Kidney Stones - Conditions

KIDNEY STONES
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Where do kidney stones become stuck ? Go
Will a stone in the ureter pass spontaneously ? Go
What are the interventions for a kidney or ureteric stone ? Go
What is a ureteric stent ? Go
What is laser treatment for kidney stones ? Go
What is ESWL ? Go
What is PCNL ? Go
Can my stone be dissolved ? Go
Stones during pregnancy Go
Can I prevent a stone from forming ? Go
When should I see a medical kidney specialist ? Go
What are the risks from surgery for a kidney or ureteric stone ? Go
What causes kidney stones ? Go
What follow-up do I need after my stone is treated ? Go
Where do kidney stones become stuck ?

This x-ray shows the outline of
the urinary tract where stones
can become stuck.

Three locations:
1. Just where the ureter enters the bladder the vesico-ureteric junction (VUJ)
2. When the ureter crosses iliac vessels at the pelvic brim
3. Just where the ureter begins to leave the kidney the pelvi-ureteric Junction (PUJ).


Will a stone in the ureter pass spontaneously ?
1. Only if it is small < 5 mm in size
2. We use non contrast CT scan to measure stone size and determine stone location
3. If you have a small stone you will be prescribed 2 drugs to help the stone pass
spontaneously:
o Anti-inflammatory tablet either ibuprofen, voltaren or indocid suppositories
and
o Flomaxtra (tamsulosin)
4. The combination of these relaxes the muscle in the ureter and helps the stone to
pass
5. It can take 2 to 4 weeks for the stone to pass
6. If the pain continues or you get fevers then we may have to abandon this approach
and perform endoscopic surgery to remove the stone.

What are the interventions for a kidney or ureteric stone ?
There are several treatment options:
1. Use medications and watch and wait until it passes
2. For larger stones insert a ureteric stent to unblock the kidney and allow urine to drain
3. Endoscopic surgery using a telescope and laser to fragment the stone
4. Open surgery is rare
5. ESWL, extracorporeal shock wave lithotripsy
6. PCNL, percutaneous nephrolithotomy

7. Dissolve a uric acid stone.
The watch and wait option:
1. For small (<5 mm ) stones
2. With no kidney blockage or infection
3. Only when pain can be controlled using oral pain tablets.

What is a ureteric stent ?
1. When the stone is causing severe pain and/or blockage and/or infection
2. The stent allows urine to pass around the stone and unblock the kidney and drain
infection
3. At a later stage usually within one week we telescopically look into the ureter or
kidney and remove or laser the stone.

Ureteric stent is a hollow plastic tube that unblocks the kidney.
They are also used after laser stone treatment for a short period
of time to allow stone fragments to pass through the system.

What is laser treatment for kidney stones ?
There are 3 steps involved in treating a stone with laser:
1. Step 1 is to place a ureteric stent to unblock the kidney, relieve pain or infection and
return to perform laser within one week when the patient has settled (or in some
situations the laser procedure is able to be done right away without having to have
the ureteric stent for one week prior)
2. Step 2 is to return within one week and insert a fine flexible telescope that enables
the stone to be fragmented using laser. A ureteric stent is more often than not
replaced at the end of this procedure in order to allow the stone fragments to pass
more easily
3. Step 3 is to have the ureteric stent removed within 48-72 hours of the laser
procedure
4. With large stones multiple attempts at laser may be required to achieve complete
stone clearance.

Laser treatment of a ureteric or kidney stone can require multiple steps.

What is ESWL ?
Ultrasound shock waves are used to break up the kidney stone using a device called
a lithotripter ad this is performed as a day procedure under a general anesthetic
The benefit is that it is non-invasive
The problems can be that if the stone is too hard or in a difficult location within the
kidney it may fail
Other problems are that large stones may not fragment enough to pass
Some patients still need a ureteric stent to allow the stone fragments to pass
Pregnant women, pacemakers, bleeding disorders and urine infection are all
situations where ESWL cannot be used.

The ESWL machine localizes shock waves onto the stone which cause it to break up.

What is PCNL ?
Access to the kidney and large stone are achieved by inserting an access sheath
through the patients side while under general anesthesia
Telescopes, lasers or other devices can be inserted through the access sheath that
break up and suck out the stone
This is very successful but the main risk is bleeding as we tunnel through the flank
muscles and kidney which are vascular structures
Contraindications are urine infection, bleeding disorder or unfavorable anatomy.

PCNL is when the access to the kidney stone is from the patients side.

Can my stone be dissolved ?
Uric acid stones are either not seen on plain x-ray or are very faintly seen
They form in gout or other conditions where uric acid blood levels are high
They can be dissolved by the patient drinking sodium bicarbonate or potassium
citrate powders
The pH of urine must get alkaline such that a pH higher than 6.5, even 7.0 to 7.2, is
needed in order for dissolving therapy to work
Cysteine genetic stones can also be treated this way
The patient must monitor the urine pH using a dipstick every day
Serial CT scans can monitor the progress of dissolving treatment
It can take up to 3 months to completely dissolve the stone
Laser treatment using a telescope may also be needed to help the process along
more quickly.

Stones during pregnancy
During pregnancy we sometimes have to place a ureteric stent for a stone. We cannot use
x-rays early in the pregnancy and opt to use ultrasound instead. We do not laser the stone
during pregnancy but rather leave the stent in place and even change the stent every 6-8
weeks. Lasering the stone cannot be performed during pregnancy so we wait until after the
baby is born to then treat the stone with laser

Can I prevent a stone from forming ?
General preventive measures are:
Keep fluid intake high at 2-3 L per day
Urine color should look clear suggesting good hydration
Low animal protein intake
Low oxalate diet beer, nuts, rhubarb, tea, spinach
Avoid excess vitamin C or D supplements
Other preventive measures are:
Treat all urine infection
Take potassium citrate powder drinks which increases urinary citrate
Gout patients need allopurinol to lower blood uric acid levels

When should I see a medical kidney specialist ?
Certain high risk or recurrent stone formers should be referred to a specialist kidney
physician who will order and interpret a 24 hour urine test along with other blood tests. This
can help identify specific disorders that can be targeted to prevent further stone formation.
High risk stone formers include:
1. Any child
2. Recurrent stones within short periods of time
3. Large stones
4. Certain professions pilots and truck drivers
5. Single kidney
6. Family history of stones
7. Uric acid or cysteine stones, when the stone is sent for analysis
8. Infection stones
9. Medical conditions such as inflammatory bowel disease, gout, parathyroid disease.

What are the risks from surgery for a kidney or ureteric stone ?
Each procedure described above has particular risks that your urologist will explain in more
detail, however risks include:
1. Ureteric injury mucosal tunneling, perforation, avulsion (rare), stricture
2. Infection blood or urine
3. Stone extrusion
4. Bleeding into the urine
5. Bleeding around the kidney
6. Voiding and stent related burning, stinging, pain, frequency, urgency
7. Several attempts at stone clearance
8. Post operative pain.

What causes kidney stones ?
1,200 to 1,400 per 100,000 people will develop a kidney stone each year
Men more than women 3:1
90% can be seen on plain x-ray
Kidney stones can be as large as 1 to 3 cm or as small as 5 mm
The smaller stones <5mm tend to pass through the system down the ureter and into
the bladder and are then passed out with the urine
Larger stones will not pass through
The patient experiences severe colicky flank pain and needs opioid analgesia
The common stone is calcium oxalate and caused by dehydration.

Calcium oxalate kidney stones.
The reasons stones form:
1. Dehydration
2. Small crystal plaques start forming within the kidney
3. The urine is very concentrated
4. Genetic reasons
5. Kidney problems
6. Calcium, parathyroid diseases
7. Small intestinal diseases
8. Anatomic problems of the urinary tract so urine does not drain adequately
9. Repeated urine infection
10. High uric acid levels or gout
11. Diet high in oxalate: tea, peanuts, beer, spinach, rhubarb
12. High intake of vitamins C or D
13. Diuretic use.

What follow-up do I need after my stone is treated ?
An ultrasound is performed to ensure the system is draining well, the stone analysis will be
explained and urine and blood test results of significance will be explained.