Part 3
By Dr Vineeth Naja, MS (Gen Surgery) MCh (Urology)
(Consulting Urologist and Andrologist)
This is the concluding part of the article and deals with ureteric and bladder stones and preventive aspects of kidney stones.
Ureteroscopic Stone Removal (URS)
Ureteroscopy may be used for stones in the middle and lower ureter. With the introduction of smaller instruments, this procedure can be done on an outpatient basis as well. The procedure involves the following:
■ The patient receives a general/regional anaesthetic, though no incision is required for the procedure.
■ The surgeon passes a small fiberoptic instrument called a ureteroscope through the urethra and bladder into the ureter.
■ The surgeon locates the stone or stones.
■ The surgeon can remove smaller stones by grasping them with a small forceps. A laser or a pneumatic device breaks up large stones.
■ The surgeon may decide to leave a small tube, or a stent, in the ureter for a few days after treatment, to help the lining of the ureter heal.
After the procedure the patient can be discharged the next morning as there is no wound and no work restriction required as in open surgical cases.
Complication rates range from 5%-10%, with major problems occurring in up to 3% of patients. In some cases, large stones are not broken up into small enough pieces and may require additional procedure.
Cystolithotripsy (CLT)
This is very safe and effective method to treat bladder stones, which can be removed without making a cut in the body. After this procedure the patient can be discharged the next morning and there is no need to keep the urethral catheter.
Open Stone Surgery (OSS)
Open surgery involves incisions through the patient’s flank or abdomen into the kidney or ureter depending on the stone’s position. The surgeon then locates and removes the stone. The surgeon will also correct any blockage in the affected area. After OSS, the patient needs to stay in hospital for 4-8 days (depending on surgery) and the wound takes 10-12 days to heal.
So in the present era because of the availability of less invasive treatment, patients do not need to worry about having surgery to remove their stone and should consult with their doctor for the management of stones.
Long term outlook
Without treatment, calcium stones recur in 10% of patients within a year of the first attack, and in half of patients within 5-7 years. Individual risk for recurrence, however, varies depending on the stone and the underlying condition. For example, a 15-year-old with inherited cystine stones has a very high risk for recurrence, while a middle-aged man with a first calcium oxalate stone has a good chance of never passing another.
Prevention
Anyone who has had kidney stones should try to prevent a recurrence. Some general observations include:
The most important dietary recommendations are to increase fluid intake, restrict sodium, and reduce protein intake. Choose water and lemon juice. Avoid grapefruit, apple, and cranberry juice. In general, patients should drink at least 10 full glasses of fluid each day (at least half should be water). Fluid intake should produce at least 2500 ml urine each day. Apple and cranberry juice contain oxalates, and both have been associated with a higher risk for calcium oxalate stones. Cranberry juice has properties that may increase the risk for both calcium oxalate and uric acid stones. Patients with stones should avoid cola drinks with phosphoric acid, because they can severely reduce citrate levels in the urine. Wine may protect against kidney stones. However, it is important to remember that beer and other alcoholic beverages also contain purines, which may increase the risk for the less common uric acid stones in susceptible people. Binge drinking increases uric acid and the risk for stones.
Salt intake increases the amount of calcium in urine, therefore patients with calcium stones should limit their sodium intake to 3 g or less a day. Sodium may also increase levels of urate, the crystalline substance that can trigger the formation of recurrent calcium oxalate stones.
Fibre may be beneficial for people with kidney stones. Some fibre-rich foods may contain compounds that help protect against kidney stones (eg, phytate found in legumes, wheat and rice bran).
A normal calcium diet does not appear to increase the risk for kidney stones as long as it also contains plenty of fluids, dietary potassium, and phosphate. (Increasing calcium alone may pose a modest risk for stones.)
Most people with calcium oxalate stones should not avoid oxalate-rich foods unless the doctor specifically recommends a restrictive diet. Oxalate binds with calcium in the intestine, which may actually reduce calcium absorption. Most of the foods that contain oxalates are very important for good health. Foods high in oxalic acid include beets, soy, black tea, chocolate, cocoa, dried figs, ground pepper, lamb, lime peel, nuts, parsley, poppy seeds, sorrel and spinach. Foods containing moderate amounts of oxalates include beans, carrots, celery, coffee (roasted), raisins, gooseberries, lemon peel, okro, green onions, oranges, green peppers, and sweet potatoes. In general moderate oxalate containing foods are recommended.
It is also important to treat and correct, if possible, any underlying disorder that may be causing stones to form. Such disorders include distal renal tubular acidosis, hyperthyroidism, sarcoidosis, and certain cancers. To prevent calcium stones that form in hyperparathyroid patients, a surgeon may remove the affected parathyroid gland (located in the neck). Removing it ends the patient’s problem with kidney stones.
Because different kidney stone types may require specific dietary changes, patients should work with their doctors to develop an individualized plan. Nutritional considerations are very important in preventing recurrences, and patients should comply with a proper diet.
Conclusion
Kidney stones are a common occurrence in our population and we have to take proper treatment with the consultation of an expert. Unattended stones may lead to recurrent urinary tract infection, kidney damage or even kidney failure. With the availability of minimal invasive treatment and following dietary recommendations this problem can be dealt with effectively.
