Dr.M.Gopichand

Consultant Urologist

Minimally Invasive Urological Oncologist

Robotic Urologist

M.B.B.S., M.S.(Surgery), DNB(Urology), M.Ch(Urology)(Bombay)

Fellow society international urology

Ex. Faculty (NIMS), Robotic Training Atlanta, Georgia USA

 

kidney Stone Treatment

The field encompassing minimally invasive stone surgery is termed Endourology and is a subspecialty within Urology. Almost all urinary tract stones can be successfully treated with minimally invasive surgical techniques, and they have evolved significantly over the last twenty years. As a result, surgery which in the past required a lengthy hospital admission can now be performed sometimes as  day only   procedure. Fundamental to this have been the improvements made to endoscopic equipment, training, and the development of lasers to fragment stones. A tailored approach to stone management is available for each patient, balancing the need for complete stone clearance, along with achieving rapid recovery and early resumption of normal activities. Each technique has their various pros and cons, and will be outlined in detail.

  • Shock Wave Lithotripsy
  • Ureteroscopy and Laser
  • Flexible Pyeloscopy & Laser
  • Percutaneous Nephrolithotomy

Laser Stone Surgery using Rigid Ureteroscopy
What is it?
Ureteroscopy is where a long thin rigid telescope is introduced into the upper urinary tract via the bladder (see diagram below). The diameter of the instrument is less than 2mm and allows visualisation of the lower half of the ureter. A small instrument port allows introduction of micro-baskets and laser fibres (0.3mm in diameter) to manipulate and fragment stones. It is used only to treat stones in the ureter, and cannot treat stones within the kidney
What are the main advantages of this approach?

  • Allows stone treatment without the need for any incision by using the urethral orifice as the entry point
  • A highly successful technique (over 95%)

What are the main disadvantages?

  • More invasive compared to shock wave lithotripsy
  • Small risk of infection and damaging the ureter (0.5%)

What happens in the operating room?
You will meet your anaesthetist prior to surgery who will take a thorough medical history. This person will be responsible for your safety whilst you are under general anaesthesia. The procedure will usually take 60 minutes and involves putting a rigid telescope into the drainage tube (ureter) of the kidney and fragmenting the stone with laser. A temporary urinary stent may be left in place for a short period to ensure the kidney drains without risk of blockage.
What are the risks?
This is generally considered a very safe operation. Specific risks to surgery include: infection, minor bleeding, and perforation of the ureter (1 in 200).
What to expect afterwards?
It is normal to feel the need to pass urine frequently and notice blood in the urine following surgery. This will settle over the ensuing days. You will sometimes have a temporary urinary stent (see urinary tract stent info sheet) following surgery which allows the swelling in the ureter to settle from where the stone was located. Follow-up
You will be advised after surgery the necessary follow-up arrangements. A script for oral antibiotics will need to be taken for 5 days to prevent infection. You need to drink at least 8 glasses of water a day (2.5L/day). Simple analgesics such as Pparacetomol and tramadoln are usually all that is required, occasionally stronger medication . You will not be able to drive for at least 24 hours after surgery as you have had a general anaesthetic

Laser Stone Surgery using Flexible Pyeloscopy
What is it?
Pyeloscopy is where a thin fibre-optic telescope is introduced into the kidney from the bladder via the urethra (see diagram). The diameter of the instrument is less than 3mm and allows visualisation of the entire kidney drainage system due to the flexible nature of the scope. It contains a small instrument port which allows the introduction of laser fibres (0.3 mm diameter) to efficiently fragment stones, and micro-baskets (less than 1mm wide) to retrieve stone fragments. Kidney stones up to 2 cm in size can be treated using this approach.
What are the main advantages of this approach?

  • Allows stone treatment without the need for any incision by using the urethra as the entry point
  • Has a very high degree of success in treating stones (over 90-95%)
  • Can be performed as day surgery

What are the main disadvantages?
MAY NEED TWO STAGE TREATMENT
1ST STAGE BEING JUST DJ STENT PLACEMENT
THEN AGAIN CALL AFTER 2 WEEK AND DO RIRS

  • General anaesthetic required
  • Small risk of damage to ureter (0.5%)

What preparation is required?
As the procedure is performed under general anaesthesia, you should have nothing to eat or drink for 6 hours prior to treatment. Regular medications can be taken with a sip of water with the exception ofblood thinning agents (eg. warfarin, aspirin, clopidogrel) or non-steroidal anti-inflammatories which need to be stopped for 7-10 days. A mid stream urine (MSU) test is required to ensure the urine is sterile before treatment is undertaken.
What do I need to bring to surgery?

  • All related imaging such as x-rays, CT scan or ultrasound
  • Your usual medications

What happens in the operating room?
You will meet your anaesthetist prior to surgery who will take a thorough medical history. This person will be responsible for your safety whilst you are under general anaesthesia. The procedure will usually take 60 to 90 minutes and involves putting a flexible telescope into the drainage tube of the kidney and fragmenting the stone(s) with laser. A temporary urinary stent may be left in place for a short period to ensure the kidney drains without risk of blockage.
What are the risks?
This is generally considered a very safe operation. Specific risks to surgery include: infection, minor bleeding, and perforation of the ureter (1 in 200).
What to expect afterwards?
It is normal to feel the need to pass urine frequently and notice blood in the urine following surgery. This will settle over the ensuing days. An oral over the counter medication called Ural can reduce the stinging sensation during urination. You will sometimes have a temporary urinary stent (see urinary tract stent info sheet) following surgery which allows the stone fragments to drain unimpeded. The stent maybe attached to a string coming out from the urethra allowing ease of removal (in the doctor’s office) when no longer required. Care needs to be taken so as not to accidently dislodge the stent by pulling on the string or catching it on your underwear.
Follow-up
You will be advised after surgery the necessary follow-up arrangements. A script for oral antibiotics will need to be taken for 5 days to prevent infection. You need to drink at least 8 glasses of water a day (2.5L/day). Simple analgesics such as Panadol and Nurofen are usually all that is required, occasionally stronger medication (eg. Panadeine Forte) may be necessary. You will not be able to drive for at least 24 hours after surgery as you have had a general anaesthetic.

Percutaneous Nephrolithotomy (PCNL)
What is it?
Percutaneous Nephrolithotomy (PCNL) is the preferred technique for treating large stones (over 2cm in diameter) within the kidney. It involves keyhole surgery performed through a 1cm incision in the skin overlying the kidney (see diagram).
What are the advantages?

  • Allows large or complicated stones to be treated in a minimally invasive fashion, where in the past this would have necessitated a large skin incision.
  • Hospital stay is 3-4 days, and out of hospital recovery time is significantly shorter than traditional open surgery.

What are the disadvantages?

  • Occasional bleeing from kidney and need for blood (1 in 100)
  • Compared to traditional treatments of large complex stones, there are no disadvantages.  Improved techniques and equipment have allowed this type of surgery to be safer than ever before.

What preparation is required?
You will be required to have detailed imaging to allow the surgeon to assess the stone in fine detail regarding its relationship to the kidney and nearby structures.  This will enable the surgeon to plan the best access point(s) to the kidney to allow effective clearance of stones.
As the procedure is performed under general anaesthesia, you should have nothing to eat or drink for 6 hours prior to treatment. Regular medications can be taken with a sip of water with the exception ofblood thinning agents (eg. warfarin, aspirin, clopidogrel) or non-steroidal anti-inflammatories which need to be stopped for 7-10 days. A mid stream urine (MSU) test is required to ensure the urine is sterile before treatment is undertaken. Other tests required include urine culture, kidney function studies, and complete blood counts. These tests will all be organized from the rooms after your consultation.
What are the risks?
This form of surgery is low risk if performed by an urologist who is specifically trained in this technique, and aided by meticulous pre-operative planning. The specific risks are uncommon but include infection, excessive bleeding (necessitating blood transfusion 2%, embolisation 1%, renal exploration 0.5%), and rarely adjacent organ injury (spleen, liver, bowel, and lung).
What do I need to bring to surgery?

  • All related available imaging such as KUB (kidneys, ureter, and bladder) x-ray, CT scan abdomen, or kidney ultrasound
  • Your usual medications

What happens in the operating room?
The operation is performed under a general anaesthetic and lasts approximately 2 to 3 hours. It is a team effort requiring coordination between surgeon, anaesthetist, radiology and nursing staff. You will be positioned on the operating room table lying on your front “stomach” for the duration of the surgery. The procedure is accomplished with the assistance of x-ray imaging to guide entry of a 1cm tube into the kidney. This provides access into the kidney drainage system allowing telescopes and instruments to visualize, fragment and remove stones. A drainage catheter (nephrostomy tube) which exits through the skin is left in the kidney at the end of the procedure.
What to expect afterwards?
You will have a temporary catheter called a nephrostomy tube draining the kidney, as well as a urinary catheter in-situ. They will be removed prior to discharge from hospital. The urine will be bloodstained for up to a week after discharge from hospital. Imaging is performed immediately after surgery to assess stone clearance. Occasionally, further minor surgery is required to clear any remaining stones to achieve complete stone clearance. Your hospital stay will be 3-4 days on average.
Follow-up
You will be required to take it easy during the recovery phase for several weeks. There should only be minimal discomfort from the wound. Oral antibiotics will be given for a further five days to prevent infection. It is important to inform us if you feel unwell with fevers, chills, or develop heavy bleeding in the urine. Your initial follow-up will be in 6 weeks after discharge. Occasionally, a urinary stent is left to ensure the urine drains correctly into the bladder. This will require removal at a later time.

Shock Wave Lithotripsy (SWL)
What is it?
Shock wave lithotripsy (SWL) uses high frequency sound waves from an external source (outside the body) to break a kidney stone into small pieces, and allow it to pass through the urinary tract.
MAY NEED DJ STENT  PLACEMENT IN OPERATION THEATRE
What are the main advantages of this approach?

  • Least invasive option available
  • Safe

What are the main disadvantages of this approach?
Compared with other available techniques:

  • Per treatment, is the LEAST  successful at achieving stone clearance in one session
  • Treatment may require MULTIPLE  sessions to achieve complete stone clearance
  • Results more likely influenced by patient size, stone types, and unfavourable kidney anatomy
  • Recent concerns regarding increased long term risk of hypertension and diabetes remains an area of contention
  • SOMETIMES WASTAGE OF MONEY ,TIME AND TREATMENT
  • BUT IT IS NON INVASIVE DOES NOT EVEN NEED ADMISION SOMETIMES

What preparation is required?
As SWL is performed under sedation or general anaesthesia, you should have nothing to eat or drink for 6 hours prior to treatment. Regular medications can be taken with a sip of water with the exception of blood thinning agents (eg. warfarin, aspirin, clopidogrel) or non-steroidal anti-inflammatories which need to be stopped for 7-10 days. A mid stream urine (MSU) test is required to ensure the urine is sterile before treatment is undertaken.
What are the risks?
SWL is considered a safe procedure. Specific complications involve:

  • Pain caused by the passage of stone fragments
  • Blockage to the urine flow as a result of stone fragments causing obstruction, necessitating further surgery
  • Infection
  • Bleeding around the outside of the kidney

ESWL is not performed if you:

  • Are pregnant as the sound waves and x-rays may be harmful to the developing baby
  • Have a bleeding disorder
  • Have a kidney infection, urinary tract infection, or kidney cancer
  • Have kidneys with abnormal structure or function

What to expect afterwards?
After SWL, stone fragments usually pass in the urine for up to several weeks after surgery and may result in mild pain. Occasionally, you will need further SWL or other minimally invasive stone treatments to complete stone clearance. Strain all urine in the first 48 hours after surgery, and bring the fragments to your doctor in a dry container for stone analysis.
Follow-up
You need to drink 8 to 10 glasses of fluid per day to aid the passage of stone fragments. You will be reviewed in the office after 1 month. A KUB (Kidneys, Ureter, Bladder) x-ray should be done just prior to seeing the doctor. MAY need dj stent and its removal