| |
 Introduction
to urinary system |
| What
is Renal Calculi? |
| How
do Renal Calculi occur? |
| What
are the Symptoms? |
| How
is it Diagnosed? |
| What
are the Treatment Options? |
| What
are the Benefits and drawbacks? |
| Care
at home |
| |
|
| |
| Introduction
to urinary system |
| |
| The urinary tract, or system, consists
of the kidneys, ureters, bladder, and urethra. The kidneys
are two bean-shaped organs located below the ribs toward
the middle of the back. They remove extra water and wastes
from the blood, converting it to urine. They also keep
a stable balance of salts and other substances in the
blood. The kidneys produce hormones that help build strong
bones and help form red blood cells. Narrow tubes called
ureter carry urine from the kidneys to the bladder, an
oval-shaped chamber in the lower abdomen. Like a balloon,
the bladder's elastic walls stretch and expand to store
urine. They flatten together when urine is emptied through
the urethra to outside the body. |
| |
|
|
| |
| One in every 20 people develops a
kidney stone at some point in their life. A kidney stone
is a hard mineral and crystalline material formed within
the kidney or urinary tract. |
| |
|
|
|
| |
| What
is Renal Calculi (kidney stone)? |
| |
|
 Kidney
stones are one of the most common disorders of the urinary
tract. In the year 2000, patients made 2.7 million visits
to health care providers and more than 600,000 patients
went to emergency rooms for kidney stone problems. Men
tend to be affected more frequently than women. The
function of the kidneys (Renal) is to remove waste products
and unwanted water from the blood, in the form of urine.
If there is too much of certain waste products in the
urine, these substances form crystals. Crystals can
then combine to form stones.
A kidney stone is a hard mass developed from crystals
that separate from the urine and build up on the inner
surfaces of the kidney. Normally, urine contains chemicals
that prevent or inhibit the crystals from forming. These
inhibitors do not seem to work for everyone, however,
so some people form stones. If the crystals remain tiny
enough, they will travel through the urinary tract and
pass out of the body in the urine without being noticed.
However, when they pass down the ureter on their way
to the bladder, pain usually occurs with anything but
the smallest stone. If a stone gets stuck on its way
down the ureter, pain usually occurs in the form of
renal colic. The pain comes and goes in waves. Blood
may be passed as well, due to the irritation of the
lining of the ureter by the sharp-edged stone.
|
| |
| Kidney stones,
one of the most painful of the urologic disorders,
are not a product of modern life. Scientists have
found evidence of kidney stones in a 7,000-year-old
Egyptian mummy. |
|
| |
| Urolithiasis is the medical term used
to describe stones occurring in the urinary tract. Other
frequently used terms are urinary tract stone disease
and nephrolithiasis. Doctors also use terms that describe
the location of the stone in the urinary tract. For example,
a ureteral stone (or ureterolithiasis) is a kidney stone
found in the ureter. To keep things simple, however, the
term "kidney stones" is used throughout this
fact sheet. |
| |
| Types of stones include: |
| |
- Calcium stones are most common. They are
two to three times more common in men, usually appearing
at age 20 to 30. Recurrence is likely. The calcium
may combine with other substances such as oxalate
(the most common substance), phosphate, or carbonate
to form the stone. Oxalate is present in certain foods.
Diseases of the small intestine increase the tendency
to form calcium oxalate stones.
- Uric acid stones are also more common in
men. They are associated with gout or chemotherapy.
Uric acid stones make up about 10% of all stones.
- Cystine stones may form in persons with cystinuria.
It is a hereditary disorder affecting both men and
women.
- Struvite stones are mainly found in women
as a result of urinary tract infection. They can grow
very large and may obstruct the kidney, ureter, or
bladder.
|
|
|
|
| |
| How
do Renal Calculi occur? |
| |
| Stones may develop just because the
urine is very concentrated. Not surprisingly, stones are
therefore more likely to occur in hot climates. On the
other hand, stones can occur because the output of a given
chemical waste product is increased. Calcium stones occur
when there is too much calcium in the urine. This may
happen if there is too much calcium in the diet from milk,
cheese or bread. Some people seem to absorb more calcium
from the gut and there is nowhere for it to go other than
into the urine. Other people may have an overactive parathyroid
gland (hyperparathyroidism). This results in calcium being
leaked out of the bones and again it has nowhere else
to go but the urine. More often, no obvious cause can
be found. Oxalate stones can occur if there is too much
oxalate in the diet (spinach, rhubarb, chocolates and
certain nuts). They are more likely to occur in people
who have a bowel problem in which fat is not being absorbed
properly. Uric acid stones form when there is too much
uric acid in the urine. This comes as a direct result
of too much uric acid in the blood. This is particularly
likely in people who are prone to the condition of gout.
Struvite stones are associated with chronic Urinary tract
infection. Cystine stones arise when Urine becomes supersaturated
with cystine and leads to crystal deposition. Some medications
also raise the risk of kidney stones. These medications
include some diuretics, calcium-containing antacids, and
the protease inhibitor Crixivan (indinavir), a drug used
to treat HIV infection. |
| |
|
|
|
| |
| What
are the Symptoms? |
| |
| Most calculi originate within the
kidney and proceed distally, creating various degrees
of urinary obstruction as they become lodged in narrow
areas, including the ureteropelvic junction, pelvic brim,
and ureterovesical junction. Location and quality of pain
are related to position of the stone within the urinary
tract. Severity of pain is related to the degree of obstruction,
presence of ureteral spasm, and presence of any associated
infection. So the symptomatic presentation of renal calculi
has been described below: |
| |
- Flank pain or back pain, which may be:
- on one or both sides
- progressive
- severe
- colicky (spasm-like)
- may radiate or move to lower in flank, pelvis,
groin, genitals
- Nausea, vomiting
- Painful urination
- Urinary frequency or urgency is increased (persistent
urge to urinate)
- Blood in the urine
- Rarely, a patient reports positional urinary retention
(obstruction precipitated by standing, relieved by
recumbency), which is due to the ball-valve effect
of a large stone located at the bladder outlet.
- Fever with chills
|
|
|
|
| |
| How
is it Diagnosed? |
| |
| An abdominal x-ray may show certain
types of stones. An ultrasound test is usually able to
confirm where the stone is lying, and the effect that
it is having on the other structures. Sometimes, a special
kidney x-ray (intravenous pylogram: IVP or intravenous
urogram: IVU) needs to be done to show the position of
the stone and to find out if there is any blockage. This
is done by giving an injection into the arm vein. Several
x-rays are taken over the next 2 hours. This shows the
stones in the kidneys, ureter or bladder. It will also
show whether any stone is producing a blockage. It is
also important to find out the chemical structure of the
stone which has been passed. Further tests can be done
by analyzing a 24-hour urine sample. Exact amounts of
calcium, oxalate, uric acid and cystine can be measured.
A stone may not pass on its own. It may get stuck in the
ureter. When the stones are too small, sometimes abdominal
CT scan may be advised. |
| |
|
|
|
| |
| What
are the Treatment options? |
| |
| Sometimes kidney stones are "silent".
They are called so because they do not cause symptoms.
Infact they are found on x rays taken during a general
health exam. If they are small, these stones would likely
pass out of the body unnoticed. But many a times there
may be complications associated with it, e.g a ureteral
stone might be associated with obstruction and upper UTI
and this truly is a urologic emergency. So it is very
important to consult a urologist. Let us see the treatments
offered for renal calculi: |
| |
| Ureteroscopic Stone Removal |
| |
| Although some kidney stones in the
ureters can be treated with ESWL (Read this technique
below), ureteroscopy may be needed for mid- and lower-ureter
stones. No incision is made in this procedure. Instead,
the surgeon passes a small fiberoptic instrument called
an ureteroscope through the urethra and bladder into the
ureter. The surgeon then locates the stone and either
removes it with a cage-like device or shatters it with
a special instrument that produces a form of shock wave.
A small tube or stent may be left in the ureter for a
few days to help the lining of the ureter heal. Before
fiber optics made ureteroscopy possible, physicians used
a similar "blind basket" extraction method.
But this outdated technique should not be used because
it may damage the ureters. |
| |
|
|
| |
| FIGURE A: shows rigid scope which
is inserted through the bladder to remove stones in the
ureter. FIGURE B: shows flexible scope which is inserted
through the bladder and ureter into the kidney to remove
small stones in the kidney. |
| |
| Percutaneous Nephrolithotomy |
| |
| Surgery should be reserved as an option
for cases where other approaches have failed. Surgery
may be needed to remove a kidney stone if it: |
| |
- does not pass after a reasonable period of time
and causes constant pain
- is too large to pass on its own or is caught in
a difficult place
- blocks the flow of urine
- causes ongoing urinary tract infection
- damages kidney tissue or causes constant bleeding
- Has grown larger (as seen on followup x ray studies).
|
| Percutaneous Nephrolithotomy is recommended
when the stone is quite large or in a location that does
not allow effective use of ESWL (read below). In this
procedure, the surgeon makes a tiny incision in the back
and creates a tunnel directly into the kidney. Using an
instrument called a nephroscope, the surgeon locates and
removes the stone. For large stones, some type of energy
probe (ultrasonic or electrohydraulic) may be needed to
break the stone into small pieces. Generally, patients
stay in the hospital for several days and may have a small
tube called a nephrostomy tube left in the kidney during
the healing process. |
| |
|
|
| |
| Extracorporeal Shockwave Lithotripsy |
| |
| Until 20 years ago, surgery was necessary
to remove a stone. It was very painful and required a
recovery time of 4 to 6 weeks. Today, treatment for these
stones is greatly improved, and many options do not require
major surgery. |
| |
| Extracorporeal shockwave lithotripsy
(ESWL) is the most frequently used procedure for the treatment
of kidney stones. In ESWL, shock waves that are created
outside the body travel through the skin and body tissues
until they hit the denser stones. The stones break down
into sand-like particles and are easily passed through
the urinary tract in the urine. |
| |
|
|
| |
| There are several types of ESWL devices.
In one device, the patient reclines in a water bath while
the shock waves are transmitted. Other devices have a
soft cushion on which the patient lies. Most devices use
either x rays or ultrasound to help the surgeon pinpoint
the stone during treatment. For most types of ESWL procedures,
anesthesia is needed. In most cases, ESWL may be done
on an outpatient basis. Recovery time is short, and most
people can resume normal activities in a few days. |
| |
| Aastha has obtained the first Lithotripsy
machine in Mulund and surrounding suburbs. We have a separate
Lithotripsy OT for the same. To know more about lithotripsy
procedure, click
here. |
| |
| Mechanical Percussion and Inversion
(MPI) |
| |
| While shockwave lithotripsy is a very
effective treatment for kidney stones, it sometimes leaves
fragments in the lower portion of the kidney. Gravity
and certain technical features of kidney anatomy can trap
these pieces so that they settle in the lower pole and
do not pass. They can enlarge over time to form new kidney
stones or infections. |
| |
| A combination of mechanical percussion
and inversion (or MPI) can eliminate the sand particles
before they can cause problems. During this treatment,
the patient is placed on a stretcher with the top half
of the body angled towards the floor. A large vibrator
called a percussor is held against the skin of your back
over the kidney that contains the stone fragments. A diuretic
is administered to increase the flow of urine. The combination
of these three factors helps the sandy particles to pass
out of the lower pole and out of the body before they
can enlarge and cause problems. |
| |
| To prevent cystine stones, you should
drink enough water each day to dilute the concentration
of cystine that escapes into the urine, which may be difficult.
More than a gallon of water may be needed every 24 hours,
and a third of that must be drunk during the night. |
| |
|
|
|
| Benefits
and drawbacks |
| |
| One advantage of percutaneous nephrolithotomy
over ESWL is that the surgeon removes the stone fragments
instead of relying on their natural passage from the kidney.
But ESWL is gaining popularity these days because of the
three main reasons: |
| |
- It is a Non-invasive approach
- Surgery and its risks are avoided.
- The side effects are minimal
|
| Though there may are few drawbacks
with ESWL. Most patients have blood in their urine for
a few days after treatment. Bruising and minor discomfort
in the back or abdomen from the shock waves are also common.
To reduce the risk of complications, doctors usually tell
patients to avoid taking aspirin and other drugs that
affect blood clotting for several weeks before treatment.
Sometimes the shattered stone particles cause discomfort
as they pass through the urinary tract. In some cases,
the doctor will insert a small tube called a stent through
the bladder into the ureter to help the fragments pass.
Sometimes the stone is not completely shattered with one
treatment, and additional treatments may be needed. ESWL
is not ideal for very large stones. |
| |
|
|
|
| Care
at home |
| |
| A simple and most important lifestyle
change to prevent stones is to drink more liquids-water
is best. Infact if a person has tendency to form stones,
they must drink enough liquids throughout the day to produce
at least 2 quarts of urine in every 24-hour period. |
| |
| People who form calcium stones used
to be told to avoid dairy products and other foods with
high calcium content. But recent studies have shown that
foods high in calcium, including dairy products, may help
prevent calcium stones. Taking calcium in pill form, however,
may increase the risk of developing stones. One may be
told to avoid food with added vitamin D and certain types
of antacids that have a calcium base. If you have very
acidic urine, you may need to eat less meat, fish, and
poultry. These foods increase the amount of acid in the
urine. |
| |
| The doctors will advice the patient
to come for a regular follow ups. This is very important
and should not be ignored. |
| |
|
|
|
|
|
| |
