Large Urinary Tract Stones: The Available Treatment Options in Rural Areas

Introduction

Large renal stones present a big problem, even for well-equipped urban centers. Large stones, especially the staghorn type, pose significant problems for treatment in rural areas. Sometimes if the other kidney is absolutely normal, removing the kidney that has the stone might offer a better option in rural areas. We present the challenges and how they have been overcome in rural areas during the last two decades.

What are the problems of large stones?

Large stones have been in the kidney for many years. Right from the beginning, they would have caused loin pain, frequent urinary infection and blood in the urinary tract. These stones are almost always infected and present with signs of chronic infection, such as generalized fatigue, malaise and weight loss (1). They can also result in pus in the kidney (pyonephrosis) or around the kidney (peri-nephric abscess). These can present with fever, nausea and vomiting.

What tests are necessary?

With large stones, the correct antibiotic should be given for few days prior to surgical intervention, and hence, urine culture and sensitivity should be carried out. It is important to know the function of the kidney, so an Intravenous Urogram (IVU) is necessary, in which medicine is given to outline the urinary tract during X-ray. Many of the patients will have anemia due to chronic infection and blood loss. The relevant pre-operative tests for fitness for anesthesia are carried out too.

What are the options available in rural areas?

The first and foremost need in rural areas is the safety of the patient. So, as mentioned in the introduction, with a normal kidney on the other side and non-functioning kidney with a stag horn calculus, removal of the kidney (nephrectomy) is a safe option.

The method that the SEESHA team is using is as follows. The kidney is exposed and mobilized, as for any open surgery. However, after opening the renal pelvis (the safe area in the kidney) we use the cystoscope or the ureterorenoscope to break the stones into small fragments under vision, and then remove them slowly. Although it takes a much longer time, it is a very safe procedure. This combined method has much better stone clearance after surgery.

How do the surgeries in urban areas compare to the above method?

Although various minimally invasive methods like Extracorporeal Shock Wave lithotripsy (ESWL), ureteroscopy, and percutaneous nephrolithotomy are used to treat staghorn calculi, percutaneous nephrolithotomy has the best stone-free rate of 78%, and ESWL has the lowest, at only 54% (2). Another study from India (3) found that 70% of patients were stone free after open surgery, while only 56% were stone free after PCNL. The results are better in larger centers, and yet the clearance was only 83% for open surgeries (4). Sometimes anatropic nephrectomy, which involves opening the kidney like a book after cooling it, is required in larger centers (5). It is advised despite the high risk, as 28% of those with a large staghorn calculus die within 10 years of diagnosis, due to the complications (5). With the SEESHA team, only two of the 21 surgeries for staghorn calculus done by the method described above had residual calculus.

What are the facilities available at SEESHA?

At Karunya Community Hospital, at ICC hospital in Coimbatore, the Bethesda Hospital at Aizawl, Sielmat Christian Hospital at Churachandpur, Family health hospital Dimapur and other places where the SEESHA health care team provides surgical camp and diagnostic camp facilities, all the treatment modes mentioned above are available.

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.