I am Dr. Tanuj Paul Bhatia, In my earlier video, I had spoken about the different symptoms of kidney stones and prostate diseases and just touched upon the different types of treatments that are available. Today we will talk about the different type of treatment which is available for the treatment of kidney stones apart from conservative management. Conservative management means when we have small stones and non-stones, we treat the patients with medicines so that which helps the stones to pass out. But when the stones stay for a long time, say more than three to four weeks or if they cause any complication like if they cause fever, if they cause derangement of the renal function or if the stone is very big then we need to take it out. Of course, the type of treatment that we administer depends on a couple of things. So how we decide about that is the first thing that we look at is what is the site of the stone. So, the site of the kidney stone can be right there in the kidney, it can be in one of the calyces or in the pelvic part of the kidney or in the ureter or lower down; so, depending on the site of the stone the treatment varies. So, as we talk about the different treatment options first, we will talk about the least invasive and then the most invasive type of treatment. So, the least invasive treatment of kidney stone is by extracorporeal shock wave lithotripsy which is routinely referred to as lithotripsy treatment by the general public.
So, what this involves is that the patient has to lie down in this couch and there are rays which are targeted on to the stone from outside the body and which help the stone to break. This was earlier a quite popular modality of treatment, however, in case of lithotripsy most of the patients if the stone is large, they require multiple sittings and sometimes if the stone is very hard the machine is not able to break the stone. So gradually the popularity of this particular technique has gone down but still, it is reserved for certain stones like soft stones or especially for stones in case of paediatric population that is children. Next commonly done surgery for stone is URS or Uretero renoscopy. So, it depends on the site of stone which type of uretero renoscopy we are doing. If the stone is in the ureter, that is the tube draining urine from kidney to bladder then we use a semi-rigid ureteroscope which is commonly referred to as URS. If the stone is in the upper part of the ureter or somewhere in the kidney then we use a flexible uretero renoscope, this is commonly referred to as RIRS or retrograde intra-renal surgery.
This is a quite popular modality of treatment nowadays because this involves treatment of the stone through the normal urinary passage, there is no cut made on the body and we are able to treat the stone right from below the normal urinary passage, we are able to go right up to the kidney and we treat the stone there with laser, so we break the stone with laser and we take out the larger particles out with baskets like this and that is how we help the patient to become stone free. Also, we break the stone into very small particles and the so that they can pass out through the normal urinary passage. When the stone is in the kidney or in the upper ureter another famous modality of treatment is percutaneous nephrolithotomy or PCNL. In PCNL, we make a small cut at the back and we make the track that is we drill hole into the kidney and we make this track and then we pass the endoscope from the skin into the kidney and we break the stone here and we take it out. The routine PCNL involves the larger size track however with time there has been technological advancement and now we have what is referred to as mini PCNL in which we use a relatively smaller sheath. This leads to lesser risk of bleeding from the kidney parenchyma and we are able to clean treat the stone with laser and we take out the particles from the kidney. To benefit of PCNL over RIRS is that all the fragments are extracted in the same sitting usually. Another new modality which has now come up is supine PCNL.
Although, this is reserved strictly for patients in whom we need to treat either multiple kidney stones or kidney with uretery stones or in very obese patients or in patients with skeletal anomalies in whom positioning in prone position is difficult. But this now this technique now becomes very popular in European countries and it is picking up fast and in future, this might be the way we would be doing all our PCNL's as well. Then another advantage that supine PCNL offers us is that we are able to approach the kidney from below that is to the ureter as well as from the back, so earlier if there are stones in multiple different calyces in the kidney, we had to make multiple punctures in the kidney. Now with the help of this technique we need not make multiple punctures, we can enter the kidney through one puncture then we can pass our flexible ureteroscope into different calyces, we break the stone there and we pass it out through this track from the back, this is referred to as passing the parcel technique and the technique is called ECIRS or endoscopic combined intra-renal surgery.
Laparoscopic surgery which involves 3 or 4 cuts on the abdomen and then taking out the making a cut on the kidney and taking out the stone is not a very popular modality of treatment for kidney stones and it is reserved for very rare cases like anomalous kidneys. Although with advancement, now we are able to do stones and operate on stones in anomalous kidneys also with techniques like RIRS. So that was about the different operative techniques for kidney stones and uretery stones. The era of open surgery for stone is now almost gone. Very rarely it is that we have to make a large cut on the abdomen to take out a stone nowadays.