What Are Percutaneous Nephrolithotomy And Percutaneous Nephrolithotripsy
These procedures are treatments for kidney stones that are used in patients with large or irregularly shaped kidney stones, people with infections, stones that have not been broken up enough by SWL or those who are not candidates for another common stone treatment, ureteroscopy. Stones that are bigger than 2 cm require this procedure.
Both procedures involve entering the kidney through a small incision in the back. Once the surgeon gets to the kidney, a nephroscope and other small instruments are threaded in through the hole. lf the stone is removed through the tube, it is called nephrolithotomy. lf the stone is broken up and then removed, it is called nephrolithotripsy. The surgeon can see the stone, use high frequency sound waves to break up the stone, and “vacuum” up the dust using a suction machine.
This is what the words mean:
- Percutaneous means through the skin
- Nephrolithotomy is a combination of the word roots nephro- , litho-, and -tomy
- Nephrolithotripsy is a combination of the word roots nephro- , litho , and -tripsy
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2. Ureteroscopy This procedure also requires general anesthesia. Once asleep small cameras are driven into the urethra, bladder and then ureter . When a stone is encountered, it is either basketed and removed or fragmented using a laser. This procedure typically requires a temporary tube in the ureter called a stent.
What Causes These Stones
Ureter stones are made up of crystals in your urine that clump together. They usually form in the kidneys before passing into the ureter.
Not all ureter stones are made up of the same crystals. These stones can form from different types of crystals such as:
- Calcium. Stones made up of calcium oxalate crystals are the most common. Being dehydrated and eating a diet that includes a lot of high-oxalate foods may increase your risk of developing stones.
- Uric acid. This type of stone develops when urine is too acidic. Its more common in men and in people who have gout.
- Struvite. These types of stones are often associated with chronic kidney infections and are found mostly in women who have frequent urinary tract infections .
- Cystine. The least common type of stone, cystine stones occur in people who have the genetic disorder cystinuria. They are caused when cystine, a type of amino acid, leaks into urine from the kidneys.
Certain factors can raise your risk of developing stones. This includes:
If youre having pain in your lower abdomen, or youve noticed blood in your urine, your healthcare provider may suggest a diagnostic imaging test to look for stones.
Two of the most common imaging tests for stones include:
These tests can help your healthcare provider determine the size and location of your stone. Knowing where the stone is located and how big it is will help them develop the right type of treatment plan.
Small stones tend to pass more easily.
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Purpose Of Kidney Stone Surgery
The purpose of kidney stone surgery is to remove a stone in order to reduce symptoms and/or reverse a medical condition associated with the presence of the stone .
Specific indications for kidney stone surgery include:
- Ureteral stones greater than 10 mm
- Uncomplicated distal ureteral stones less than 10 mm that have not passed after four to six weeks of observation
- Symptomatic kidney stones without any other explanation for the patients pain
- Ureteral or kidney stones in pregnant women that have not passed after an observation period
- Persistent kidney obstruction related to stones
- Recurrent urinary tract infections linked to stones
Aside from the above indications, emergency surgery to remove a kidney stone may be warranted in the following cases:
- If the flow of urine from both kidneys is blocked and there is acute kidney injury
- If a patient has acute kidney injury from an obstructing stone and only one functioning kidney
- If a patient has an obstructing stone and a urinary tract infection
Treatment Of Adult Patients With Renal Stones
Guideline Statement 21
In symptomatic patients with a total non-lower pole renal stone burden < 20 mm, clinicians may offer SWL or URS. Strong Recommendation Evidence Level Grade B
Discussion
Treatment options for patients with a < 20 mm non-lower pole renal stone burden include SWL, URS, and PNL. Of these treatment options, PCNL stone-free rates are the least affected by stone size, while stone-free rates of both SWL and URS decline with increasing stone burden.105 However, for stone burdens < 20mm, stone-free rates of both URS and SWL are acceptable and have less morbidity compared to PCNL. Of the two options, URS and SWL, URS is associated with a lower likelihood of repeat procedure therefore, the patient will become stone-free quicker than with SWL.106 While SWL and URS are acceptable modalities, treatment selection process must include a shared decision-making approach.
Guideline Statement 22
In symptomatic patients with a total renal stone burden > 20 mm, clinicians should offer PCNL as first-line therapy. Strong Recommendation Evidence Level Grade C
Discussion
Guideline Statement 27
Clinicians may perform nephrectomy when the involved kidney has negligible function in patients requiring treatment. Conditional Recommendation Evidence Level Grade C
Discussion
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Quality Of Individual Studies And Determination Of Evidence Strength
The quality of individual studies that were either RCTs or CCTs was assessed using the Cochrane Risk of Bias tool.9 The quality of CCTs and comparative observational studies was rated using the Newcastle-Ottawa Quality Assessment Scale.10 Because there is no widely-agreed upon quality assessment tool for single cohort observational studies, the quality of these studies was not assessed.
The categorization of evidence strength is conceptually distinct from the quality of individual studies . Evidence strength refers to the body of evidence available for a particular question and includes not only individual study quality but consideration of study design consistency of findings across studies adequacy of sample sizes and generalizability of samples, settings, and treatments for the purposes of the Guideline. The AUA categorizes body of evidence strength as Grade A , Grade B , or Grade C . By definition, Grade A evidence is evidence about which the Panel has a high level of certainty, Grade B evidence is evidence about which the Panel has a moderate level of certainty, and Grade C evidence is evidence about which the Panel has a low level of certainty.7
When Can Swl Be Used
SWL works better with some stones than others. Very large stones cannot be treated this way. The size and shape of stone, where it is lodged in your urinary tract, your health, and your kidneys’ health will be part of the decision to use it. Stones that are smaller than 2 cm in diameter are the best size for SWL. The treatment might not be effective in very large ones.
SWL is more appropriate for some people than others. Because x-rays and shock waves are needed in SWL, pregnant women with stones are not treated this way. People with bleeding disorders, infections, severe skeletal abnormalities, or who are morbidly obese also not usually good candidates for SWL. lf your kidneys have other abnormalities, your doctor may decide you should have a different treatment. lf you have a cardiac pacemaker, a cardiologist will decide if you can have SWL.
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Recovery Instructions After Kidney Removal
Activity
- Take rest whenever you feel tired. Getting plenty of sleep may speed your recovery.
- Go to walk every day. Increase the distance you walk daily. Walking increases circulation of blood and prevents constipation and pneumonia.
- Dont do strenuous activities and exercises in which your belly muscles are used such as jogging, cycling, aerobic exercises or weight lifting until your physician recommends you to do them.
- For a period of at least four weeks, dont lift anything that causes straining of muscles such as lifting a child, milk containers, heavy bags of groceries, cat litter, vacuum cleaner or heavy backpack or briefcase etc.
- Place a pillow on the incisions while you take deep breaths or coughs to support your stomach and decrease pain.
- What is the recovery time for kidney removal? Discuss with your physician about the time you can resume driving.
- You may have to take four to six weeks off from your work.
- You may take showers however, if a drainage tube is put near the incisions avoid taking bath for the initial two weeks. Follow the instructions of your doctor to empty and take care of the drainage tube.
- Ask your physician when you can resume having sex.
Diet
Incision Care
Follow-Up Care Forms a Vital Part of Treatment
Make sure to be regular with all appointment. Call your physician or nurse line in case of any problems. You can also keep a list of medications you take and know the results of your tests.
Monitor Your Kidney Function
Kidney Stone Surgery Recovery
Our urology experts will be there for you throughout your recovery to monitor your progress and ensure you are in good health.
We may prescribe medication like tamsulosin to relax and open your ureter for a period after surgery. Tamsulosin can make it easier for stones or stone fragments to pass. We may also have you use a strainer to collect stone pieces if they pass in your urine so we can test them.
If we placed a temporary stent in your ureter during surgery, we will remove it during an office visit two to 10 days after your procedure.
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Retrograde Intrarenal Surgery :
Retrograde intrarenal surgery is one of the advanced kidney stone removal surgeries recommended to treat kidney stones ranging between 8mm to 15mm or up to 2 cm. This is a painless surgery as the patient is given general anesthesia.
Once the patient is sedated, a flexible endoscope is inserted into the natural urine passage and passed into the kidneys collecting part. From there, the scope is moved up to the urinary tract system . Once the flexible endoscope reaches the target location, the surgeon can see the kidney stones.
Then, the surgeon uses a laser probe to crush or manipulate kidney stones. In the case of large stones, small forceps are used to grab the kidney stones. The broken or fragmented kidney stones are collected in the basket and removed. Patients may take at least a week to return to their daily activities.
What Would Happen If Kidney Stones Are Left Untreated
In situations where there is a kidney stone which is large enough that it cannot pass through the urine can block the urinary tract which may cause obstruction of urine. This obstruction further causes pain. If the individual leaves the kidney stone condition as is and does not get it treated, the pain might go away after some time and the individual may think that the problem has been dealt with however, in actuality the exact opposite happens and the blocked kidney stops functioning.
If the condition of kidney stone is left untreated then it may lead to complete shut down of the kidney resulting in renal failure which will then have severe repercussions for the affected individual. In some cases, the stone may even cause the kidney to get ruptured which is even more challenging to treat.
In conclusion, it is extremely important to treat a kidney stone as soon as it is diagnosed. If the kidney stone is small, the physician may give some pain killers and advice to drink more water to allow the stone to pass through the kidneys. However, if the stone is big then laser treatments may be required to treat this condition. If left untreated, kidney stones may lead to complete shut down of the kidney causing permanent damage and even complete failure of the kidney to function which can be catastrophic for the individual.
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Kidney Stone Treatment Options
We work with patients in every stage of their condition, creating a personalized plan whether surgery is needed or not. We also try to identify factors that may be causing the stones, so we can keep current stones from getting larger and reduce the risk of developing future stones.
When suspected of having a kidney stone, we take a history, perform a physical, exam, and obtain radiological imaging. Studies may include a plain x-ray of the abdomen, a renal ultrasound, or a CT scan. They help us determine the location of the stone, its size, the degree to which the stone may be causing an obstruction to urine flow, and what types of therapy would be appropriate for management.
Recovery Immediately After Nephrectomy
After surgery, you will wake up in a recovery area. You will probably have a catheter to drain your urine it will likely be removed the next day. You also may have a nasal cannula placed under your nostrils to provide oxygen.
Your surgeon may have injected a long-lasting pain-relieving medication at the surgery area to alleviate pain and discomfort for at least the first day. If you do have pain, let your care team know they can manage your with additional pain relief medication. If you had a laparoscopic surgery , you will have several small incisions, typically in your abdomen or sometimes on your back. If you had traditional open surgery youll have a 3 to 4 inch incision on your side, which requires more wound recovery.
In the first hours after the surgery, your health team will have you up and walking around as soon as possible. Your goal is to walk every two hours to prevent in your legs. You also will be asked to do breathing exercises to expand your lungs and prevent pneumonia. And youll be encouraged to drink plenty of water to help avoid .
As you are recovering, your medical team will check your blood pressure and signs that your remaining kidney is working properly by checking your fluid balance and electrolytes. They also will watch for complications, such as infection, , bleeding severe enough to cause transfusion, blood clots and .
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Extracorporeal Shock Wave Lithotripsy For The Treatment Of Ureter Stones
Extracorporeal shock wave lithotripsy is a minimally invasive procedure that uses shock waves â applied outside of the body â to shatter the ureter stone into smaller pieces. Once the ureter stone is broken down, the pieces may be more capable of passing through the ureter, bladder and urethra spontaneously. ESWL may cause discomfort for the patient and is often performed with the aid of general or local anesthesia. Although ESWL is highly effective for treating ureter stones, more than one session may be needed to completely remove the stone.
The pass rate for ureter stones when using ESWL has been noted to be as high as 90 percent. However, the location of the stone in the ureter and the size of the stone will impact the success of this procedure. Stones that are larger than 10 mm in diameter and located in the upper region of the ureter have a lower pass rate than those located in the lower ureter with a diameter under 10 mm.
Although ESWL is a highly effective treatment for ureter stones, the procedure does have some potential complications. Stone fragments may block the ureter, causing hydronephrosis or a urinary tract infection. Stone fragments may also remain in the ureter or bladder, growing into larger stones over time. Also, the procedure can cause trauma to the small vessels of the kidney and other structures of the urinary tract. This can lead to renal hematoma or hemorrhage in the short-term and the development of scar tissue over the long-term.
Treatment For Pregnant Patients With Ureteral Or Renal Stones
Guideline Statement 54
In pregnant patients, clinicians should coordinate pharmacological and surgical intervention with the obstetrician. Clinical Principal
Discussion
Stone disease during pregnancy can be a challenging condition to diagnose and treat as standard imaging and treatment algorithms for urolithiasis can pose undo risk to the developing fetus. Investigations are complicated by the normal changes during pregnancy that can resemble obstructing calculi. The risks to the fetus of ionizing radiation, analgesics, antibiotics, and anesthesia must also be considered. All these factors can lead to a delay in diagnosis, inappropriate diagnosis, and difficult treatment decisions.
Guideline Statement 55
In pregnant patients with ureteral stone and well controlled symptoms, clinicians should offer observation as first-line therapy. Strong recommendation Evidence Level Grade B
Discussion
Guideline Statement 56
In pregnant patients with ureteral stones, clinicians may offer URS to patients who fail observation. Ureteral stent and nephrostomy tube are alternative options with frequent stent or tube changes usually being necessary. Strong Recommendation Evidence Level Grade C
Stone material should be sent for analysis. Clinical Principle
Guideline Statement 26
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Guideline Statement 36
Discussion
This is particularly valuable during URS when the ureter is at risk This is particularly true for semi-rigid and flexible ureteroscopy for ureteral stones.
Discussion
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Do I Need Surgery For My Kidney Stone
Kidney stones are small, hard deposits that can form in one or both of your kidneys. Created by a build-up of minerals, these deposits are usually passed through the urinary tract without issue. Unfortunately, a larger stone can become lodged inside the ureter the small tube between the bladder and kidney. While kidney stones are usually no larger than a tiny pebble, they can cause immense pain for those struggling to pass them.
If youre a patient suffering from kidney stones, you may be wondering whether youll need to undergo surgery. Here are five important questions to consider about stone removal and treatment options: