Kidney Stone Surgery
What are Kidney Stones?
Kidney stones, also known as renal calculi, nephrolithiasis, or urolithiasis, are solid deposits composed of minerals and salts that form within the kidneys.
Various factors, including diet, obesity, certain medical conditions, and specific supplements or medications, can contribute to the development of kidney stones. These stones can affect any part of the urinary tract, ranging from the kidneys to the bladder. Typically, stones form when urine becomes concentrated, allowing minerals to crystallize and stick together.
Passing kidney stones can be extremely painful; however, timely recognition of the stones usually prevents permanent damage. Depending on the situation, pain medication and increased fluid intake may be sufficient for passing a kidney stone. In more complex cases, such as when stones become trapped in the urinary tract, are associated with a urinary infection, or cause complications, surgical intervention may be necessary.
If you are at a higher risk of recurring kidney stones, your doctor may recommend preventive treatment to reduce the likelihood of future occurrences. This may involve lifestyle modifications and medication to minimize the risk of developing new stones.
What are Kidney Stones?
A kidney stone typically remains asymptomatic until it starts to move within the kidney or passes into the ureters, the tubes that connect the kidneys to the bladder. When a kidney stone becomes lodged in the ureters, it can obstruct the flow of urine, resulting in swelling of the kidney and spasms in the ureter. This can lead to severe pain. The following signs and symptoms may manifest at this stage:
- Severe and sharp pain below the ribs in the side and back
- Radiating pain that extends to the lower abdomen and groin
- Waves of pain that vary in intensity
- Pain or a burning sensation during urination
Additional signs and symptoms may include:
- Urine that is pink, red, or brown in color
- Cloudy or foul-smelling urine
- Frequent urge to urinate or increased frequency of urination in smaller amounts
- Nausea and vomiting
- Fever and chills if there is an accompanying infection
The pain caused by a kidney stone may change over time, such as shifting to a different location or increasing in intensity, as the stone progresses through the urinary tract.
When to see a doctor
It is important to schedule an appointment with your doctor if you experience any concerning signs and symptoms.
Seek immediate medical attention if you encounter the following:
- Intense pain that prevents you from finding a comfortable position
- Pain accompanied by nausea and vomiting
- Pain accompanied by fever and chills
- Presence of blood in the urine
- Difficulty passing urine
- Causes
The formation of kidney stones is often multifactorial, with several factors contributing to an increased risk.
Kidney stones develop when the urine contains a higher concentration of crystal-forming substances, such as calcium, oxalate, and uric acid, than the urine can effectively dilute. Additionally, the urine may lack substances that inhibit the adherence of crystals, thereby creating an environment conducive to kidney stone formation.
Causes
The formation of kidney stones is usually not attributed to a specific cause, but there are several factors that can contribute to an increased risk. Kidney stones develop when there is an imbalance in the concentration of crystal-forming substances, such as calcium, oxalate, and uric acid, in the urine. When these substances are present in higher amounts than the urine can adequately dilute, they can crystallize and combine to form kidney stones. Additionally, if the urine lacks substances that prevent the crystals from sticking together, it creates an environment conducive to the formation of kidney stones.
Risk factors
Risk factors for kidney stones include:
Digestive diseases and surgery
Family or personal history
If a family member has had kidney stones, you have a higher risk of developing them as well. Previous episodes of kidney stones also increase the risk of recurrence.
Dehydration
Insufficient daily water intake can increase the risk of kidney stones. People living in hot and dry climates or those who perspire excessively may have a higher risk.
Certain diets
Diets high in protein, sodium (salt), and sugar may elevate the risk of certain types of kidney stones. High sodium intake can increase calcium levels in the urine, significantly raising the risk.
Obesity
Being overweight, having a high body mass index (BMI), a large waist size, and weight gain are associated with an increased risk of kidney stones.
Digestive diseases and surgery
Conditions like gastric bypass surgery, inflammatory bowel disease, or chronic diarrhea can affect the digestive process, leading to changes in calcium and water absorption, and increasing the levels of stone-forming substances in urine.
Other medical conditions
Certain conditions such as renal tubular acidosis, cystinuria, hyperparathyroidism, and repeated urinary tract infections can raise the risk of kidney stones.
Certain supplements and medications
Intake of certain supplements and medications like vitamin C, dietary supplements, excessive use of laxatives, calcium-based antacids, as well as certain medications used for migraines or depression, can increase the risk of kidney stones.
Complications
Kidney stones can lead to complications such as urinary tract infections (UTIs) and kidney infections if they block the passage of urine. This can increase the risk of chronic kidney disease. Additionally, about 50% of individuals who have had a kidney stone are likely to develop another one within 5-7 years. Preventive measures, regular check-ups, and addressing the underlying causes of stone formation are essential to minimize complications and reduce the risk of recurrence.
Diagnosis
If a kidney stone is suspected, your doctor may perform several diagnostic tests and procedures:
Blood testing
Blood tests can detect elevated levels of calcium or uric acid, indicating the presence of kidney stones. These tests also help evaluate kidney function and identify any underlying medical conditions.
Urine testing
The 24-hour urine collection test assesses the levels of stone-forming minerals and stone-preventing substances in your urine. It may involve collecting urine samples over two consecutive days to provide a comprehensive analysis.
Imaging
Various imaging techniques can visualize kidney stones in the urinary tract. High-speed or dual-energy computerized tomography (CT) scans are highly effective in detecting even small stones. Simple abdominal X-rays are less commonly used but can still identify larger stones. Ultrasound, a quick and noninvasive test, is another option for diagnosing kidney stones.
Analysis of passed stones
You may be asked to strain your urine to collect any stones you pass. Laboratory analysis of these stones helps determine their composition, which can assist in identifying the underlying causes of kidney stones and developing a prevention plan
Prevention
Preventing kidney stones involves a combination of lifestyle adjustments and, in some cases, medications. Here are some preventive measures:
Lifestyle changes
You may reduce your risk of kidney stones if you:
Drink water throughout the day
Drinking an adequate amount of water throughout the day is crucial. Doctors often recommend consuming enough fluids to produce about 2.1 quarts (2 liters) of urine daily. Monitoring your urine output can help ensure sufficient hydration. In hot climates or during intense physical activity, you may need to drink even more water. Clear and light-colored urine is a good indicator of proper hydration.
Eat fewer oxalate-rich foods
If you’re prone to forming calcium oxalate stones, your doctor may advise reducing your intake of foods high in oxalates. Examples include rhubarb, beets, okra, spinach, Swiss chard, sweet potatoes, nuts, tea, chocolate, black pepper, and soy products.
Choose a diet low in salt and animal protein
Adopt a low-salt, low-animal protein diet: Decrease your salt intake and opt for non-animal protein sources like legumes. Consider using a salt substitute such as Mrs. Dash.
Continue eating calcium-rich foods, but use caution with calcium supplements
Dietary calcium does not significantly impact kidney stone risk. Unless advised otherwise by your doctor, continue consuming calcium-rich foods. However, exercise caution with calcium supplements, as they have been associated with an increased risk of kidney stones. Taking supplements with meals and consulting your doctor is recommended. Note that a low-calcium diet can promote kidney stone formation in certain individuals.
Medications
During kidney stones treatment, medications can play a crucial role in managing the levels of minerals and salts in the urine, particularly for specific types of stones. Here are some examples of medications used:
Calcium stones
For preventing calcium stones, your doctor may prescribe a thiazide diuretic or a preparation containing phosphate.
Uric acid stones
To reduce uric acid levels in the blood and urine, as well as to maintain alkaline urine, your doctor may prescribe allopurinol (Zyloprim, Aloprim) or other medications. In some cases, a combination of allopurinol and an alkalizing agent can dissolve uric acid stones.
Struvite stones
Preventing struvite stones involves strategies to keep the urine free from bacteria that cause infection. This may include maintaining good urine flow by drinking plenty of fluids and frequent voiding. In certain instances, long-term use of antibiotics in small or intermittent doses may be necessary, especially before and after surgery to treat kidney stones.
Cystine stones
In addition to recommending a diet low in salt and protein, your doctor may advise increasing fluid intake to produce a larger volume of urine. If increased fluid intake alone is insufficient, a medication that enhances the solubility of cystine in the urine may be prescribed.
During Kidney Stones Treatment
Determining the type of kidney stone you have is essential for understanding its cause and developing strategies to prevent future occurrences. If you pass a kidney stone, try to save it so that your doctor can analyze it. Here are the common types of kidney stones:
Calcium stones
Calcium stones, predominantly calcium oxalate, are the most common type. Oxalate is produced by the liver or acquired from the diet. Foods high in oxalate, such as certain fruits, vegetables, nuts, and chocolate, can contribute to their formation. Factors like dietary choices, high vitamin D doses, intestinal bypass surgery, and certain metabolic disorders can increase calcium or oxalate concentration in urine. Calcium phosphate stones, another form of calcium stones, are more prevalent in metabolic conditions like renal tubular acidosis or associated with specific medications like topiramate.
Struvite stones
Struvite stones develop in response to urinary tract infections. They can grow rapidly and become large without causing significant symptoms.
Uric acid stones
Uric acid stones may form in individuals with conditions such as chronic diarrhea, malabsorption, high-protein diets, diabetes, metabolic syndrome, or certain genetic factors that increase uric acid levels.
Cystine stones
Cystine stones are associated with a hereditary disorder called cystinuria, which leads to excessive excretion of a specific amino acid by the kidneys.
Treatment
The treatment for kidney stones varies depending on the type and cause of the stone. For small stones with minimal symptoms, the following approaches may be used:
Small stones with minimal symptoms
Most small kidney stones won’t require invasive treatment. You may be able to pass a small stone by:
Drinking water
Increasing your water intake to 2 to 3 quarts (1.8 to 3.6 liters) per day helps keep your urine diluted and may prevent stone formation. Aim to drink enough fluids, mainly water, to produce clear or nearly clear urine, unless advised otherwise by your doctor.
Pain relievers
Mild discomfort caused by passing a small stone can be relieved with over-the-counter pain relievers like ibuprofen (Advil, Motrin IB) or naproxen sodium (Aleve).
Medical therapy
Your doctor may prescribe medication to facilitate the passage of the kidney stone. Alpha blockers, such as tamsulosin (Flomax) or the combination of dutasteride and tamsulosin (Jalyn), can relax the muscles in your ureter, aiding in the faster and less painful passage of the stone.
Large stones and those that cause symptoms
Kidney stones that are too large to pass spontaneously or lead to complications such as bleeding, kidney damage, or recurrent urinary tract infections may require more extensive treatment. The following procedures may be considered:
Using sound waves to break up stones
If your kidney stones are of a certain size and location, your doctor may suggest extracorporeal shock wave lithotripsy (ESWL) as a treatment option.
ESWL utilizes sound waves to generate powerful vibrations, known as shock waves, which effectively break the stones into small fragments. These smaller pieces can then be easily passed through the urine. The procedure typically lasts between 45 to 60 minutes. To ensure your comfort during the process, you may receive sedation or light anesthesia.
It’s important to note that ESWL can have some side effects. These include the presence of blood in the urine, bruising on the back or abdomen, bleeding around the kidney and nearby organs, as well as discomfort as the fragmented stone pieces traverse the urinary tract. However, these effects are usually temporary and will subside as your body eliminates the stone fragments.
Surgery to remove very large stones in the kidney
In cases where kidney stones are large or ESWL is not effective, a procedure called percutaneous nephrolithotomy may be recommended. This surgical procedure involves the removal of a kidney stone using small telescopes and specialized instruments that are inserted through a small incision in your back.
During the surgery, you will be under general anesthesia to ensure you are comfortable and pain-free. Following the procedure, you can expect to stay in the hospital for one to two days for recovery and monitoring.
Percutaneous nephrolithotomy is an alternative option when ESWL is not successful in breaking down or removing the kidney stone. Your doctor will assess your specific situation and determine the most appropriate treatment approach for you.
Using a scope to remove stones
To address smaller stones in the ureter or kidney, a procedure called ureteroscopy may be performed. During this procedure, a thin, illuminated tube called a ureteroscope, which is equipped with a camera, is inserted through your urethra and bladder to reach the ureter.
Once the stone is visualized, specialized tools are used to either capture and remove the stone or break it into smaller fragments that can pass through your urine. In some cases, a small tube called a stent may be placed in the ureter to reduce swelling and support healing. The procedure can be performed under general or local anesthesia, depending on your specific needs and the recommendation of your doctor.
Parathyroid gland surgery
Hyperparathyroidism, an overactivity of the parathyroid glands, can contribute to the formation of calcium phosphate kidney stones. These small glands are situated near the thyroid gland, below the Adam’s apple, at the four corners. Excessive production of parathyroid hormone can result in elevated calcium levels, leading to the development of kidney stones.
Hyperparathyroidism can be caused by the presence of a benign tumor in one of the parathyroid glands or by other conditions that stimulate the glands to produce excess hormone. Treating hyperparathyroidism involves removing the abnormal growth from the gland, which helps prevent the formation of kidney stones. Alternatively, your doctor may recommend addressing the underlying condition responsible for the overproduction of parathyroid hormone. By managing the root cause, the formation of kidney stones can be mitigated.
After Kidney Stones Treatment
Recovery
Our team of urology experts will closely monitor your recovery process and ensure your well-being. As part of your post-surgery care, we may prescribe medications such as tamsulosin (Flomax) to relax and widen your ureter, facilitating the passage of stones or fragments. To evaluate the composition of any passed stone pieces, we may ask you to collect them using a strainer.
If a temporary stent was inserted in your ureter during the surgery, we will schedule an office visit to remove it within two to ten days following the procedure.
The recovery period after kidney stone surgery varies depending on the specific procedure and your individual circumstances. Generally, you can expect to resume your normal activities within the following time frames:
External shock wave lithotripsy or ureteroscopy and laser lithotripsy: Within two to three days.
Percutaneous nephrolithotomy: Within one to two weeks.
However, if you have a temporary stent in place, you may experience some discomfort that could limit certain activities during this period. Rest assured, our team will provide guidance and support throughout your recovery journey.
Post-Surgery Symptoms
Following your surgery, it is normal to experience certain symptoms, which may include:
Soreness and bruising in the area where the lithotripter made contact with your skin, in the case of external shock wave lithotripsy.
Discomfort and the presence of blood in your urine for a few days, particularly if a ureteral stent was inserted.
Pain and nausea as any remaining stone fragments pass through your urinary tract. If your surgery involved an incision, you may also experience pain at the incision site.
These symptoms are common and expected during the recovery process. However, if you have concerns or experience severe or prolonged pain, excessive bleeding, or other worrisome symptoms, it is important to reach out to your healthcare provider for guidance and further evaluation. They will be able to provide appropriate support and ensure your well-being throughout your recovery.
FAQ about kidney stone treatment in Iran
Common surgical options for kidney stone removal include minimally invasive techniques like shock wave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PNL). Less common procedures include laparoscopic, robot-assisted, and open surgery. The choice of procedure depends on factors such as stone size, location, and patient health.
In open surgery for kidney stone removal, the surgeon makes an incision in the abdomen or side of the patient to access the kidney and extract the stones. A small tube, known as a catheter, is placed near the kidney to facilitate urine drainage during the healing process.
ESWL: Non-invasive procedure that uses sound waves to crush kidney stones for easier passage into the bladder.
PCNL: Surgical procedure involving a small incision in the back to access the kidney and remove or break up larger stones.
URS: Minimally invasive procedure using a thin tube with a camera to remove or break up stones in the ureter or kidney.
Pyelolithotomy: Surgical procedure that entails making an incision in the kidney to directly remove or extract stones from the renal pelvis.
The study found that the overall prevalence of kidney stones was 17.6% (95% CI: 16.1-19.2). Among the participants, 21.53% of men and 14.36% of women had kidney stones. Additionally, 14.18% of the poorest group and 23.17% of the richest group were found to have kidney stones.
Potassium citrate is recommended as the initial treatment option to neutralize urine acidity, along with increasing fluid intake. This recommendation is supported by expert opinion from the American Urological Association (AUA) and a strong recommendation from the European Association of Urology (EAU).
The likelihood of a kidney stone passing without surgery decreases as its size increases. Surgical treatment is generally recommended for stones that are 0.5 centimeters in size or larger, as well as for patients who do not respond to conservative management approaches.