Thursday, 4 February 2016

Urinary Stone Disease

Urinary stone disease is a well-known common problem in our country, affecting 10 to 15 % of the population. What is of increasing concern is that most of them are between 20 and 50 years of age. Men are affected three times more than women. People who are more likely to be affected by urinary stone disease include those: living in hot and dry climate; having a sedentary life style; exposed to high temperature while working; eating foods high in salt, and junk food. Obesity is another key risk factor, besides family history and urinary tract infections.
Stone formation occurs when minerals in the urine become very concentrated, leading to precipitation and crystal formation. This, in turn, may lead to crystal nucleation, aggregation and growth. There are various types of urinary stones, the commonest being calcium oxalate. Other types of stones are calcium phosphate, uric acid, struvite etc.
Symptoms of stone
Symptoms of stones in the kidney are hardly noticed until the stones grow big enough to irritate and tend to block the urinary system. You may experience dull back pain, suffer from urinary infections and notice rarely blood in urine. Unattended large stones in the kidney may lead to loss of kidney function, spreading of infection to your blood and very rarely septic shock, a life-threatening condition.
Sometimes, a kidney stone may travel into the ureter, the tube between the kidney and the bladder, and stay there. Such a ureteric stone may cause you severe pain in your sides below your ribs; you may roll in the bed with unbearable pain, as you may not respond to oral tablets, and may get some relief only with injectable pain killers.
Also, you may vomit, experience pain while passing urine, notice blood in urine and suffer frequent urination. Even though the symptoms are severe, such stones are spontaneously flushed out when you pass urine, provided they are less than 6 mm.
Stones in either ureter, or a single functioning kidney with ureteric stone may lead to sudden stoppage of urine production with no warning symptoms. Unless treated as emergency cases, such patients will suffer acute renal shut down. Stones in bladder or urethra can cause painful urinary retention.
Diagnosis
Ultra sound imaging of the kidneys, ureters and bladder is an ideal screening test to identify the problem of urinary stones. Blood test should be done to examine kidney function, and a routine urine examination to rule out urinary infection. However, a CT scan or an IVP (intravenous pyelogram), which is an x-ray test, is a ‘must’ to plan treatment for the stone. It is like a road map for treatment planning.
Management
The first step of urinary stone management is to relieve the pain with a safe pain killer. Once pain subsides, the medical condition of the patient has to be evaluated. Stone size of 5 to 6 mm in the kidney and up to 6 mm in the ureter can be safely managed with medication. Interventional treatment becomes necessary if the patient has abnormal kidney function, sepsis or intolerable pain even after medication or stones larger than 6 mm in the ureter and kidney.

Pictures above show in a 5-year child a large stone in the right kidney removed through a key hole in the back with Holmium laser Percutaneous Nephrolithotomy (PCNL).
Pictures below show stones in the kidney and ureter treated by flexible ureteroscope retrograde intrarenal surgery (RIRS) and Holmium Laser.

There are different methods available for urinary stone breaking like pneumatic, ultrasonic, electro-hydraulic etc. However, Holmium laser is a versatile laser in stone treatment; stones of any size in the kidney, ureter or urinary bladder are best managed, irrespective of the nature and hardness of stones, with least complication and best results.
Various setting options in the 100-watt laser help in the fragmentation and dusting of the stones, with superior stone clearance rate and shorter time than those of shock-wave lithotripsy (a procedure that uses shock waves to break up stones). Also, Holmium laser is quite effective in patients who are unhealthily obese, or pregnant, or on blood thinners, whereas shock-wave lithotripsy is not medically advisable.
Prevention
Patients with urinary stone disease must reduce salt intake, increase fluid intake and cut down on red meat. Medication and periodic check-up with an Ultrasound Sonography Test (USG) or an x-ray would help plan appropriate treatment and avoid recurrence of the disease.
Further metabolic evaluation is needed in cases of frequent stone formation, single functioning kidney, anatomical defects in the urinary system, chronic diarrhea with stone disease, infected stones and strong family history of stone disease.
Myths
There are certain popular beliefs which are not medically true. For example, the common belief is that reduced sodium intake helps prevent urinary stone formation. But, in fact, reduced calcium intake beyond normal requirement is not advisable. Reduction of the daily required calcium in our diet usually results in increased absorption of oxalate from the gut, which in turn increases the oxalate in urine leading to stone formation.
There isn’t enough scientific evidence to support the belief that restriction of a particular fruit, nut or vegetable helps in preventing stone disease. However, it really helps to eat all the vegetables and fruits, in moderation. There is no relationship between stone formation and hardness of water.
Carbonated water and beer tend to increase urinary excretion of oxalate leading to stone formation. Eating leafy vegetables after cooking is safer than taking uncooked fresh ones as in salads: boiling prevents absorption of oxalate. Yet another myth is that once a patient has had a procedure, recurrence of the illness is a certainty, which is simply not true. A careful reevaluation has to be done at the time of completion of treatment through confirmatory tests.
Conclusion
The most important thing in urinary stone disease management is its early identification and timely expert advice on treatment. Taking home remedies, following the advice of quacks and neglecting proper treatment may lead to increased stone size, kidney dysfunction, and infection and in some rare cases, life-threatening sepsis.
Healthy life style, eating any food in moderation with low salt, avoiding red meat, drinking plenty of oral fluids and more importantly, periodic check-ups will surely prevent stone formation and its recurrence.
Article by Dr. Jeevagan, Senior Consultant Urologist, Kauvery Hospital

Dr. Jeevagan, Senior Consultant Urologist is acclaimed for his excellent work in the field of laser laparoscopy and endourology. He has nearly 10 years of experience in the management of stone disease by endoscopic and percutaneous procedures. He has performed numerous reconstructive laparoscopic procedures for kidney, ureter and bladder diseases. He is one of the very few laser-trained surgeons in Tamil Nadu who can perform holmium laser enucleation of prostate (Holep). Kauvery Hospital has a 100 W Holmium laser facility for this purpose.

Kauvery Hospitals

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