Managing Ureteric Calculi with Obstruction and Hydronephrosis in Rural Areas

By: Dr. J. Gnanaraj and Dr. Nandakumar Menon

INTRODUCTION

Ureteric calculi are common and present often to the rural surgeon. The incidence is about 200 per 100,000 population and the trend is that it is increasing [1]. The increasing trend is also observed in the western countries and the incidence is more in men [2]. The increase is similar in Asian countries too [3] and is attributed to the changes in dietary habits and climate change.

They present with ureteric colic and often are associated with hydroureteronephrosis. The presence of pain and hydroureteronephrosis implies that the rural surgeon has to treat the patient and does not have time to refer the patient to an urban center.

The following are some of the guidelines for rural surgeons with sufficient knowledge to put in a DJ stent.

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PRE-OPERATIVE ANTIBIOTIC COVER

The common organisms that cause infection are E. Coli, Klebsiella, Eneterobacter and Staphylococci [4]. Hence preoperative antibiotic cover is very important. Usually a combination of aminoglycoside and third generation cephalosporin is used till the cultures are available. With obstruction the urine culture might not show any significant growth. It is better to have the antibiotics for at least 24 hours prior to the procedure.

OTHER MEDICATION

Painkillers are necessary as the pain could be as severe as labor pain. NSAIDs and morphine derivatives might be necessary. Anti-inflammatory medication reduces the swelling and is helpful. Alpha one selective blockers [like Tamsulosin at 0.4 mg] would help in muscle relaxation of the ureter and help relieve obstruction. Studies [4] have shown that use of calcium channel blockers like Nifedipine augmented the expulsion of stones.

DOUBLE “J” STENTING

DJ stenting is the procedure of choice especially in areas where ureterorenoscopy is not available [6]. If the regular guide wire fails to go above the impacted calculus the hydrophilic guide wire could be tried. If none these work then the DJ stent could be place below the impacted stone. With the DJ stent the part of the ureter below the calculus starts to dilate and this would relieve obstruction slowly. It may or may not facilitate the passage of the calculus but in addition to relieving the obstruction would make the subsequent procedures easier.

URETERORENOSCOPY FOR PATIENTS WITH OBSTRUCTION

During the last 3 years during the surgical camps in Northeast India 48 Ureterorenoscopies were carried out for impacted ureteric stones. The following are the lessons that we learnt from such experience.

  1. If DJ stent is above the stone pass a guide wire through the stent before removing the DJ stent especially in women where it is easy to do so. There was a lady who had a large mid ureteric calculus with hydronephrosis. Part of the stent was above the calculus. However after removing the DJ stent it was difficult to pass the guide wire above the calculus despite breaking the calculus with lithoclast. The patient was referred to a medical college as a prophylactic measure because of the possibility of sepsis. However, she did not develop Urosepsis.
  2. With the obstructed system and use of high pressure during ureterorenoscopy there is always the possibility of septicemia. Hence it is advisable to have the patient on injectable antibiotics for a day or two prior to the procedure.
  3. While doing Ureterorenoscopy it is important to have the URS above the guide wire so that the guide wire is always in view.
  4. If it is difficult to break the stone completely especially if adherent to the wall then it might be a good idea [if possible] to leave the guide wire for a day or two before placing the DJ stent. This would allow the smaller pieces to come out and the edema to decrease to make it easier to pass the DJ stent.
Gnanaraj-64 Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.
Dr. Nandakumar Menon, Director and Co-Founder of Gudalur Adivasi Hospital, Gudalur, Nilgiris. He is the co-founder of ASHWINI Institute of Health for training tribal youth which is involved in the training of medical students who come as a part of their elective placement from India and abroad. He also established the Sickle Cell Centre at Gudalur Adivasi Hospital and the ASHWINI- NIEPMD- ROTARY Disability Centre.

Image: Kidney stone. Source/Author: http://en.wikipedia.org/wiki/Kidney_stone / Robert R. Wal. Date: 7 January 2007. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Nefrolit.jpg

References (click to show/hide)

  1.  Almby B, Meirik O, Schönebeck J. Incidence, morbidity and complications of renal and ureteral calculi in a well defined geographical area.
  2. Christopher M. Johnson 1, David M. Wilson 1, William M. O’Fallon, Reza S. Malek, Leonard T. Kurland. Renal stone epidemiology: A 25-year study in Rochester, Minnesota. Kidney International. Volume 16, Issue 5, November 1979, p 624 -629.
  3. Victoriano Romero, Haluk Akpinar, and Dean G Assimos. Kidney Stones: A Global Picture of Prevalence, Incidence, and Associated Risk Factors. Rev Urol. 2010 Spring-Summer; 12(2-3): e86–e96
  4. Available from: http://emedicine.medscape.com/article/437096-treatment
  5. Masarani M, Dinneen M. Ureteric colic: New trends in diagnosis and treatment. Postgrad Med J. 2007 Jul; 83(981): 469–472
  6. Gnanaraj J. What are DJ stenting and why DJ stenting? Available from: http://mdcurrent.in/patients/what-why-dj-stenting/
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