated upon, after 1-2 days.
10. What are the complications of a surgery?
Every surgery has certain complications which can be avoided with utmost care and sanitary protocols. These are commonly bleeding & infections. A mere 2-3% of patients need blood transfusions and very rarely, a bleeding vessel will require its blockage.
11. Is there absolutely no harm or complication of making a hole in the kidney in this surgery?
No harm at all. Many studies have shown that it affects less than 1% of the total kidney function & it does not harm the kidney functioning in any way. This surgery is safe and is routinely performed even in patients who are on dialysis, with chronic kidney failure, without harming their kidneys in any way. The hole in the kidney heals up quickly within few days.
12. Is there any other treatment for kidney stones where no hole is made in the kidney?
Yes. Retrograde Intra Renal Surgery (RIRS) is a new modality in which a kidney stone is converted into finer dust with the help of Holmium Laser. Fiber is passed through a very thin, flexible, diameter long telescope called flexible ureterorenoscopy. This endoscope/tiny camera object is passed up, till the stone through normal natural urinary passages & no cut is made anywhere on the body & no hole is made in the kidney. These patients undergoing RIRS can be discharged from the hospital either on the same evening or next day of the procedure and the stone dust is passed out with their urine.
13. Is RIRS available in India?
Although RIRS is an excellent, non-invasive, safe procedure of kidney stone removal, it is not very popular in India. The main reason is its cost factor. The flexible instrument that’s used for RIRS is very expensive and is prone to damage after 15-20 uses. This also involves the usage of Holmium Laser & a single-use laser fiber and fine delicate expensive guide wires, disposables, and baskets- all of which tend to increase the costs of this operation.