H.T. Kurkjian, M.D.        Kidney Stones
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Kidney Stones

Kidney stones are calcifications in the urinary system that can cause pain, infection and, at times, can be dangerous enough to cause death.  Kidney stones can be in any location in the urinary system.  

Kidney stones in the kidney proper
Stones found in the kidney are mostly in the pelvis of the kidney.  This is the major drainage part of the kidney.  Sometimes, they can be in the Calyces, which are the small collecting parts in the kidney.  If a kidney stone is in the pelvis of the kidney or the calyces of the kidney, depending on the size, ESWL (shock wave treatment) would be the best treatment.  At times percutaneous lithotripsy is performed by putting a needle through the flank and then going in with wires inside the kidney.  Larger and larger tubes are then used until the space is large enough to insert a special tool used to breakup the stones and remove them.Of course, open kidney surgery is still available and is done for very large stones or stones which cannot be approached by.the two above methods

 

Stones in the ureter
The ureter is the duct that leads from the kidney to the bladder.  If the stone is high in the ureter, it is best to push the stone back into the kidney and do ESWL (shock wave) procedure to break the stone.  Sometimes, ESWL can be done with the stone in the upper ureter but success rates vary from 50% to 70%.

Mid-ureter
If the stone is in the middle part of the ureter, it will be necessary to push it up into the kidney or wait until it moves down the ureter.  In the middle part of the ureter, there is no good way to break up the stone.  One can try ESWL but the success rate is 50%.  Sometimes if there is blockage and fever, surgery or ureteroscopy may be required to remove it.

Stones in the lower part of the ureter
Stones in the lower part of the ureter are usually removed by a basket procedure.  This procedure consists of a basket that is packed inside a small catheter.  The catheter is passed through a cystoscope inside the bladder and then up the ureter.  It is inserted behind the stone so when it is opened, like an umbrella, it will catch the stone and bring it out. Sometimes it becomes necessary to dilate the ureter as in angioplasty to be able to insert a ureteroscope and remove the stone. It may become necessary to use laser in conjunction with a catheter that needs to be placed very close to the stone.  Consequently, laser procedures cannot be used through the body like shock wave treatment.

Bladder stones
Bladder stones can usually be broken up by a machine called a Lithotriptor, laser, electro-hydraulic machines or can be removed by surgery.

Stones in the prostate
Stones in the prostate are embedded in the substance of the prostate and cannot be removed or pulverized.  They usually are removed by removal of the prostate.

Surgical indications

  1. Fever - If fever develops during the course of the patients illness with a kidney stone or ureter stone, it means that area behind the stone has become infected. The urine behind the stone will contain pus and bacteria.  If the bacteria gets into the blood stream a very dangerous and life threatening condition called bacteremia can occur.  So, if fever develops, an operation is  usually performed on the patient within 24 to 48 hours.
  2. Pain - Some recurring pain is to be expected in the beginning.   However, intervention will be required if the pain is such that, over a 48 hour period, intramuscular or IV injections are required to control the pain.
  3. Obstruction - If the kidney is totally blocked and there is no pain or fever, treatment can wait a while.  However, if treatment is delayed to long, kidney damage can occur.
  4. Intervention - The pain due to a kidney stone is rarely ever due to the kidney stone itself.  It is usually due to the distention or swelling of the kidney and the ureter behind the point of blockage.  That is why sometimes, even if the stone is still retained, the pain may disappear for days because the urine is able to drain around the stone.

Management

  1. Pain pills or shots as needed.
  2. Fluids should be cut down in the beginning until the sever pain subsides.  Then fluids can increased.  Sometimes there is nausea, abdominal discomfort and bloating.  These are all caused by the stone.

Prevention

After the stone is removed it is sent for analysis. Sometimes, it becomes necessary to study the urine and the blood to determine the cause of the specific type of stone formation.  This is specially important as there are more than one type of stone. The metabolic study of kidney stones consists of 24-hour urine and blood collections.

  1. The patient is instructed to collect 24-hour urine on a regular diet.  This is done from 7:00 a.m. one day  to 7:00 a.m. the next day. After the urine is collected the patient brings the urine to the lab. A blood specimen  may be requested too.  After completing this the doctor will see the patient in the office where results are discussed and he or she is placed on a special diet or given special tablets.  While on this diet or tablets,  another 24 hour urine is collected to make sure the diet or tablets are working.  If not, the dose or diet is adjusted.  This treatment usually lasts from six months to one year.   Most patients who have done this metabolic work up have done very well and not had any recurrent kidney stones.

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