I’m Dr. Tanuj Paul Bhatia, senior consultant of urology at Sarvodya hospital, Faridabad.
So I will discuss what is urology? And mainly about kidney stones today. Urology is a branch of medicine which deals with male and female urinary tract and male reproductive organs. Basically in this we deal with the kidneys, where it is formed and then it comes to ureter and through the ureter it comes to the bladder and then it does empties through urethra and comes out of the body. So this is our entire urinary system and the diseases of this entire system is dealt by urologist i.e. us. So when we come to kidney stones we know that kidney stone is a very common disease, it is highly prevalent in almost whole of entire north India and states like Punjab, Haryana, Delhi and Rajasthan. They form part of stone built of India and stone built of the world. That is mainly because in this regions the temperatures are very high mainly due to summers and water consumption is not enough and most of the people tend to be dehydrated which is also occurring in the formation of kidney stones. Now if we come to etiology of kidney stone that is why our kidneys stones formed? In some people it is because the condition is genetic, they have parents or grandparents who were the stone former so the genes are passed on and they have the tendency of formation of stones. Sometimes there are patients who have other diseases which can lead to stone formation or sometimes during treatment e.g. some forms of bilateral surgery or excessive dieting can also lead to the formation of kidney stones most of the patients, however, do not have a specific reason of stone formation and they are etiologic stone formers. When it comes to symptoms of kidney stones, most common symptoms of kidney stone is pain and the pain is very typical, patients usually typically complain of back pain which rotates either from back to front or lower part of abdomen or from lower part of abdomen to the back. And sometimes male can experience pain in the scrotum and females can experience pain in the vulva region as well because of the kidney stone when they are obstructing. Having said that it is rather ironical sometimes bigger stones can actually be asymptomatic and detect on investigations done on the other purposes. So when it comes to diagnosis of kidney stones most useful entity to us for diagnosis is ultrasound.
Ultrasound is a non-invasive test and it offers them as a screening test. For urologist it is a examination of a clinical examination, it is the extension of the clinical examination. So most of the times stones are identified on ultrasound and when required we do the CT scan to further confirm the size and location of kidney stone as well as the density i.e. how hard is that stone. And these tool examination mainly form are basic outcomes. So when it comes to treatment of kidney stones the treatment of kidney stones depends on the size of the kidney stones, the location of the kidney stones and whether it is causing any complications. So when we talk about size it has been seen in most of the studies that stones that are lesser than 6mm have good chance of passing out by itself. So we always try conservative approach for these patients and we keep them on medications. Most of the patients that is about 80-90% of the patients who develop the pain due to stones have small stones and they do not require any surgery and they will pass out the stones with themselves with some additional medicines which will keep them pain free and their ureter to relax and in turn helps the stone to pass out themselves. When the stones is bigger than 6mm the chances of passing out spontaneously decrease. As the sizes increases further the chances decreases further. Similarly if the stone is tuck in the upper part of the urinary tract the chances of passing out spontaneously are less however if the stone is tuck in the lower part of urinary tract the chances of passing spontaneously is good. So third thing is complications, so whenever there is stone and it is causing recurrent urinary tract infection or it is causing fever or it is cause disengagement of the renal functions then it requires urgent treatment and it has to be removed. When we talk about surgeries of kidney stone there are different types of surgeries. So when the stone is in the kidney itself basically we can do 3 types of surgeries. One is ESWL or lithotripsy. In ESWL the patient is made to lie on a bed and some shock waves are applied to this part of the abdomen and they help the stones to break. However disadvantages of ESWL is that the success rate is relatively poor when compared to other modalities and they usually requires repetition.
So then came the era of PCNL. PCNL is the procedure which is called as percutaneous nephrolithotomy. In this the hole is made at the back and into the kidney and endoscope is passed into the kidney and stone is broken and removed. So it is a very good techniques but nowadays it is prefer only for very large stones and the latest technique in treatment of kidney stones is RIRS which is retrograde intrarenal surgery. In RIRS we basically go through a normal urinary tract and that is we go through the urethra up into the bladder and through the ureter we go into the kidney. And with this flexible urethroscope we break the stone there and there in the kidney itself, we make it into a very fine dust like substance and then we put it in a stand and come out. So most of the time this dust clears has ureter dilates because of the strand. However it has its own limitations specially when there is a very large stone e.g. stones larger than 2cm you may require multiple sitting of RIRS but for stones less than 2cm RIRS is now the preferred procedure. It is also preferred when the kidney is located in the abnormal position like in the pelvis or it is the malrotated kidney because when the kidney becomes difficult to approach via other modalities and but flexible endoscopy or RIRS we can reach it and we can break the stone then and there. When it comes to stone in ureter there are 2 modalities that are used to treat.1 is ureteroscopy which is a straight reject stereoscope and it is used to access the ureter and the stone is broken and removed. When the stone is in the upper part of kidney again there is a high chance of reproduction. Retrobuction is passing out the stone back into the kidney so if it is going back into the kidney the advantages of RIRS comes in, we can pass the flexible ureteroscope through the same route going into the kidney and break the stone which is retro pass back into the kidney. When it comes to bladder stones there are 3 procedures which are done one is cystolitholapaxy, then cystolithotripsy, and percutaneous cystolithotripsy. It depends on the size of the stone that which procedure will be done. If the stone is not very big it can be crush using a special forceps which is called as cystolitholapaxy. If the stone is between 1-5 cm then it can be broken through the normal urinary tract to transvaginal cystolithotripsy. If the stone is very big a small tract is made in the upper pelvic area and the stone is fragmented and removed.