RURAL UROLOGY

URINARY TRACT STONES IN RURAL AREAS

RURAL UROLOGYRURAL UROLOGY

RURAL UROLOGY

Historical evidence


RURAL UROLOGY: URINARY TRACT STONES

§ First description by Hippocrates in 4th century BC

§ Found in Egyptian mummy El Amrah

§ Sushrutha performed perineal lithotomy in 12 centry BC

Historical development



§ First open surgery for renal stone by Heinecke in 1879

§ Fernstrom and Johansson did the first PCNL in 1976

§ Chausy performed the first ESWL in 1980

Incidence



§ 12% have stone in their lifetime§ 12% of men will suffer from kidney

stone by age of 70§ 5% of women will suffer from kidney

stone by age of 70§ 50% have recurrence within 5-10 yrs§ 7-10 of every 1000 hospital admission

is of renal stone§ Highest incidence of kidney stone is in

30-45 years

Clinical Presentation



§ Renal Colic§ Hematuria [both microscopic

and macroscopic]§ Lower Urinary Tract Symptoms

[LUTS]§ Incidental finding§ Urinary Tract Infections§ Renal Impairment

The Indian Scenario



§ 1 out of 1000 Indians suffer from stone disease

§ More common in the stone belts [Maharashtra, Gujarat, Punjab, Haryana, Delhi and Rajasthan]

§ Studies have shown that they pass only about 1 to 1.5 liters of urine in these areas

The theories of Stone formation



§ Many substances are in super saturation [180 liters of blood to 2 literes of urine]

§ Most of the stones are by Idiopathic stone formers

§ Metabolic abnormalies too contribute to stone formation

The Metabolic abnormalities



SUSPECT IF§ Bilateral§ Recurrent§ Occur in the young age§ Are multiple

What happens?



§ Most of the small stones pass but some act as nidus

§ Some can fill the Kidney as Staghorn calclus

§ They can get blocked at various places causing symptoms

§ Stones in the bladder could cause retention of urine

Common types of Stones






§ Incidental diagnosis on routine health checkups.

§ Dull aching pain in the back§ Acute colic.§ Classical pain is described as pain

from loin to groin, accompanied by nausea, vomiting and gaseous distension.




§ Urinary tract infection.§ Increased frequency of urine§ Pain and or burning while

passing urine.§ Passage of blood in urine

(Hematuria) which can be gross or microscopic

Investigations



§ Urine microscopy.§ Urine Culture & Sensitivity § X ray KUB.§ Ultrasound abdomen

Investigations



§ Blood tests [Creatinine, Electrolytes]

§ Routine tests for surgical procedures

§ IVU or Intravenous Urography

Investigations for cause



§ Serum Calcium§ Serum Phosphorus.§ Serum Uric acid§ 24 hour urinary calcium / 24

hrs urinary uric acid§ Stone analysis of the

retrieved calculus.

Immediate Treatment



§ Significant obstruction§ Progressive deterioration of the kidney§ Irreversible infection of the kidney

(Refractory pyelonephritis)§ Unremitting pain§ Stone obstruction an infected kidney

Conservative Treatment



§ Antibiotic to control infection.§ Analgesics to give relief from

the pain§ Alpha blockers to dilate the

ureters [Tamsulosin] § Oral Hydrotherapy.§ IV fluids if there is nausea /

Vomiting

Treatment Options



§ ESWL (Lithotripsy)§ Ureteroscopy (URS) § Percutaneous

Nephrolithotomy (PCNL) § Open surgery

ESWL



§ ESWL in 1980 Chaussy in Germany § ComfortabLe for stones between 1.5

to 2 cm both renal & upper ureteric§ Might require DJ stenting for larger

stones§ Good diuresis is require post

treatment

PCNL



§ PCNL started in 1976 and used for stones larger than 2 cm

§ After placing a open ended catheter the collecting system is punctured and guide wire is placed

§ The tract is dilated & scope is passed to break and remove the stone

§ Good diuresis is require post treatment

Open Surgeries



§ Open renal surgeries are also difficult in rural areas

§ First pyelolithotomy was by Heinecke in 1879

§ Gil-Vernet in 1965 popularized modern surgery

§ We use URS & Cystoscope for stone clearance

Small Stones



§ Up to 5 mm pass within two weeks [71 to 98%]

§ Medical Expulsion Therapy for stones up to 7 mm

§ 7 to 12 mm DJ stenting could be tried if MET not sucessful

§ We use URS lithotripsy after 6 weeks with DJ stent

Medium Sized Stones



§ DJ stenting & wait for 6 weeks§ The Ureter dilates, inflammation

fixes Urothelium, less infection & improved renal function

§ URS & Lithotripsy after 6 weeks§ We use URS lithotripsy after 6

weeks with DJ stent

Large Sized Stones



§ We prefer removal using URS and DJ stenting with several sittings

§ Centers that have the facility would prefer PCNL with multiple punctures if necessary

§ We do open surgeries if facilities are available and prefer using Cystoscope or URS for stone clearance

The URS technique



§ Prior DJ stenting 6 weeks earlier § Pass guide wire and then remove DJ

stent§ Use Lithoclast to break the stones

into fragments§ Head down / tilt, etc are necessary

for visualizing the stone§ Flushing and alternating with suction

helps

The Prophylactic Antibiotics


RURAL UROLOGY: DJ STENTING

§ The Aminoglycosides [Gentamicin / Amikacin]

§ The Cephalosporins [Ceftriaxone]§ The fluoroquinolones

[Ciprofloxacillin]

Post Operative Instructions



§ Sufficient water to pass 3.5 liters of urine a day

§ Usually the stents are removed in 6 weeks but should not have more than 3 months.

§ Reflux of urine might cause some discomfort

§ There might be pain while stone pieces come down

§ Less water would cause encrustations

Post Operative Medication


§ Bed time dose of antibiotics § Alpha blockers like Tamsulosin.§ Alkalinizers like Sodium bi

carbonate

Date post:	04-Apr-2022
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