Innovative and Cost-Effective Treatment of Renal Stones in Remote Areas by the Surgical Services Initiative

Urinary calculi affect about 5-15% of the population in industrialized countries [1]. With ureteric stones of sizes up to 5mm, 71-98% generally pass within a few weeks [2]. The incidence of urinary calculi in industrialized countries ranges from 0.5 to 1.9%. However, in India, the incidence has a wider regional variation and could be as high as 7.6% [3].

In patients with renal stones, extracorporeal shockwave lithotripsy (ESWL), flexible ureterorenoscopy (URS), and percutaneous nephrolithotripsy (PCNL) are the available options for treatment. ESWL was a major development in the 1980s, with a minimally-invasive approach and few complications. An alternative is ureterorenoscopic stone removal (URS), which has been improved by miniaturization. Small flexible and semi-rigid equipment now has good optical quality, and the holmium/YAG lasers currently in use only penetrate 0.5mm, lowering the risks of damage and improving stone clearance. Lastly, percutaneous nephrolithotripsy (PCNL) is mostly used on large stones above 20mm, staghorn calculi, and impacted stones over 15mm in the upper ureter [4].

However, the primary drawbacks of all these procedures in rural areas are their high costs and difficulty in setting up minimally invasive units. Here we describe the low-cost methods of dealing with renal stones in rural areas that were carried out at the innovative surgical and diagnostic camps in North and Northeast India [5].

METHOD

The Surgical Services Initiative is a group of Doctors who have come together as a non-profit organization to provide quality multispecialty, cost-effective surgical services to rural-based Christian hospitals and other charitable hospitals in India. The local doctors also receive training in our fields.

Patients with renal stones in the rural and remote areas are diagnosed at high-tech diagnostic camps [5]. In the first stage of treatment, also often carried out at the diagnostic camps, the patient has[s2If !is_user_logged_in()]…

[/s2If][s2If is_user_logged_in()] a double J (DJ) stent inserted. In women, the procedure is done under local anesthesia since the shorter urethra does not make it as uncomfortable. This dilates the ureter up to three times the original size. It keeps the ureter open at all times, and the movement of the stent while walking and moving facilitates movement of the stones.

About 6 weeks later, a ureterorenoscopy with a rigid scope is carried out. The dilatation of the ureter and the mild inflammation of the transitional urothelium make the ureterorenoscopy easier and safer. First, the guide wire is placed adjacent to the DJ stent, which is then removed. Next, the ureterorenoscope can be passed comfortably to the renal pelvis and the upper calyces. The stones are then broken down with the lithoclast [6].

Figure 1 shows how ultrasound could be used to locate the calyces in which the smaller stones are lodged.

RESULTS

Table 1 shows the results of the procedures carried out at the surgical and diagnostic camps over the last two years. 355 double J stenting procedures were carried out, and the stone sizes varied from 7mm up to 3 x 2 x 2cm. Many of the stones under 10mm in size came out on their own after the DJ stenting procedure.

Description Number
Left DJ stenting 154
Right DJ stenting 161
Bilateral DJ stenting 40
Lithotripsy with lithoclast on left 48
Lithotripsy with lithoclast on right 78
Bilateral lithotripsy 19
Requirement for more than 3 sittings 23
Table 1: Details of procedures during camps

Renal Stones / Ultrasound

Figure 1: Use of intra-operative Ultrasound in localizing the stones

DISCUSSION

Ureterorenoscopic removal of renal stones is possible with a rigid ureterorenoscope once the ureter is dilated from a period of DJ stenting. Intraoperative ultrasound examination facilitates location of the stones. Although it is not a one-time treatment method, it has the following advantages:

  1. It is minimally invasive, as there is no incision, and hence there is less trauma to the kidney or destruction of the renal tissue.
  2. At least part of the treatment can be provided in rural areas, even in remote locations.
  3. The initial equipment is much less compared to other modalities like ESWL, PCNL, etc.
  4. The equipment is portable and can be carried to the various places where treatment is offered.
  5. The cost of treatment is more easily affordable for rural patients ($100 to $150 per sitting).
  6. It helps rural patients get back to work very quickly after treatment.

SUMMARY

The Surgical Services Initiative is able to take the advanced minimally invasive surgery to the poor and the marginalized living in remote and rural areas. For rural patients, the benefits of minimally invasive procedures, like the removal of these renal stones, are significant in terms of affordability and recovery time.

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.
Sungti Jamir Dr. Sungtiakum Jamir is one of the early surgeons to do the rural surgery DNB course in India. He is from Nagaland and worked in mission hospitals after his graduation. He is now settled in Switzerland married to a gynecologist there and is actively involved in the Surgical Services Initiative to take modern surgery to the poor and the marginalized.
nandamani Dr. Nandamani Chongtham is from northeast India and did his postgraduate study in rural surgery in 2007.

References (click to show/hide)

  1. Moe OW. Kidney stones: pathophysiology and medical management. Lancet 2006;367:333–44.
  2. Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE, et al. Ureteral Stones Clinical Guidelines Panel Summary report on the management of ureteral calculi. J Urol 1997;158(5):1915–21.
  3. Rana Gopal Singh, Sanjeev Kumar Behura, Rakesh Kumar. Litholytic Property of Kulattha (Dolichous Biflorus) vs Potassium Citrate in Renal Calculus Disease : A Comparative Study. The Journal of Association of Physicians of India. Volume 58. May 2010.
  4. Pallaniappan Sundaram, Yeh Hong Tan. Minimally invasive Medical and Surgical Management of Urinary Calculi. Proceeding of Singapore Health Care Vo. 21 November 2012 p120 – 124.
  5. J. Gnanaraj. Diagnostic and surgical camps: Cost effective way to address the surgical needs of the poor and the marginalized. mdCurrrent-India. Jan 2014. Available at: http://mdcurrent.in/primary-care/diagnostic-surgical-camps-cost-effective-way-address-surgical-needs-poor-marginalized/.
  6. J. Gnanaraj, Balaji Prasad. Ureteroscopic removal of renal stones: Cost effective and patient friendly method in rural areas. Tropical Doctor Vol. 41, April 2011, p 102.


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4 Comments

  1. Girijadutt Sharma
    Posted Jun 2014 at 4:14 pm | Permalink

    Good method , but once fragmented the fragments go to all calyces, the suprior is accessible , the other two r not
    For over 25 yrs , i pracice posterior lumbotomy and find it an excellent technique for a poor mans pcnl.
    Pl tell u r views on lumbotomy…girijadutt sharma

    • Dr. J. Gnanaraj
      Posted Jun 2014 at 5:50 am | Permalink

      We do not have much experience with posterior lumbotomy. However it might be a good option if we are able to combine with cystoscopy to visualize the calyces and break the stones with lithotripsy.

      • Dr. J. Gnanaraj
        Posted Jun 2014 at 5:54 am | Permalink

        During the last lumbotomy that we did several years ago we were not able to give complete clearance and had residual stones

        • Dr. J. Gnanaraj
          Posted Jun 2014 at 5:58 am | Permalink

          May be you could join us in Northeast for a surgical camp and we can try a small incision lumbotomy with Cystoscope and lithotripsy. Please write to jgnanaraj@gmail.com. Thanks

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