Medium-Sized Urinary Tract Stones: The Available Treatment Options in Rural Areas

Introduction

We had a patient with a 2.5 cm left renal calculus, or kidney stone, who came to us very sick. He was operated elsewhere for the stone and had a very large incision. He had lost a lot of blood and was told that the surgeons were not able to find the stone. We were able to do a ureterorenoscopy and locate the stone in the kidney, and we broke it into small pieces and placed a Double “J” (DJ) stent.

We told the patient’s relatives that it was not the incompetence of the surgeon that caused the problem. Had we operated too, we might not have found the stone either. Finding these types of mobile stones in a healthy kidney is difficult, because the opening in the kidney is away from the skin, and it is difficult to feel the stones in a healthy kidney. Also, smooth mobile stones are difficult to feel with instruments.

Minimally invasive options like ESWL (Extracorporeal Shock Wave Lithotripsy), PCNL (Percutaneous Nephrolithotomy), flexible ureterorenoscopy and breaking with a laser, etc., are very expensive and available only in cities.

In this article, we describe what we have been doing for these medium-sized stones, with experience gathered from working in rural areas for two decades.

How do these stones present?

The most common way of presentation that we have noticed is that these stones are diagnosed several years earlier when they were small. Patients do not receive treatment for a variety of reasons, and the most common factor is the financial difficulties.

Some of them continue to have pain. Few have frequent urinary tract infections or blood in the urine.

Stones in the urinary bladder are sometimes secondary to bladder outflow obstruction, often due to benign prostatic enlargement.

What tests are necessary?

Ultrasound examination and X-ray of the KUB region confirms the presence and size of the stones. Urine cultures are necessary if there are lots of pus cells in the urine, and appropriate antibiotics are necessary during treatment. The investigations that are routinely carried out for pre-operative evaluation of fitness for anesthesia are carried out.

What are the treatment options?

The treatment is carried out in stages. In the first stage DJ stent is placed (1). This has the following advantages:

1. It dilates the ureter, making instrumentation possible later
2. It causes mild inflammation, which helps the inner layer stick to the muscle layer of the ureter and prevents the inner layer from 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 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 is dilated to pass the ureterorenoscope to visualize and break the stone. Since the patient has had DJ stenting on the previous occasion, the broken pieces could be washed away.

Discussion

For medium-sized stones, the minimally invasive procedures that are advocated are miniaturized percutaneous nephrolithotomy or flexible ureterorenoscopy and breaking with a laser. However, these are very expensive and available only in few centers (2). Open surgeries for these stones are overkill, and these surgeries have the problem stated in the introduction, where the stones may not be found.

Hence, the treatment offered by the SEESHA team is an ideal one for rural areas. It is minimally invasive and less expensive. The only drawback is the multiple sittings that are required.

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. Several papers have been published in national and International journals about these low-cost techniques.

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.