One of India’s most common problems is stone in kidney. Kidney stones are hardened mineral deposits formed in the kidney. They start as microscopic particles and over the course of time develop into bigger stones. The kidneys filter waste products from the blood and adds them to the urine. When waste materials in the urine do not dissolve completely and the kidney is unable to evacuate them, crystals and kidney stones are likely to form. A stone lodged in the outlet of kidney can block the flow of urine, build a backpressure in the affected kidney and cause severe pain.
Various factors responsible for stone formation are insufficient fluid intake, excessive calcium and other salts in diet, high concentration of calcium and other salts in urine and obstruction or infection in the urinary system.

Many kidney stones do not cause any symptom (silent stone). However, generally the symptoms are:

• • Strong or dull pain in the upper back or side
• • Nausea and vomiting
• • Blood in the urine
• • Burning sensation while urinating
• • Fever and rigor or chills
• • Signs of kidney failure

WHO HAVE GREATER TENDENCY TOWARDS KIDNEY STONES?

• • People who tend to form stones have certain factors in common.
• • Those who stay in the hot environmental condition, such as tropical area.
• • Positive family history of the stone disease in first blood relation.
• • Decreases fluid intake, which reduces urine output, and forms supersaturated urine.

WHAT CAUSES STONE FORMATION?

Medical science have advanced considerably particularly in the last decade. These advances have greatly improved our understanding of course of the stone disease and the management of this ailment has undergone revolutionary changes. This knowledge has further been helpful in the prevention and treatment of stone disease.

Various factors play a role in the formation of kidney stone in a susceptible individual. These factors are diet, water intake, urinary output, climate, occupation, and heredity, radical and family background.

• • Diet - Ingestion of excessive amount of calcium, oxalates, purines (uric acid), phosphates and other elements often results in excessive excretion of these components in the urine. The stone formation can be precipitated by high intake of calcium in the form of milk, ice creams, cheese, chocolates, cocoa, calcium containing drugs or vitamin D.
• • Water Intake and Urinary Output - It has been well established that increased water intake and increased urinary output decrease the incidence of urinary stone in patients predisposed to the disease.
• • Climate - High environmental temperature increases sweating, which may result in increased concentration of urine. This hyper concentration may contribute to stone formation.
• • Occupation - Stone disease is more likely to be found in individuals with sedentary occupation like professionals and managerial class rather than unskilled and partly skilled labourers.
• • Genetic Disorders - Like Gout, Cystinuria, primary Oxaluria, metabolic disorders like bowl, endocrine and kidney problems that increase blood and urine calcium and oxalates can promote the tendency for stone formation. Other rarer conditions like rickets, hyperparathyroidism and demineralization of bone may lead to stone formation.
• • Obstruction and Infection - Due to stricture or enlarged prostate may cause stagnation of urine leading to stone formation. Chronic infection in the kidney may also allow stone formation around the debris in the urine.

In stone belts, where the disease is endemic, it is the hot dry climate and the high content of calcium in the hard water and in the food grown in the soil that leads to stone formation. In areas where this disease is not endemic, in most cases no cause can be detected and it may be the tendency of the kidneys in the individual to form urine of high calcium or urate content. In some it may be due to a period of negligence in intake of adequate fluids worsened by excessive sweating.

WHY DO STONES FORM?

Stones form due to many reasons are as

• • Supersaturation of urine by decreases intakes of water and or hot environmental condition where there is loss of body fluid in atmosphere by perspiration, and in breathing.
• • Urine infection where crystals deposit themselves on and around the infection causing organism, and the stone grows over the period in the supersaturated urine.
• • Diet rich in oxalates, Uric acid, can increase the incidence of stone formation.
• • Functional or structural obstruction of the urinary system can precipitate the stone formation. Like Pelviureteric junction obstruction, Ectopic kidney, Horseshoe kidney.

DOES WATER HELP IN FLUSHING OUT THE STONES?

Yes. Water helps in the flushing out the stones. But fortunately not all stones, stones which are in the size range of 3-6 mm can be passed out with the increased in take of water

WHAT SHOULD I DO I F I HAVE PASSED A STONE IN URINE?

If you find a stone, bring it in to your doctor for analysis. The type of stone you have, will determine the diet and prevention programme your doctor recommends. You may need additional tests and X-ray in future to ensure that new stones do not form.

I HAVE STONE BUT I DON’T HAVE ANY SYMPTOMS SHOULD I UNDER GO TREATMENT?

Knowing the fact that you are harbouring the stone you should not ignore that. You should go for check up for the stone size every 6 months and should notice for increase in the size of the stone. Increase in size is the indication that stones need some intervention. There is high chance of the repeated urinary tract infection because of the stone. Above all symptomatic obstructing stone can lead to kidney failure.

IS ESWL SAFE?

ESWL is an absolute safe procedure in almost all cases.

WILL THERE BE PAIN AFTER THE PROCEDURE?

There may be dull aching pain in site of treatment after the procedure for few hrs. Further there will be colic pain due to passage of stone particles. This normally responds to the medication.

IS THERE ANY DAMAGE TO THE KIDNEY OR OTHER ORGANS DURING LITHOTRIPSY?

There is no damage to the other organs as the shock waves are effective on the targeted point at the junction of solid and liquid, which is stone and urine respectively.

IS THE TREATMENT POSSIBLE IN PATIENT WITH DIABETES, BLOOD PRESSURE, HEART DISEASE OR RENAL FAILURE?

Lithotripsy is safest with above diseases as it is totally non-invasive procedure. However, one should keep these diseases under control when treating with Lithotripsy.

HOW CAN I PREVENT URETERAL STONES?

A good first step for prevention is to drink more liquids – water is the best. If you tend to form stones, you should try to drink enough liquids throughout the day to produce at least two litres of urine in every 24 hours period. People who form calcium stones used to be told to avoid dairy products and other foods with high calcium content. However, recent studies have shown that foods high in calcium, including dairy foods, help prevent calcium stones. Taking calcium in pill form, however, may increase the risk of developing stones. Women taking vitamin D and calcium pills in the postmenopausal period to prevent osteoporosis, especially with family history of stones, need to be careful.

MY STONE HAS NOT PASSED DO I NEED SURGERY?

In general, you require surgical intervention if your stones are large enough to obstruct urine flow, if they are potentially harmful to your kidneys or if they are causing symptoms for which medication does not help.

WILL MY CHILDREN GET STONES BECAUSE I HAVE THEM?

Any person with a family history of stones may be at higher risk. Stone disease in a first degree relative, such as a parent or sibling, can dramatically increase the probability for you. In addition, more than 70 percent of people with certain rare hereditary disorders are prone to the problem. Those conditions include cystinuria, an excess of the amino acid, cystine, that does not dissolve in urine and instead forms stones of cystine; and primary hyperoxaluria, an excess production of the compound oxalate, which also does not dissolve in urine, forming stones of oxalate and calcium.

ARE GALLSTONES ARE URETERAL STONES RELATED?

No there is no known link. They are formed in different areas of the body. Also, if you have a gallstone, you are not necessarily more likely to develop kidney stones.

Diagnosis of stone is mainly radiological with ultrasound and x-rays. Laboratory Tests are performed to look for urine infection and function of the kidneys:

• • Complete Blood Count
• • Serum Creatinine
• • Urine microscopy and culture
• • X Ray abdomen and pelvis
• • Ultrasound KUB
• • IVU (Intravenous Urography)
• • CT Urography

1. PCNL with Holmium Laser (Laser Mini Perc)

Percutaneous nephrolithotomy (PCNL) is a surgical procedure to remove stones from the kidney by a small puncture wound (up to about 1 cm) through the skin. It is most suitable to remove stones of more than 2 cm in size and which are present near the pelvic region. It is usually done under general anesthesia or spinal anesthesia. A retrograde pyelogram is done to locate the stone in the kidney. With a small 1 centimeter incision in the loin, the percutaneous nephrolithotomy (PCN) needle is passed into the pelvis of the kidney. The position of the needle is confirmed by fluoroscopy. A guide wire is passed through the needle into the pelvis. The needle is then withdrawn with the guide wire still inside the pelvis. Over the guide wire the dilators are passed and a working sheath is introduced. A nephroscope is then passed inside and small stones taken out. In case the stone is big it may first have to be crushed using ultrasound probes and then the stone fragments removed. The most difficult portion of the procedure is creating the tract between the kidney and the flank skin. Most of the time this is achieved by advancing a needle from the flank skin into the kidney, known as the 'antegrade' technique. A 'retrograde' technique has recently been updated wherein a thin wire is passed from inside the kidney to outside the flank with the aid of a flexible ureteroscope. This technique may reduce radiation exposure for patient and surgeon.

It is a keyhole surgery for removal of kidney stones in which instruments with small diameter are used for smaller kidney punctures. Laser, pneumatic and ultrasound devices are used in the process to fragment stones and there is very less bleeding in the process. With high energy new generation Auriga XL Holmium Laser machine, even hard and large stones are fragmented quickly with less bleeding. We are one of the pioneers in offering the PCNL treatment in India since 2008 and have over 1000 successful cases to our credit. Dr Paruliya has vast experience in simple and complex PCNL in single kidney, large and multiple stones, bilateral PCNL in single sitting, paediatric PCNL, stones with renal impairment with excellent results – high rate of complete clearance, minimal morbidity.

Minimal-invasive PCNL (Mini-Perc)

Standard percutaneous nephrolithotomy is an extremely effective procedure that helps to remove renal calculi. However, this procedure results in significant morbidity. A major disadvantage of this procedure is that it results in a huge increase in health care expenses. Mini-percutaneous nephrolithotomy, performed using a 13F sheath, tremendously reduces the morbidity associated with standard percutaneous nephrolithotomy and at the same time maintains the effectiveness of stone removal. We are one of the pioneers in offering the PCNL treatment in India since 2008 and have over 1000 successful cases to our credit. Dr Paruliya has vast experience in simple and complex PCNL in single kidney, large and multiple stones, bilateral PCNL in single sitting, paediatric PCNL, stones with renal impairment with excellent results – high rate of complete clearance, minimal morbidity.

Advantages

• • 1-2 days hospitalisation, usually
• • Complete clearance in over 90% cases in single session
• • With Holmium Laser, even large and hard stone is fragmented quickly with higher precision and less bleeding

2. Lithotripsy (ESWL)

This treatment is highly effective for small and uncomplicated stones only. In this treatment, patient lies on a special machine (PCK-Stone lith) which generate high pressure shock waves which pass through the skin to fragment the stones. Then the small pieces pass with urine through the natural passage. Dr Paruliya is one of the Specilized Persone in lithotripsy in India since 2007. Dr Paruliya has vast experience with various lithotripters (different manufacturers) over the years.

3. RIRS (Retrograde Intrarenal Surgery)

Retrograde intrarenal surgery (RIRS) is a procedure for doing surgery within the kidney using a viewing tube called a fiberoptic endoscope. (flexible Uretero renoscope).
In RIRS the scope is placed through the urethra (the urinary opening) into the bladder and then through the ureter into the urinary-collecting part of the kidney. The scope thus is moved retrograde (up the urinary tract system) to within the kidney (intrarenal). RIRS may be done to remove a stone. The stone is seen through the scope and can then be manipulated or fregmented or evaporated by a laser probe or grabbed by small forceps, etc.
RIRS is performed by a specialist, a urologist (endourologist) with special expertise in RIRS. The procedure is usually done under general or spinal anesthesia.
The advantages of RIRS over open surgery include a quicker solution of the problem, the elimination of prolonged pain after surgery, and much faster recovery.

The treatment of renal calculi has undergone significant changes over the last decade. The endo-urologist has a large armamentarium of treatment options. The advent of ESWL, along with improvements in fiberoptic technology and video equipment has virtually eliminated the need for open stone surgery. In an era of minimally invasive surgery, the use of ureteroscopy, Lithotripsy, and Percutaneous procedures has expanded the use of endoscopic management of renal stones. Continued progress in Lithotripsy technology, advances in endoscopic techniques and refinements in medical management will improve our ability to choose the appropriate treatments for renal calculi in an era of cost confinement.