Kidney Stones in Adults

Urolithiasis or kidney stones is a condition which recurs in up to half of all first time stone
formers. The incidence of stone disease is also increasing due to change in dietary and
lifestyle habits. The advances in medical technology have made it relatively easier for
patients to get themselves treated without having to go through the painful open surgery. I
have treated successfully thousands of patients with stone disease with the latest available
technology. However I still continue to see patients with kidney failure and very large stones
due probably to ignorance. In this article I have tried to elaborate few points so as to
understand about this disease easily.
What is urinary tract and what are its functions?
The urinary tract consists of the kidneys, ureters, bladder, and urethra. The kidneys are two bean-
shaped organs located at the middle of the back, one on each side of the spine. The kidneys
produce urine by remoing wastes and e!tra water from the blood. They also balance salts and
other substances in the blood and produce hormones responsible to form red blood cells. The tubes
called ureters carry urine from the kidneys to the bladder in the lower abdomen.

What is a kidney stone and what causes it?
Kidney stones are solid concretions formed from minerals which are e!creted in urine. "ormally,
urine contains chemicals that preent these minerals from forming crystals. Some people hae
imbalances allowing e!cess minerals like calcium in urine which cannot be dissoled to form
crystals and grow in si#e forming large stones. These chemicals are part of a person$s normal diet.
%f the crystals remain tiny enough, they will trael through the urinary tract and pass out in urine.
We do not always know why stones form. &ertain foods may promote stone formation in people
who are susceptible' howeer they do not cause stones in people who are not susceptible. We hae
some geographical areas called (stone belts$, where stone disease is common e.g. dry climate areas
such as northern region, )u*arat and some parts of +aharashtra. A person who has family history
is more likely to deelop stones. ,rinary tract infections and some kidney and metabolic disorders
e.g. gout is linked to stone formation.
What are the symptoms of kidney stones?
Kidney stone is synonymous with e!treme pain, which begins suddenly due to moement of stone
and blockage of flow of urine. %t$s a cramping pain in the back and side of abdomen usually
associated with burning in urination, nausea or omiting. -atients may also hae blood in urine. %f
urine is infected it causes feer and chills. .oweer kidney stones often do not cause any
symptoms and these patients may present later with big si#e stones and kidney failure.
What tests are done to diagnose stones?
"owadays adults are being diagnosed with stones on sonography done for general health
e!amination. /ften, -atients need to test their urine and do blood test to know kidney function. &T
scan is done during seere pain to diagnose the cause of pain as stone disease. They need
intraenous pyelogram 0%1-2 or &T urography which tells the doctor about kidney function being
affected or not, number, si#e and location of stones. This information is needed to decide the mode
of treatment.
.ow are kidney stones treated?
Surgery is not always necessary and most small stones can pass through the urinary system.
+edical Therapy
The most important lifestyle change to help passage of stones spontaneously and preent new ones
is to drink more li3uids, water being the best. The dietary changes may be needed in some
depending on the cause of stones. The patient may need medications to control the amount of acid
or alkali in the urine responsible for crystal formation e.g. in gout. Antibiotics would be needed for
a long term if infection is suspected.
Surgical Treatment
The open surgery with long scars and long hospitalisation is the thing of past. With the adances in
technology and understanding of the disease most of the stones can be treated by noninasie
means on day care basis, or by minimally inasie means with couple of days of admission.
Extracorporeal Shock ave !ithotripsy
The discoery of 4!tracorporeal shock wae lithotripsy 04SW52 made the treatment of stones
truly non inasie. %n 4SW5, The patient is made to lie down on a table with minimal or no
anesthesia. The stone is localised by 6 ray or sonography. The shock waes that are created
outside the body are focused on to the stone leading to its breakage into small particles which are
then passed in urine. The patient can go home in few hours. %n some cases a tube m called as stent
may be needed to aoid the blockage of ureter by passage of stone particles. Some patients may
hae blood in urine for a few and in some bruising in the back from the shock waes can occur.
Sometimes the stone is not completely shattered with one treatment, and additional treatments may
be needed. %f the stone does not get shattered completely in one session the treatment may be
repeated.
"ercutaneous #ephrolithotomy
-ercutaneous nephrolithotomy or -&"5 is a highly sophisticated minimally inasie procedure in
which a small incision 0app 7 cm2 is made in the back and a tunnel is made into the kidney. A
telescope is then passed through the tunnel to reach the stone which is broken with an energy
source e.g. 5AS48 or 5ithoclast. The broken stone pieces are then remoed through the same
tunnel. This procedure needs 9 to : days of admission in the hospital. %t is indicated for large
stones in the kidney which are not amenable to 4SW5. % see lot of %ndian patients almost eeryday
with large stones and do this procedure on them.
Ureteroscopy
,reteroscopy is a procedure done on stones in the ureter, a tube which carries urine from the
kidney into the bladder. Though stones in the ureters can be treated with 4SW5, ureteroscopy is
needed for stones in mid and lower ureter. Surgeon passes a small fiber optic instrument called an
ureteroscope through patients$ urinary passage in the ureter to reach the stone. The stone is then
broken into small pieces by 5AS48 and remoed. "o incision is made in this procedure. A small
tube or stent may be left in the ureter for a few days.
With the aailability of highly sophisticated instruments such as flexible ureteroscope and
Holmium laser % hae treated some patients with stones in the upper ureter and een kidney thus
aoiding -&"5.
,reteroscopic stone remoal can be done on a day care basis or with oernight stay.
hat is the role of open surgery today$
The role of open surgery for stone disease is almost negligible. %t has become almost redundant
with adances in minimally inasie techni3ues. % hae combined techni3ues such as laparoscopy
and -&"5 to treat stones in the kidneys which are abnormally located in the body by birth thus
aoiding long scars and hospital stay. %t may be done in failed endoscopic procedure or
occasionally in ery large stones.
How can I "revent %idney Stones$ hat is the diet restriction$
Kidney stones can be preented by following few simple tips and some diet modifications. A
patient is asked to undergo some laboratory tests to help determine their cause. The analysis of
remoed stone is also of help. /ne must remember that stones can recur anytime during the
lifetime and hence the precautions are needed lifelong. /ne should undergo annual sonography
and urine e!amination without fail.
Some specific type of stones e.g. ,ric acid and cysteine stones will need specific medical therapy.
.oweer some general adice to be followed by all is as follows
Take plenty of water throughout the day i.e. at least a glass eery hour so as to produce 9 to
9.; liters of urine. <rink a glass of water before going to bed.
=ou should restrict food rich in proteins, nitrogen sodium and o!alate such as "on eg,
egetables like spinach, tomato, cauliflower, brin*als, "uts like cashew, pistachio, almonds,
figs, fruits like chikoo, custard apple. &hocolates, rhubarb, spinach beets, swiss chard,
wheat germ, soybean crackers, peanuts, okra, black %ndian tea, sweet potatoes are high in
o!alates. =ou should maintain ade3uate intake of dietary calcium. %f you are on calcium
supplements continue them but increase citrate and fluids
%ncrease the intake of food items such as >ruits like
apple,papaya,watermelon,pineapple,sweetlime,bananas and orange, egetables like, white
gourd, ladyfinger, pumpkin, pulses like toor dal, moong dal, bengal gram, &ereals like
*owar corn,wheat,ba*ra,nachni. <ry fruits like <ates and apricot
%t$s a mistaken belief that these patients should not consume milk and milk products. They
can hae a glass or two of milk and as said maintain normal intake of calcium.
.ae a glass or two of lemonade or orange *uice daily.
8educe salt intake to ma!imum of one tablespoon daily. Aoid pickles, papads and canned
food.
Another mistaken belief is drinking beer flushes kidney stones. Well it not only causes
dehydration but also has substances which can actually increase the risk. .aing e!tra
glass of water is more helpful.
-oints to 8emember
%idney stones is a condition which recurs in up to half of all first time stone formers
-erson with a family history of stones, with habit of drinking less 3uantity of fluids,
outdoor *obs or a past history of stones should get themseles e!amined.
The best way aoid formation of any type of stone is to drink plenty of li3uids e.g. water
coconut water, *uices.
Some people with metabolic disorders will need medicines to preent stones.
-eople with repeated urinary tract infections and stones must hae careful follow-up to be
sure that the infection is eradicated.
Kidney stones may be asymptomatic.
+ost of the stones can be treated by noninasie means on day care basis, or by minimally
inasie means with couple of days of admission
<r. +ukund ). Andankar . +.S.0gen surgery2 +.&h. 0,rology2, <.".?
&onsultant Urologist' !aparoscopic and Transplant Surgeon
&onsultant at (ombay Hospital' )umbai and *ssociate "rofessor at T. #. )edical &ollege
and #air Hospital )umbai
.osp+ ,--.--,/0/0/ ext.000 )obile+ 12-,3 41,/, email+ mukundandankar5rediffmail.com