LECTURE: Rural Surgery Urinary Tract Stones – Thursday, July 23, 2020

The details for the call-in Zoom Meeting lecture is ONLY good for Thursday July 23, 2020.

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Managing Urinary Tract Stones in Rural Areas

Mankind has been affected by urinary stones for several centuries and has been the silent cause of renal failure. Even in the 4th century BC, Hippocrates (father of modern medicine) notes the presences of the renal stone together with renal abscess and he wrote in his Hippocratic Oath "… I will not cut, even for stone, but leave such procedures to the practitioners of the craft." The specialty of urology has been recognized ever since. And the surgeons who treat urinary stones and other urinary diseases are called Urologists.

Types of stones

The following table gives the milestones in stone disease management

The first evidence of urinary stones was found in an Egyptian mummy at E1 Amrah - Egypt4800 B.C
Susruta performed perineal lithotomy (open surgery for the stone in the urethra)12th century BC
Heinecke performed Pyelolithotomy (open surgery for the Calculus in Kidney).1879
Fernstrom and Johansson described planned endoscopic surgery for the large kidney stone - PCNL (Percutaneous nephrolithotomy)1976
Chausy first used the sound wave to break the kidney stones (Lithotripsy) ESWL1980


The following table gives some of the important figures

12% have stone in their lifetime.
12% of men will suffer from kidney stone by age of 70
5% of women will suffer from kidney stone by age of 70
50% have recurrence within 5-10 yrs.
Highest incidence of kidney stone is in 30-45 years of age group, and incidence declines after age of 50
7-10 of every 1000 hospital admission is of renal stone


  • Renal Colic
  • Hematuria [both microscopic and macroscopic]
  • Lower Urinary Tract Symptoms [LUTS]
  • Incidental finding
  • Urinary Tract Infections
  • Renal Impairment

Urinary stone constitute one of the commonest diseases in our country and pain due to kidney stones is known as worse than that of labour pain. In India, approximately 5 -7 million patients suffer from stone disease and at least 1/1000 of Indian population needs hospitalization due to kidney stone disease.

Thus, the disease is as widespread as it is old, particularly in countries with dry, hot climate. These "stone belt regions" of the world are located in countries of Middle East, North Africa, the Mediterranean Regions, North Western state of India and Southern State of USA and areas around the great lakes.

In India, the "stones belt" occupies parts of Maharashtra, Gujarat, Punjab, Haryana, Delhi and Rajasthan. In these regions, the disease is so prevalent that most of the members of a family will suffer from kidney stones sometime in their lives. Surgery for removal of urinary stones forms one of the commonest operations in hospitals in these regions.

The kidneys are solid; bean shaped, reddish brown-paired structure, which lie behind the abdominal cavity one on either side of the vertebral column. This kidney acts like the filter organ, which removes the waste products from the blood, which forms urine.

About 180 litres of blood, which run through these nephrons (functional unit of the kidney), are reduced to urine by the process of filtration, re - absorption, and secretion by the nephrons. The urine enters the pelvis of the kidney where it collects and continues down the ureters to the bladder. In the urinary bladder urine is temporarily stored and is finally eliminated from the body. Human being on an average excretes about 1 to 1.5 litres of urine per day.


One of the commonly accepted theories is the super - saturation theory. There are many factors that help in keeping the solutes in a state of super saturation and impairment of these lead to stone formation. About two thirds of the patients are idiopathic stone formers or those with no obvious cause for the stone formation.

Metabolic abnormalities can be present in the rest and should be suspected if the stones are

  1. Bilateral
  2. Recurrent
  3. Occur in the young age
  4. Are multiple


Virtually all stones are formed in the kidneys, initially as small particles. These particles grow within the kidney to varying sizes, often filling up the whole kidney as a branched stone (the stag horn calculus). Sometimes they move out of the kidney when relatively small, and then migrate down the ureter into the bladder. Some stones less than 5 mm in size pass out spontaneously, but occasionally they migrate down the ureter & they may block the ureter causing obstruction to the flow of urine. This results in pain, which may be very severe (ureteric colic). Nausea and vomiting can also be associated with the colic pain. Some stones reach the bladder, and lodge there, growing larger and larger. Rarely the stones block the urethra causing a painful retention of urine.

Types of stone

There are various types of urinary stones, but the most common ones are

  • Calcium oxalate.
  • Uric acid.
  • Struvite.
  • Cystine stones


Kidney stones in the kidney or ureter do not cause any symptoms until and unless they obstruct the urinary passage. The nature and the location of the pain can vary from person to person depending upon the size of the stone, the position of the stone within the urinary tract, and the damage it causes to the urinary system. "It should be however remembered that the size of the stone does not interrelate with the severity of the pain."

Stones can be diagnosed with following symptoms:

  • Incidental diagnosis on routine health checkups.
  • Dull aching pain in the back
  • Acute colic.
    Classical pain is described as pain from loin to groin, accompanied by nausea, vomiting and gaseous distension.
  • Urinary tract infection.
  • Increased frequency of urine
  • Pain and or burning while passing urine.
  • Passage of blood in urine (Hematuria) which can be gross or detected in the Urine test.


  1. Urine routine which will show:
    • Crystals in urine.
    • Blood cells in urine
    • Pus cells in urine.
  2. Urine Culture colony count & sensitivity test to rule out the urinary tract infection and to select the best antibiotic that will treat the infection if present.
  3. X-Ray KUB
    • To detect size and site of stone
  4. Ultrasonography of kidney, ureter, and bladder.
    • To show the size of the kidney & swelling (Hydronephrosis) of the kidney in obstructive uropathy. It will also show ureters if they are dilated. However, it does not give information about the function of the kidney.
    • Will also screen other abdominal organ for any pathology.

To plan treatment once kidney stone is diagnosed 

  1. Blood test to look for normal functions of the kidney
    • Serum Creatinine
    • Serum Blood Urea.
    • Serum Electrolytes.
  2. Intravenous Urography. This is the specialized test were series of X- ray are taken after injecting the special medicine, a dye - Contrast, which has radiopaque property. The kidneys excrete these contrasts and kidneys are out lined on X rays and serial films are taken. This is a very useful test. It gives lot of information including size and shape of kidneys, function of kidney – comparative and individual, presence of obstructive uropathy, delineates the anatomy of kidney, ureter & bladder etc.
  3. Test to find out the cause of the urinary stone disease.

Metabolic tests may have to be done to look for any defects in your body, which may be responsible for kidney stone formation. This is very important, as it is not only sufficient to treat for the kidney stone but to find out why kidney stone has been formed. The recurrence of kidney stone formation can be prevented. Therefore, an appropriate treatment can be given so that one does not form kidney stones again.

  • Serum Calcium
  • Serum Phosphorus.
  • Serum Uric acid
  • 24-hour urinary calcium / 24 hrs. urinary uric acid
  • Stone analysis of the retrieved calculus.


It has been said that "once a kidney stone former, always a kidney stone former". Once a kidney stone has been diagnosed, the choice is between expectant treatment and more aggressive forms of treatment, such as transurethral, percutaneous, or opens surgeries or the relatively new extra corporeal modalities. Although some kidney stones may pass spontaneously and unless complicating conditions arise, surgical intervention may not be necessary. Thus, identification of kidney stones that are likely to pass is of utmost importance.

The primary decision is whether to apply surgical treatment or wait. Removal of kidney stones by any methodology is necessary when there is evidence of:

  1. Significant obstruction
  2. Progressive deterioration of the kidney
  3. Irreversible infection of the kidney (Refractory pyelonephritis)
  4. Unremitting pain
  5. Stone obstruction an infected kidney requires emergency intervention

Various general and specific medical measures are used to treat the kidney stone disease. A significant percentage of patients will at sometimes or the other requires intervention for the recovery of the urinary stone.


Most of the kidney stones of small size pass spontaneously in the urine without any need for intervention. The probability of a kidney stone passing down spontaneously will depend upon the size of a stone, its location, shape etc. Such patients are treated symptomatically with:

  • Antibiotic to control infection.
  • Analgesics to give relief from the pain
  • Alpha blockers to dilate the ureters [Tamsulosin]
  • Oral Hydrotherapy. The patient is generally instructed to maintain a high fluid intake ranging from 5 to 6 liters/day so that they can produce at least 3.5 liters of urine in 24 hours.
  • If the colic is severe and associated with the nausea, vomiting, fever then such patients are treated with Intravenous saline to produce adequate amount of urine so that kidney stone can be flushed out.
  • Endoscopic procedure is carried out like DJ Stenting, Ureteroscopy in some cases where the urinary stone causes severe obstruction and infection.

Principal Therapeutic Procedures Are:

  1. ESWL (Lithotripsy)
  2. Ureteroscopy (URS)
  3. Percutaneous Nephrolithotomy (PCNL)
  4. Open surgery.
  • Extra Corporeal Shock Wave Lithotripsy (ESWL)

For many centuries, surgery was the only option in treating stones that would not pass spontaneously. In 1980 the German aeronautics company Dornier, through ground breaking research, developed the means for focusing external energy to treat Kidney stones and pulverize them to small fragments that are voided naturally with the urine.

This was a major advancement, perhaps one of the most significant medical advancements of the last century. Over the last 30 years lithotripter applications for renal stone therapy have been perfected, and these days Lithotripsy is performed as an outpatient procedure in a painless fashion.

  1. All the kidney stone with size of up to 1.5 -2 cms can be treated with the Lithotripsy.
  2. Non impacted upper ureteric stone can be also treated with Lithotripsy

For this treatment the patient lies on a special couch. X-ray and/or ultrasound are used to target the kidney stone, and by a computerized system the kidney stone is placed at the focal point of the energy source of the lithotripter. Having realized the stone, the shock waves are delivered through a remote control, which leads to fragmentation of kidney stone into fine particles.

Treatment usually lasts about 45 minutes. 

After the procedure is complete, the patient is kept under observation for an hour then he is allowed to return home. He is asked to take plenty of liquid orally to maintain his urinary output to 2-2.5 litres per 24 hrs. He may require some antibiotics and some painkiller. It takes few to several weeks for final stone fragments to pass out through urine. The patient may experience some burning sensation and blood in urine for few days. The patient is generally advised to do routine urine test with X- ray KUB for 7-10 days.

The patient rests for a while and then is allowed to return home. Sometimes a "stent" is placed in the ureter if it is anticipated that the stone fragments may block the ureter after Lithotripsy. Repeat sessions of Lithotripsy may be required, usually not earlier than 3-5 days.

However, all urologists realize that Lithotripsy is sadly not an answer to many of the stones seen in day-to-day practice. The reason is that for stones that are more than 2 cms in size, branched stones and various other complicated situations Lithotripsy is either not effective or is slow to work with patients needing multiple procedures and hospital visits. In these patients, other options should be considered. In an average practice in India, where patients present with advanced and neglected disease, at least 40% of kidney stones fall into this category. These larger stones are removed by a new technique called Percutaneous Nephrolithotomy or PCNL.


In this technique the stone is removed by making a small tunnel into the kidney from the back. A fine needle is used to puncture the renal collecting system with the aid of X-ray and/or Ultrasonography, and a guide wire is led into the kidney through the needle. This tract is dilated over the guide wire and a Nephroscope (kidney telescope) is inserted into the pelvis of the kidney. The stones are visualized, fragmented using Swiss Lithoclast and extracted using fine forceps, allowing the kidney to become free of stones at the end of the operation, in the vast majority patients. This is of course an operation, needing full general anaesthesia, average 90 minutes of operation time, 3 -4-day hospitalization, and an occasional need for blood transfusion. Patient returns to light work in 5-7 days’ time. Nevertheless, the operation is safe, for both the patients and the kidney. This operation has really reduced the need for open surgery (cutting surgery), which is now reserved for exceptional indications.

This technique is used to treat kidney stones of:

  • Large than 2.5 cms,
  • Staghorn calculus,
  • Calyceal diverticular calculus. 

If facilities for PCNL is not available open surgeries are carried out. Although the first Pyelolithotomy was carried out by Heinecke in 1979 it was Gil Vernet who popularized it in 1965. Despite these techniques stone clearance is difficult, and we often use the Cystoscope or Ureterorenoscope to help with clearance.

The treatments that are available depend mostly on the size of the stone and the location of the stone.
A. Small stones up to 5 mm in size: These stones are passed on their own within a few weeks [71 to 98%]. Plenty of fluids, pain killers and anti-inflammatory medicines to decrease the swelling around the stones are the only medicines that are required. Fluids are the most important of these.
B. Stones up to 7 mm in size: These stones or even the stones of previous category would benefit by what is called Medical Expulsion Therapy [MET]. This consists of special medicine called alpha - 1 blockers and calcium channel blockers. They reduce the spasm of the ureteric muscles and encourage peristalsis or movement. These are given along with pain killers and anti-inflammatory medicines.
C. Stones from 7 to 12 mm in size: These stones can pass comfortably if the passage is made wide. The passage could be made wide by using Double “J” [DJ] stents.
The DJ stent makes the ureter dilate sometimes up to three times the original size. It keeps the ureter open all the time and the up and down movement aids the passage of the stones.
D. 7 to 12 mm stones in the lower calyx: This type of stone is difficult to treat as they might not come out with a placement of a DJ stent. Half these stones can come out by treatment with special techniques during ureterorenoscopic removal of the stones. The stones that do not come out with DJ stenting alone when they are in the ureter, renal pelvis or upper or middle calyces of the Kidney could be seen with ureterorenoscope and broken with lithoclast. In experts hands the ureterorenoscope can reach the above places after the ureter dilates due to placement of the DJ stents.

E. Larger stones: These require open surgical procedures and safer method during surgeries are the use of cystoscope or URS to visualize, break and remove the stones at open surgery.
F. Stones in bladder or urethra: These are broken with lithoclast after locating them during cystoscopy. The broken pieces are then washed out.

The treatment is carried out in stages. In the first stage, the DJ stent is placed. This has the following advantages:
1. It dilates the ureter making instrumentation possible later
2. It causes mild inflammation that helps the inner layer stick to the muscle layer of the ureter and prevents the inner layer tearing away during treatment
3. It improves renal function because of the unobstructed drainage that it provides
4. It decreases infection as the infected urine is washed or drained away
During the second stage ureterorenoscopy is carried out and the stone is broken into small pieces using the lithoclast. The DJ stent is replaced.
One more sitting might be required for further breaking of stones.
Medicines are given to relax the ureteric smooth muscles and aid the passage of the broken pieces along with antibiotics and anti-inflammatory medicines. Once the stones are clear the DJ stent is removed.

For lower calyceal stones that are not visualized at URS the following could be tried:
Keep the URS at the PUJ and trying to flush the stone out of the lower calyx  Use flushing and suction alternatively to bring the stone into view
Use of ultrasound guidance to basket and bring the stone to the renal pelvis.  The position of the patient could be changed [head down, lateral side up] to bring the stones into view during the Ureterorenoscopy
For medium sized stones in the lower calyx which are not possible to visualize by the Ureterorenoscope a special minimally invasive procedure is developed and is in the stage of refinement. Here the Kidney is thin over the stone because of the back-pressure changes. The lower pole of the Kidney is exposed through a small incision and the calyx with the stone is punctured using ultrasound guidance. A guide wire is passed, and the passage dilated to pass the ureterorenoscope to visualize and break the stone. The patient has DJ stenting on the previous occasion so that the broken pieces could be washed away.


All the ureteric stone can be treated with this endoscopic technique.

  1. Upper ureteric
  2. Middle ureteric
  3. Lower ureteric 


Ureteroscopy is highly successful procedure for the retrieval of stone in the ureter. It is passed through the normal urinary opening through the bladder into the ureter. It involves the passage of an instrument namely Ureteroscope through normal urinary passage. The instrument is as thick as a pen and is about 40 cm long. The Ureterorenoscope is advanced under vision through the normal urinary passage under anesthesia. The Ureterorenoscope is advanced on the side of the ureteric stone and up to the ureteric stone. Once the ureteric stone is localized, various options are available. If the ureteric stone is small, it can be picked up by the forceps & pulled out. But, if the ureteric stone is larger, the ureteric stone can be broken into tiny fragments using Swiss lithoclast or ultrasound or even a combination of both as in Swiss Lithoclast master. A variety of other instruments can be passed in through the scope, which can be used to break the stones and remove them. Patients have to be admitted in the hospital for a few days (2-3 days) for this procedure and it has to be done under anesthesia. Double J stent is usually kept post procedure to drain the kidney.

It is a very safe procedure in experienced hands and Ureterorenscopy can treat almost all the ureteric stones.


These techniques are not competitive with one another but are greatly complimentary to each other. Though ESWL is the ideal treatment for urinary calculi but in selected cases a combination of the above treatment modalities is much better off. Kidney stones up to 2-2.5 cms can be treated by introduction of Double - J stent and multiple sessions of ESWL therapy. However, kidney stones larger than 2.5 cms or partial or complete stag horn will do better with a combination of PCNL and ESWL. PCNL can be used to debulk the kidney stone mass and can be followed up with lithotripsy for residual fragments, if any are left behind. Impaction of stone fragments in lower ureter after lithotripsy may need URS. With the advancement of medical science and availability of these modalities, open surgery for the stone shall be rarely necessary. However, in certain selected cases, open surgery still remains the best modality of treatment. 


With the advent of new technologies to treat kidney stone disease, the need for open surgery has been drastically reduced. However, in some cases it might be required. The type of open surgery will depend upon the site and size of the stone within the urinary tract.


Renal stones are very common in rural areas, especially in areas like Northeast India where it is hot and humid most of the year.  Moderate-sized renal stones of diameters 1 to 2 cm are often difficult to treat but can cause complications. Patients are unwilling to undertake, and often surgeons are reluctant to offer, open surgical methods for treating the smaller stones, which can be quite difficult to find. Minimally invasive techniques such as extracorporeal lithotripsy and percutaneous nephrolithotripsy are too expensive for rural patients.

We have used the rigid ureterorenoscope (URS), which is traditionally used for lower ureteric stones, and the method of prior Double ‘J’ (DJ) stenting to dilate the ureter. The DJ stents were placed under local anaesthesia in the interior villages and at hospital, URS was used for their retrieval and a lithoclast was used to fragment the stones. Figure below shows X-rays before and after the procedure.

Figure showing the calculus before and after URS

This is a minimally invasive technique that is easily affordable for the rural patients.

This image has an empty alt attribute; its file name is Gnanaraj150-80x80.jpg
Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is an urologist and laparoscopic surgeon trained at CMC Vellore. He is the Past President and Project Lead for the Project GILLS of the Association of Rural Surgeons of India, the Secretary of the International Federation of Rural Surgeons and board member of the G 4 Alliance. He is also an Adjunct Professor at Karunya University. He has over 400 publications in national and international Journals related to rural surgery and has won many innovations award like the EHA innovation award, Antia Finseth award, the Lockheed Martin award, the Millennium Alliance award, etc., He has few patents and the low cost equipment is listed in the WHO compendium of medical equipment for resource poor setting. He has helped many hospitals start Minimally Invasive Surgeries. The popular innovations that have made MIS possible in rural areas are the Gas Insufflation Less Laparoscopic Surgeries and the Laptop cystoscope. 

References (click to show/hide)

  1. Gnanaraj J, BalajiEllapan. Ureterorenoscopic removal of renal stones. Cost effective and patient friendly method of treatment in rural areas. Tropical Doctor 41:102 April 2011
  2. Available from: https://www.medindia.net/patients/patientinfo/urinarystonedisease.htm#, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3856162/

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