Kidney stone disease history dates back to 4000-5000 B.C. Although various theories have been suggested for stone composition, it has not been fully elucidated yet. However, some conditions that cause or predispose to kidney stones are known.
Various of the anatomical and functional diseases of the kidney, some genetic and metabolic diseases, geography (especially the hot climate),race, family history, occupation, fluid consumption habits and eating, drinking culture are the most known of these.
They are formed when some of the minerals in the urine produced from the kidneys pass the soluble level and crystallize and these crystals combine in the renal collecting system and turn into stones.
Although urinary system stone disease is mostly known as kidney stone disease among the people, stones that cause serious pain are usually located in the ureter, which is the channel that provides urine transport between the kidney and the bladder.
Urinary system stone disease may cause serious loss of kidney function and kidney failure. Sometimes it can progress insidiously without any symptoms but often stone can evince serious symptoms depending on the location of the urinary system and the obstruction in the kidney or ureter.
These stones may be located in various parts of the kidney, ureter, bladder, and sometimes even in the urethra, which is the urinary tract beyond the prostate.
The most common symptoms are:
As in the diagnosis of every disease, the patient's history is very important in this pathology, because kidney stone pain is a typical pain. Again, there are clear findings pointing to urinary system stone disease in the examination. Some tests are required to see the systemic effect of the stone. While different analyzes may be required for each patient, urinalysis, urine culture, urea- creatinine tests, blood electrolytes, and hemogram tests are the most frequently applied ones.
Imaging methods should also be applied to see the localization and size of the stone. The most sensitive radiological film in the diagnosis of kidney stones is computed tomography without contrast (drug-free). Since the highest accuracy, tomography is mostly required imaging for the patients who need surgery.
However, due to the radiation dose received during tomography, harmless imaging methods such as ultrasonography are also instructive in special cases such as the pediatric age group and pregnant women. X-rays are also frequently used in the follow-up (whether the stone falls spontaneously or in the evaluation of the remaining fragments after surgical treatment).
Another important imaging method in the diagnosis of kidney stones is IVP, which is a contrast applied film. It is very valuable both in terms of showing kidney function and when it shows the anatomy of the kidney before surgery. Sometimes, image based measuring the function level of the kidney and the transport state of the urine in the collecting system is also needed, and kidney scintigraphy may be requested (DMSA, DTPA, MAG3).
While discussing kidney stone treatment options, the most accurate decision is made by evaluating the size of the stone, its localization, the functional status of the kidneys, and the factors related to the patient.
For stones that can pass spontaneously (it is considered 50% for stones 6 mm and below); various drug recommendations, lifestyle recommendations and increasing fluid intake are recommended to the patients and they are waited for stone removal.
Various endoscopic surgeries (URS, RIRS),performed with the use of LASER; operations performed by opening a hole of approximately 1-2 cm from the flank region of the patient (Percutaneous Nephrolithotomy); open and laparoscopic stone surgeries can be applied. Shock wave lithotripsy (SWL) is another option for suitable cases (< 2 cm kidney stone, upper ureteral stone).
It may rarely be necessary to combine several methods in a single session or in several sessions. In kidney stone surgery, as in other operations, the experience and ability of the surgeon in these operations and the operating room instruments are very important for the success.
The incidence of urinary system stone disease is increasing due to both the increasing sedentary lifestyle and the change in dietary habits. A man's lifetime risk of developing kidney stones is about 20% and for women about 5-10%. In individuals with a history of kidney stone once, the stone will recur with a 50% probability in the following 5 years.
Family history and some genetic and metabolic diseases (cystinuria, gout) are other factors that increase the risk of stone formation. In the light of these known scientific data, important lifestyle changes can be applied to reduce the risk of kidney stone formation, especially in risky patients, to both protect kidney health and maintain a more comfortable life.
These lifestyle changes can be listed under the main headings as follows;
Stone analysis is a guide for some medical treatments in some patients (especially in recurrent stone patients and pediatric patients) who have previously removed a stone piece by surgery or who have dropped a stone and have a stone sample.
For example, potassium citrate and allopurinol treatment in uric acid stones, and tiopronin and potassium citrate treatment in cystine stones significantly reduce the likelihood of stone recurrence.
It is known as stone breaking with shock waves from outside the body. It is a method that does not require incision and does not need to be entered through the urinary canal with the help of optics.
Its working principle is based on the principle of breaking the stone into pieces with the vibration created by the sound waves focusing on the stone. While focusing the stone, the location of the stone is determined with the help of fluoroscopy (like x-rays) and ultrasonography. The process takes about half an hour.
Advantages of SWL; Except for the pediatric age group, anesthesia is not required and it is a procedure that does not require a daily hospitalization. Complications (undesirable side effects) are less than other methods.
Disadvantages of SWL; The probability of getting stone free in a single session is lower than other methods. 2nd and 3rd session procedures are usually required and the probability of stone-free recovery even at the end of the 3rd session is lower than flexible ureterorenoscopy (RIRS) and percutaneous nephrolithotomy methods. In addition, since it is usually 1 week between sessions, it can lead to long labor loss for patients with severe pain.
Ureteroscopy (URS) is the most commonly used method for stones in the ureter, which is the channel that carries the urine produced in the kidney to the bladder. Contrary to what is known, most of the stones that cause severe pain and obstruction are not in the kidney, but are located in this canal.
It is applied endoscopically with the help of fine optical instruments and does not require incision. It is reached by entering the urine through the canal. The stone is broken into pieces by sending LASER energy through these tools.
If the stone constitute edema in the ureter and an additional session is required, a catheter (double j stent) is placed to the ureter (one end in the bladder and the other end in the kidney) for ensuring urinary drainage of the canal. It is usually and easily removed after a few days or weeks.
It is a very advantageous and frequently used surgical method due to its high stone-free rate in a single session, low complication (side effects) rate and being comfortable enough for the patient to return to normal life within 1-2 days.
With the help of flexible optical instruments, the stone is visualized by entering the urinary canal again and advancing to the bladder, ureter and kidneys, respectively. In this endoscopic surgery, which does not require incision, after the stone is found, the stone is divided into pieces that cannot be seen with the LASER energy.
Sometimes, operations may be required in a repeated session due to the size, localization of the stone and stenosis in the urinary canal.
Again, as in the ureteroscopy method applied to ureteral stones, a catheter (double j stent) with one end in the bladder and the other end in the kidney is placed in the ureter and removed after a few days or weeks in order to provide urinary drainage depending on the remaining stone volume and edema in the urinary system after the operation.
This method is generally preferred for small and modarate size kidney stones (<2-3 cm) and stones located in the upper part of the ureter.
Being able to be discharged even on the same day, returning to business life quickly (2-3 days),low complication rate, high stone-free rate make this surgery advantageous compared to other alternative kidney stone surgeries (percutaneous nephrolithotomy, open surgery).
Percutaneous nephrolithotomy (PNL) is a surgical method performed by making a hole of approximately 1-2 cm from the flank region of the patient and is widely used in the treatment of kidney stones larger than 2-3 cm.
With the help of the tunnel created through this hole, the stone is visualized by using optical system and fluoroscopy (x-ray) devices, and the stone is broken out with various energy methods (pneumatic, ultrasonic, laser).
This method has now reduced the use of open stone surgery to less than 1% in patients with large kidney stones. Compared to open stone surgery, it is a very advantageous method due to its rapid recovery time, high stone-free rate, and low need for repetitive interventions.
It is also a great advantage that stone fragments can be easily taken out of the body during surgery, allowing stone analysis, especially in patients with recurrent stones.
Unfortunately, there are important complications of this surgery, which is known as an endoscopic operation. Serious bleeding and infection, injury to adjacent organs are not to be underestimated. Experienced team and equipment are very important to avoid these undesirable situations.
Considering that stone-free methods cannot be achieved with endoscopic methods, open methods are frequently on the agenda for urologists. However, in today's world where cosmetic results and returning to social life in a short time are very important, I believe that we, surgeons, should produce alternatives to open surgeries as much as possible.
For example; usually laparoscopic pyelolithotomy is more advantageous procedure than percutaneous nephrolithotomy for horseshoe kidney stone. Laparoscopic ureterolithotomy is a alternative method for large ureteral stones. I often prefer these laparoscopic surgeries for suitable cases.
Unfortunately, some of our patients may also present with impaired kidney function due to stones. With the imaging method called scintigraphy (DMSA),nephrectomy (removal of the kidney) is often required in these patients with advanced loss of function. Laparoscopic nephrectomy (removal of the kidney) is also superior to open surgery in terms of both rapid recovery and cosmetic results.
As mentioned in other stone surgery methods, open stone surgery is rarely preferred today due to both the poor cosmetic result caused by large surgical incisions and the long recovery time. Experience is also very important for this procedure, which may be required in very special cases.
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Assoc. Prof. Dr. Arif DemirbasUrology Specialist
Assoc. Prof. Dr. Arif Demirbaş
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