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Glamorgan Urology: Kidney Stones

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Content:

Kidney Stones

Kidney Stones / Urinary Stones

Description

Kidney stones or renal calculi, are crystal aggregations formed in the kidneys from dietary minerals in the urine. Kidney stones are a significant source of morbidity. Eighty percent of those with kidney stones are men. Men most commonly experience their first stone episode between 30–40 years of age, with women being over a decade later.

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Small Kidney stones often don’t cause symptoms and be detected during scans for other conditions. Kidney stones typically leave the body by passage in the urine stream, and many stones are formed and passed without causing symptoms.

If stones grow to sufficient size, (3-4mm) they can cause blockage of the ureter. This can lead to severe pain termed ‘renal colic’. Renal colic typically comes in waves lasting 20 to 60 minutes, beginning in the flank or lower back and often radiating to the groin or genitals. The pain is most commonly felt in the flank, lower abdomen and groin and can be associated with nausea, vomiting, fever, blood in the urine and painful micturition.

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Diagnosis

The diagnosis of kidney stones is made on the basis of information obtained from the history, physical examination, urinalysis, and X ray studies (CT urogram or an IVU – IntraVenous Urogram).

Blood tests to look at kidney function and biochemical tests (serum Calcium and uric acid) may be performed to ascertain the cause of the stone. A urine culture may be performed to exclude a urinary tract infection.

Treatment

When a stone causes no symptoms, watchful waiting is a valid option. For symptomatic stones, pain control is usually the first measure, using medications such as non-steroidal anti-inflammatory drugs (diclofenac via tablets, suppositories).

Some renal stones require treatment and the choice of treatment depends on the size and location of the stone.

Glamorgan Urology offers three types of treatment for kidney stones:

  1. Extra-corporeal shock wave therapy (ESWL)

  2. Ureteroscopy and holmium laser ablation of urinary stones.

  3. Percutaneous nephrolithotomy (PCNL)

Treatment 1: ESWL

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This is the most common method of dealing with small kidney stones. The kidney stone is located using X-ray imaging or ultrasound scanning. While you are lying down, a machine called a lithotriptor sends targeted shock waves to break up the kidney stone into pieces small enough to be passed out. Sometimes you will experience pain as the stone fragments pass. This procedure is usually performed either using standard pain killers or with mild sedation as a daycase, without the need for a general anaesthetic

Treatment 2: Ureteroscopy

Ureteroscopy involves passage of a very thin endoscope (Figure 1a) through the urethra, into the bladder and then through the ureteric opening into the ureters and if necessary up to the kidneys.

Glamorgan Urology use a 20 watt holmium laser (www.surgical.lumenis.com/urinary_lithotripsy) (Figure 1) to fragment kidney and ureteric stones (Figure 2) via a very fine laser fibre that can be passed through a ureteroscope. The stone is fragmented into tiny pieces without damaging the surrounding tissue. Most of these fragments will pass spontaneously, but some can be removed with a small basket for analysis.

This technique is performed under general anaesthetic on a day case basis.

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Figure 1. A flexible ureteroscope

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Figure 2. A 20 watt holmium laser unit

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Figure 3. A ureteric stone

Treatment 3: PCNL

Large stones in the kidneys (> 1.5cm in diameter) often need to be removed by ‘keyhole surgery’.

Mr Thomas and Dr Tudor perform this technique together. Two approaches are commonly employed:

  1. a traditional puncture with the patient lying prone and,

  2. increasingly through an ‘anterior puncture’ with the patient lying on his/her side.

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Figure 4. IVU: a stone in the renal pelvis of the kidney

Using ultrasound and X-ray imaging, Dr Gareth Tudor will create a small track between the skin and the kidney using a balloon dilator over a guidewire.

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Figure 5. Dr Gareth Tudor, inserts a guidewire onto the kidney

A tube called an amplatz sheath is then (Figure 6) directed into the kidney next to the kidney stone.

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Figure 6. An amplatz sheath being placed by Dr Gareth Tudor

Mr Thomas will then pass a nephroscope (Figure 7.) down the sheath to view the stone.

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Figure 7. The nephroscope

Depending on the size, consistency or location of the stone, it will then be removed whole or broken into fragments using 1) a swiss lithoclast 2) an ultrasound probe or 3) a holmium laser.

The procedure involves a general anaesthetic and a two day hospital stay.

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