Urinary stones – kidney, ureteric and bladder stones

We at Malaysia are situated in the Endemic Stone Belt which comprises of countries in the Middle East, South Asia, China, Thailand, Malaysia, Indonesia, Philippines and New Guinea. The urinary stones incidence here is very high, which may be due to its geographical area, food and its tropical climate.

Urinary tract stones occurs as a result of a concentrated and subsequently supersaturated urine full of various crystals. They begin to form in the kidney or bladder and may subsequently enlarge. They can fall down from the kidney into the ureter and bladder causing pain. 

Depending on where the stone is located, it may be called a kidney stone, ureteral stone, or bladder stone. The process of stone formation is called urolithiasis, renal lithiasis, or nephrolithiasis.

Stone can vary in size, shape and composition. If it is very large and follows the outline of the kidney, then it is called a staghorn stone. If it is small and situated in the various pockets in the kidney called the calyx, then it is called a calyceal stone. If it migrates and stays at the pelvis of the kidney then it is called a pelvic or pelvi-ureteric junction stone.

The various types of stones varying in size, shape and composition.

About 85% of the stones are composed of calcium, and the remainder are composed of various substances, including uric acid, cystine, or struvite. Struvite stones—a mixture of magnesium, ammonium, and phosphate—are also called infection stones, because they form only in infected urine.

They are various modalities of treatment for stone diseases depending on the type, size and location of the stones; which include:

  1. conservative treatment (wait and watch) for small stones,
  2. ESWL therapy (Extracorporeal Lithotripsy),
  3. Retrograde Endourological procedures (Ureteroscopy, RIRS / Retrograde Intrarenal Surgery,
  4. Ureteric stent insertion),
  5. Antegrade Endourological procedures and PCNL (Percutaneous Nephrolithotomy).
  6. Open operations for stones are rarely performed, being reserved for very large stones. But such operations are still safe to be done.

Dr Rajeentheran may explain to you the benefit and indications for the various procedures by which stones may be removed.

A very large bladder stone successfully removed. This can still be done safely.

Pic from file Dr Rajeentheran

Bladder stone weighing 1.2kg

Treatment

ESWL therapy

ESWL, or extracorporeal shockwave lithotripsy, is a non-invasive method for treating stones in the kidney or ureter, by utilizing an energy source which generates a shock wave that is directed at the stone. The shock wave is focused to the stone by either an X-ray unit or ultrasound.

You will be made to lie on the ESWL bed, and the ESWL will be focused to your kidney and the stone.

You may be given some pain killers or sedation before the procedure. You will be awake during the procedure which will last approximately 1-1 ½ hours. The machine will deliver shock waves to your kidney stones.

The purpose of the ESWL therapy is to break the stones non-invasively (i.e. it is not an operation; the procedure is done without any incision or cutting). 

There are very specific indications where ESWL therapy may be done, and you can discuss this with your doctor.

The ESWL machine

The ESWL procedure of blasting the stone with shock waves (Pic from Urology Asssociates)

The ESWL procedure of blasting the stone with shock waves

Retrograde Endourological procedures

This is done by using various camera / scopes and done under anesthesia either general anesthesia (GA) or spinal anesthesia.

The endourology scopes

The procedure is done by inserting the camera / scope through the urinary passage under anesthesia. X-rays are done and a dye is injected into the urinary passage to assist the doctor while going up the urinary tract. Once the stone is seen, an instrument is used to break the stone and remove it. A ureteric stent will be inserted to allow easy urine passage from the kidneys as this procedure and the stone may cause swelling and bruising of the ureter.

It is important to understand that the upper urinary tract may be narrow especially in patients who have never had stones before. In these cases, when the stone is high up the urinary tract, the camera / scope may not reach the stone during the attempt due to tightness of the ureter. The doctor will explain this to you, and when this occurs, a ureteric stent will be inserted to bypass this stone so as to allow the urine passage to be unblocked. After a few weeks, the ureter will become larger and will allow for the camera / scope to be inserted to the upper tract to remove the stone.

The retrograde endourology procedures done under anesthesia

There are various instruments that may be used to remove / extract the stones out of the urinary tract

The various accessories used for stone extraction

Ureteric stents

Ureteric stents are tubes about 24-26 cm made of polyurethane and are inserted into the ureter. Your doctor will explain to you about the procedure.

The purpose of inserting a ureteric stent is to facilitate the passage of urine along the ureter, as well as relieving any post-operative obstruction.

Stent-related symptoms may affect over 80% of patients, most of them are mild and tolerable. They include irritative voiding symptoms including urinary frequency, urgency (rushing to the toilet to pass urine), dysuria (discomfort on passing urine), incomplete emptying the bladder; flank and suprapubic (bladder) pain especially when straining to pass urine or while clearing your bowels; rarely incontinence (leaking of urine), and hematuria (blood in the urine). There is nothing to worry about. Although you might have these symptoms, it will not damage your kidney or bladder.

NOTE: It is critical that patients who have stents inserted must return to have their ureteral stent removed as instructed by their surgeon as a prolonged indwelling ureteral stent can result in encrustation by stone debris, infection, and obstruction and potential loss of the kidney.

Image of Ureteric Stent

Ureteric stent (blue) inserted into the ureter to facilitate unimpeded flow of urine through the ureter

PCNL (Percutaneous Nephrolithotomy) for kidney and upper ureteric stones

Percutaneous nephrolithotomy (PCNL) is a minimally-invasive procedure to remove stones from the kidney by a small puncture wound (up to about 1 cm) through the skin of your back. It is most suitable to remove stones of more than 2 cm in size and which are present near the pelvic region of the kidney and within the kidney.

After removal of the stone, a tube known as a nephrostomy is inserted into the kidney which drains from your back into a drainage bag and kept there for 3-5 days to allow the tube to tamponade bleeding from the puncture tract between the skin and the kidney. Urine from the kidney is often blood-tinged and will clear over the ensuing days following surgery.

On occasions, a second PCNL procedure may be required as a “second look” procedure through the original nephrostomy tract to retrieve any retained stone fragments. This procedure may be performed within 3-5 days during your hospitalization or at a second surgery date as determined by your surgeon.

PCNL, minimally invasive operation done via a small puncture in the kidney. Pic from Health Travelers Worldwide

Informative link on PCNL:

Percutaneous Nephrolithotomy (PCNL)

Prior to PCNL

What to expect during you preoperative consultation:

Prior to your initial consultation, it is important for patients to obtain all Xray films (e.g. KUB, CT scan, MRI, sonogram) and reports to bring to your surgeon for review.  Your surgeon will review your medical history and perform a brief physical examination. A urinalysis will also be performed at your initial visit. All options for treatment of your stone(s) will be discussed at this time as well as the risks and benefits of each treatment. If your surgeon determines that you are a candidate for PCNL, he will then arrange for the date of your operation.

What to expect prior to the surgery:

Once your surgery date is secured, the items listed below will be ordered as necessary based upon your age, medical history and risk for surgery.  You will have the opportunity to speak to the anesthesia staff regarding the types of anesthesia available and the risks / benefits.

Physical exam

ECG (electrocardiogram)

CBC (complete blood count)

Comprehensive Metabolic Panel (blood chemistry profile)

Urinalysis and Urine Culture

Preparation for surgery

Medications to Avoid Prior to Surgery:

The following is a list of medications to avoid at least 7-10 days prior to surgery.  Many of these medications can alter platelet function or your body’s ability to clot and therefore may contribute to unwanted bleeding during surgery. Please contact your surgeon’s office if you are unsure about which medications to stop prior to surgery. Do not stop any medication without contacting the prescribing doctor to get their approval.

Antiplatelets: Aspirin, Cardiprin, Plavix (Clopidogrel), Ticlid, Prasugrel, Ticagrelor (Brilinta), and any blood thinners

Anti-coagulants: Warfarin, Rivaroxaban (Xarelto), Dabigatran (Pradaxa), Apixaban (Eliquis), Edoxaban (Lixiana), etc

NSAIDs and COX2 inhibitors: Ibuprofen, Diclofenac (Voltaren), Mefenemic acid, Indomethacin, Celebrex, Vioxx, etc

Inform your doctor if you are taking herbal, traditional medicines or any unregistered medications

Signs and Treatment of Urinary Infections Prior to Surgery:

It is very important that your urine remain free of infection prior to PCNL.  Therefore if you suspect that you may have a urinary tract infection (burning on urination, blood in the urine, urinary frequency and urgency, fevers), please notify your surgeon immediate so that proper cultures and treatment may be provided.

The Surgery

PCNL is performed under general anesthesia with the patient lying face down on their abdomen.

Once anesthesia is administered, your surgeon will perform cystoscopy (telescopic examination of your bladder) and instill x-ray dye into your kidney through a small catheter placed up through the ureter or drainage tube of the affected kidney to “map” the branches of the collecting system. This allows your surgeon to precisely locate the stone within the kidney and place a small needle through the skin under x-ray guidance to directly access the stone.

This needle tract is dilated to approximately 1-cm to allow placement of a plastic sheath and telescope to directly visualize the stone. Using an ultrasonic, mechanical or laser lithotripsy device, the stone is fragmented into small pieces and extracted out of the body through the sheath. On occasions, more than one tract may be required to access and attempts removal of all stones.

A small ureteral stent may be left draining the kidney to the bladder in addition to a nephrostomy tube draining the kidney to an external drainage bag at the end of the operation. The length of the surgery is generally 3-4 hours.

Potential Risks and Complications

As with any surgical procedure there are risks and potential complications that are associated with PCNL. Potential risks include:

Bleeding: 

Blood loss during PCNL is generally minimal, and risk of blood transfusion ranges from 2-5%, depending on stone size, location, and number of tracts dilated.

Infection

Bacteria can at times grow within stones and therefore cause a urinary infection and rarely sepsis during stone surgery. As a result, urinary infections should be treated before surgery and broad-spectrum antibiotics are administered at the start of the operation to minimize the risk of a urinary infection.

Adjacent Tissue and Organ Injury: 

Rarely organs surrounding the kidney such as bowel, colon, blood vessels, spleen, and liver may be injured during surgery requiring emergent open surgery or further surgery.

The chest cavity is in close proximity to the upper pole of the kidney and can be accidentally entered when accessing an upper pole kidney stone resulting in a pneumothorax (or air surrounding the lung). This may require that a small chest tube be placed temporarily to drain air and fluid from around the lung.

Permanent damage to the kidney during PCNL resulting in loss of the kidney is extremely rare.

Damage and perforation to the ureter draining the kidney may result in scarring and obstruction requiring further surgery.

Failure to Remove the Stone:  

Despite placement of one or more tracts into the kidney to remove stones, there is a small chance that PCNL may not be able to successfully remove all stones as a result of either size, number or location of the stone within the collecting system. Additional treatment may be required.

 

What to Expect After Surgery

Following your surgery you will be transferred to the recovery room and then to your hospital room once you are fully awake.

Post-operative pain: 

Following surgery, pain in the flank area overlying your kidney is common for the first few days, but well controlled with intravenous or oral pain medication provided to you on request by your nurse.

Nephrostomy Tube: 

A nephrostomy tube drains urine directly from your kidney into a drainage bag. It is routinely placed to tamponade bleeding from the tract between the skin and the kidney.

Urine from the kidney is often blood-tinged and will clear over the ensuing days following surgery.

There is a possibility that you will either get your nephrostomy tube removed within 3-5 days, or be discharged from the hospital with the nephrostomy tube as deemed necessary by your surgeon. The nephrostomy tube will then be removed in the office at the bedside generally 1-2 weeks following surgery.

Ureteral Stent: 

A ureteral stent is a small flexible plastic (polyurethane) internal tube that is placed to promote drainage of your kidney down to the bladder. This will be removed in your surgeon’s office in typically 1-3 weeks following surgery.

Nausea

Often patients experience transient nausea the first day or two following surgery under general anesthesia. Medication is available to treat persistent nausea.

Urinary Catheter: 

A bladder catheter called a Foley is placed in the operating room while you are asleep and left in place for approximately one day after the surgery. This allows your surgical team to continuously monitor your urine output. It is not uncommon to have blood-tinged urine for a several days after surgery.  The catheter will be removed prior to discharge.

Diet: 

Your diet will be advanced slowly from clear liquids to solid foods as tolerated following surgery. In addition, intravenous fluids will be administered to keep your body well hydrated following surgery.

Fatigue: 

Fatigue is common and should start to subside in a few weeks to a month following surgery.

Incentive Spirometry: 

Deep breathing exercises are important in reducing the incidence of pulmonary complications such as pneumonia. These exercises will be performed with the use of an incentive spirometer, which your nurses and surgical team will explain how to use.

Physical Activity: 

It is very important to get out of bed and begin walking with the supervision of your nurse or family member to help prevent blood clots from forming in your legs. You can also expect to have SCD’s (sequential compression devices), if you are high risk, to prevent blood clots from forming in your legs. During your hospital stay it is advised that you walk at least 4-6 times in the hallways per day to minimize risks of clots.  The more walking you can tolerate the better.

Hospital Stay: 

The length of hospital stay for most patients is approximately 3-5 days.

Secondary Procedures: 

At times it may be difficult to visualize all areas of the collecting system despite the use of flexible telescopes and therefore some stones may not be retrievable.

On such occasions, a second PCNL procedure may be required as a “second look” procedure through the original nephrostomy tract to retrieve any retained stone fragments. This procedure may be performed during your hospitalization or at a second surgery date as determined by your surgeon.

If stone fragments remain within the urinary tract, more time may be required to allow for spontaneous passage, which often takes several weeks. Alternatively your surgeon may recommend further treatment with repeat PCNL, ESWL, or ureteroscopy.

 

What to Expect After Discharge from the Hospital

Pain Control: 

Mild pain at the nephrostomy tube site may require pain medication.

Showering: 

Showering with your nephrostomy tube in place is permissible; however, the site should be patted dry immediately after showering. Tub baths or hot tubs should be avoided while your nephrostomy tube is in place.

Activity: 

Taking daily walks is advised to minimize blood clots, called a deep vein thrombosis, from forming in your legs. Prolonged sitting or lying in bed should be avoided. Climbing stairs is possible, however, should be taken slowly.

Driving should be avoided for at least 1-2 weeks after surgery and only after narcotic pain medications have been stopped. After this time, activity can begin as tolerated.

You can expect to return to work as soon as 1-2 weeks following surgery or as instructed by your physician.

Nephrostomy Site Care: 

Caring for your nephrostomy tube is critical to ensure proper healing of your kidney. It is important that urine flow freely from the tube and into the drainage bag, which should be kept below the level of your kidney at all times.

Clean the area around the nephrostomy tube insertion site wound with mild soap and water each day when you shower. Pat the area dry after showering and clean directly around the insertion site. Apply a clean gauze dressing after cleaning the area.

If urine stops draining from your tube, this may result in obstruction of your kidney, increased pain and infection. Immediately check your nephrostomy tube to ensure that it is not kinked or has not been pulled or dislodged from proper position.

If you experience any change in pain, fever, chills, pus forming around the insertion site, the catheter not draining or leaking around the tube you must contact your doctor immediately.

 

Follow-up for Stent Removal: 

The ureteral stent is generally removed within 1-3 weeks following surgery and will be determined by your surgeon. While your stent is in place, it is common to feel a slight amount of flank fullness and urgency to void as a result of the stent. These symptoms often improve over time as the body adjusts to the indwelling stent.

The stent is removed by cystoscopy during which time your surgeon will place a small flexible telescope into the urethra to visualize and grasp the terminal end of the stent that rests in your bladder. This generally takes less than a couple of minutes to perform.

NOTE: It is critical that patients return to have their ureteral stent removed as instructed by their surgeon as a prolonged indwelling ureteral stent can result in encrustation by stone debris, infection, and obstruction and potential loss of the kidney.

 

When to call your Doctor

Although serious adverse events are uncommon following PCNL, it is important for patients to recognize these events and know when to contact their surgeon. You should contact your surgeon or primary care doctor immediately if any of the following occur:

Worsening pain over the ensuing days following PCNL. If this pain continues to escalate despite the use of oral pain medication, this may indicate obstruction of the kidney from a large stone fragment lodged within the ureter, hematoma around the kidney or infection of the kidney.

Large amounts of blood clots in the urine that may lead to difficulty with voiding and fully emptying the bladder.

Fevers >101o F may indicate a serious infection within the urinary tract.

Nausea and vomiting

Chest pain or difficulty breathing

 

Frequently Asked Questions (FAQs)

What is the advantage of PCNL as compared to other stone treatments?

The primary advantage of PCNL over other treatments such as ESWL or ureteroscopy is that it provides a minimally invasive approach to treating and removing large stone burden in a single setting as compared to the need for multiple surgeries with the other therapies mentioned.

Are there disadvantages?

Whereas ESWL and ureteroscopy can be performed under intravenous sedation, PCNL requires a general anesthesia. Some patients may not be able to tolerate a general anesthesia due to their medical condition(s). As compared to other stone treatments, PCNL is slightly more invasive carrying with it a slightly higher risk. However, for most patients with large stone burdens, multiple stones or stones resistant to other forms of treatment, the benefits of PCNL outweigh the risks.

Which patients are good candidates for PCNL?

PCNL is an excellent option for patients with large kidney or ureteral stones (generally > 2 cm), multiple large stones, or stones resistant to prior treatment with ESWL or ureteroscopy.

What patients are not good candidates for PCNL?

Patients who have severe heart or lung conditions or have an uncorrectable bleeding propensity are not good candidates for PCNL. Patients with an active urinary infection are at a higher risk of sepsis during surgery and therefore should be treated with antibiotics to clear up the urinary infection prior to PCNL.

Can multiple stones be treated simultaneously with PCNL?

Multiple stones can be treated with PCNL. This is one of the advantages of this approach as a flexible telescope can be passed through the skin and directly into the kidney to attempt identification and removal of multiple stones in one setting. However, at times it may be difficult to visualize all areas of the collecting system despite the use of flexible telescopes and therefore some stones may not be retrievable. This may require placement of a second needle tract to access the remaining stones or a second PCNL procedure at a later date.  Alternatively, PCNL can be used to remove the majority of the stone burden with ureteroscopy and ESWL left to clean up the remaining stone fragments.

Will I need placement of an indwelling ureteral stent following PCNL?

In most cases an indwelling ureteral stent is placed to promote drainage of urine from the kidney to the bladder.

What is the overall success rate with PCNL?

The success of PCNL is dependent on many factors such as stone composition, stone size, number of stones, location within the urinary tract, patient body habitus (obesity), and anatomy of the collecting system of the kidney. Your doctor will carefully consider all of the aforementioned variables and will discuss this with you in order to maximize success and determine if PCNL is right for you. Overall stone free success rate is approximately 80-90% following an initial PCNL and 90-100% following a “second look” procedure.

How do I know if PCNL was successful? 

Following PCNL, your surgeon will determine whether the treatment was successful based upon an ultrasound, X-ray or CT scan that is performed during your hospitalization.

If stone fragments remain within the urinary tract, more time may be required to allow for spontaneous passage, which often takes several weeks. Alternatively your surgeon may recommend further treatment with repeat PCNL, ESWL, or ureteroscopy.

Can PCNL be repeated?

Yes. Often due to stone density or size or difficult anatomy of the collecting system, fragments may at times remain in the urinary tract that may require a “second look” procedure to attempt removal.  This is usually performed a few days after your initial surgery. Alternatively this second procedure may be staged at a later date depending upon your surgeon.

Can PCNL be performed on both of my kidneys at the same time?

If patients present with large stone burdens in both kidneys, bilateral PCNL surgeries can be performed at the same setting or alternatively staged at a later date as two separate surgeries. This decision will be made with you by your surgeon.

 

Prevention of urinary stones

As mentioned earlier, urinary stones occur as a result of a concentrated and subsequently supersaturated urine full of various crystals. Hence drinking adequate amounts of water is the best proven way to prevent urinary stones.

Diet Recommendations for Kidney Stones

From the National Kidney Foundation; https://www.kidney.org/atoz/content/diet

General Recommendations

1. Drink plenty of fluid: 2.5 – 3 liters/day

    • Try to drink at least 2.5 liters of fluids a day. Water is best, although juice (other than grapefruit juice) and other beverages can add to the total.
    • This includes any type of fluid such as water, and lemonade which have been shown to have a beneficial effect with the exception of grapefruit juice and soda. Citrous fruits have been shown to be advantageous as citrate has been shown to reduce aggregation of crystals in forming stones.
    • Limit your intake of caffeine-containing beverages like coffee, tea, and cola to one or two cups a day, since caffeine acts as a diuretic, causing your body to lose fluids too quickly. These beverages also contain oxalates.
    • A good gauge of whether or not you are drinking enough fluids is urine color. Except for the first thing in the morning—when urine tends to be more concentrated—it should be pale in color. If your urine is dark yellow, that’s an indication to drink more fluids.
    • The other good gauge is thirst. If you are thirsty it would usually mean that you have inadequate fluid intake.
    • This will help produce less concentrated urine and ensure a good urine volume of at least 2.5L/day
    • If you are hesitant to drink too much during the day because you have a bladder control problem, discuss this concern with your doctor.

2. Limit foods with high oxalate content

    • Spinach, many berries, chocolate, wheat bran, nuts, beets, tea and rhubarb should be eliminated from your diet intake

3. Eat enough dietary calcium

    • Three servings of dairy per day will help lower the risk of calcium stone formation. Eat with meals.

4. Avoid extra calcium supplements

    • Calcium supplements should be individualized by your physician and registered kidney dietitian

5. Eat a moderate amount of protein

    • High protein intakes will cause the kidneys to excrete more calcium therefore this may cause more stones to form in the kidney

6. Avoid high salt intake

    • High sodium intake increases calcium in the urine which increases the chances of developing stones
    • Low salt diet is also important to control blood pressure.

7. Avoid high doses of vitamin C supplements

    • It is recommend to take 60mg/day of vitamin C based on the US Dietary Reference Intake
    • Excess amounts of 1000mg/day or more may produce more oxalate in the body

 

What kind of diet plan is recommended to prevent stones?

There is no single diet plan for stone prevention.  Most diet recommendations are based on stone types and individualized for each person.

  1. Calcium Oxalate Stones: most common stones

Oxalate is naturally found in many foods, including fruits and vegetables, nuts and seeds, grains, legumes, and even chocolate and tea. Some examples of foods that have high levels of oxalate include peanuts, rhubarb, spinach, beets, Swiss chard, chocolate and sweet potatoes. Limiting intake of these foods may be beneficial for people who form calcium oxalate stones which is the leading type of kidney stone.

Eat and drink calcium foods such as milk, yogurt, ice cream and some cheese and oxalate-rich foods together during a meal. The oxalate and calcium from the foods are more likely to bind to one another in the stomach and intestines before entering the kidneys. This will make it less likely that kidney stones will form.

Calcium is not the enemy but it tends to get a bad rap! This is most likely due to its name and misunderstanding that calcium is the main cause in calcium-oxalate stones. A diet low in calcium actually increases your chances of developing kidney stones.

Don’t reduce the calcium in your diet. Work to cut back on the sodium in your diet and to pair calcium-rich foods with oxalate-rich foods. The recommended calcium intake to prevent calcium stones is 1000-1200 mg per day (you can eat 3 servings of dairy products with meals to meet the recommendation).

Extra sodium causes you to lose more calcium in your urine. Sodium and calcium share the same transport in the kidney so if you eat high sodium foods it will increase calcium leakage in the urine. Therefore, a high sodium diet can increase your chances for developing another stone. There are many sources of “hidden” sodium such as canned or commercially processed foods as well as restaurant-prepared and fast foods.

You can lower your sodium intake by choosing fresh low sodium foods which can help to lower calcium leakage in the urine and will also help with blood pressure control if you have high blood pressure.

 

  1. Uric acid stones: another common stone

Red meat, organ meats, and shellfish have high amounts of a natural chemical compound known as purines. High purine intake leads to a higher production of uric acid and a larger acid load for the kidneys to excrete. Higher uric acid excretion leads to more acidic urine. The high acid concentration of the urine makes it easier for uric acid stones to form.

To prevent uric acid stones, cut down on high-purine foods such as red meat, organ meats, beer/alcoholic beverages, meat-based gravies, sardines, anchovies and shellfish. Follow a healthy diet plan that has mostly vegetables and fruits, whole grains, and low-fat dairy products. Limit sugar-sweetened foods and drinks, especially those that have high fructose corn syrup. Limit alcohol because it can increase uric acid levels in the blood and avoid short term diets for the same reason. Decreasing animal-based protein and eating more fruits and vegetables will help decrease urine acidity and this may help reduce the chance for uric acid stone formation.

Will it help or hurt to take a vitamin or mineral supplement?

It is best to check with your healthcare professional or dietitian for advice on the use of vitamin C, vitamin D, fish liver oils or other mineral supplements containing calcium since some supplements can increase the chances of stone formation in some individuals.

 

When to see your urologist

All urinary stones including kidney, ureteric and bladder stones require a consultation with the urologist, even if you do not have any symptoms.

Significant stones, even without any symptoms, may cause progressive kidney damage.

A decision on what to do with the stones – whether observation, surveillance or intervention – is an important decision to be made by the urologist.

Drinking adequate amounts of water (about 2.5 L of water a day) is the best method to prevent and reduce urinary stone formation.

Citrate has been showed to reduce aggregation of crystals in the urine during stone formation. Citrate is found in citrous fruits and intake of this has been shown to reduce urinary stone formation.

Avoid vitamin C supplements and calcium supplements when not indicated. Vitamin C metabolizes to form oxalates which can increase the risk of calcium oxalate stone formation.

Currently there are no medications that have been shown to successfully break urinary stones. Herbal and traditional medications have not been proven to be effective.

Alkalization of the urine may dissolve pure uric acid stones only, but this treatment must be discussed with your urologist first as over-alkalization of your urine may increase the risk of phosphate and brushite stones which are very hard stones.

Traditional and herbal medications has not been conclusively shown to break or dissolve urinary stones.

All urinary stones including kidney, ureteric and bladder stones require a consultation with the urologist, even if you do not have any symptoms.

Significant stones, even without any symptoms, may cause progressive kidney damage.

If you have severe pain due to a passage of urinary stone, the first management would be pain killers. After this, you will require a urologist referral to confirm the presence of stones, and whether it is amenable to natural passage of the stone or not. The absence of pain does not mean your stone has passed out.

A decision on what to do with the stones – whether observation, surveillance or intervention – is an important decision that will be made by your urologist.

 

NOTE: If a stent has been inserted by your urologist, it is critical that patients return to have their ureteral stent removed as instructed by their surgeon as a prolonged indwelling ureteral stent can result in encrustation by stone debris, infection, and obstruction and potential loss of the kidney.

Informative links

– A review of various urinary stones, how stone forms, the endemic stone belt, and the various treatment for urinary stones – PCNL, ESWL therapy, Retrograde Ureterorenoscopy and RIRS, Antegrade Ureteroscopy

https://www.youtube.com/watch?v=_rfVGKd1ur4

 

Other links:

https://www.youtube.com/watch?v=0hKRYVrlfdI

https://youtu.be/oU_GUAWz52w

https://www.youtube.com/watch?v=ayCH5cc0y1M

https://www.youtube.com/watch?v=D6vO2ASsQaU

https://www.youtube.com/watch?v=kcaOMrOiyJs      

Percutaneous Nephrolithotomy (PCNL)