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Information on Kidney stones

Kidney stones are known to man ever since history of mankind. The earliest report of stone dates back to 4800 BC when stones were found in Egyptian mummies. It has been estimated that about 3% of the adult population in America is affected by stones. Approximately 1 in 10 people may develop urinary stones at some point in their lifetime. Stones account for 10% of acute Urological hospital admissions and many more visits to emergency departments and General practitioners.

Treatment of stones depends on the stone factors (size, location and composition), anatomy of the urinary tract (obstruction, size of ureter, configuration of pelvicalyceal system, etc) and presence of infection.

Treatment options

 

1.Shock wave lithotripsy

2.Telescopic removal of stone from ureter or kidney

3.Keyhole surgery (Percutaneous Nephrolithotomy)

 

Shockwave lithotripsy

 

Introduction

This leaflet tells you about the procedure known as Lithotripsy and serves to explain what is involved and the possible outcomes and complications. It is not meant to replace informed discussion between you and your surgeon but can act as a starting point for such a discussion

Lithotripsy is likely to be a pre-planned  procedure and you should have plenty of time to discuss it with your consultant so that you have sufficient explanation before you sign the consent form.

What is Lithotripsy?

Extracorporeal shock wave lithotripsy (ESWL) is a procedure in which renal and ureteral stones are broken into smaller fragments by shock waves. These small fragments can pass naturally. This approach may leave patients stone-free without surgical intervention or invasive procedures.

 

 

The stones are fragmented by high-energy shock waves created outside the body. The machine used to deliver the shock waves is called a Lithotriptor. 

Which stones are suitable for Lithotripsy?

1. Stones in the kidney

2. Stones in the ureter (tube draining urine from the kidney to the bladder)

Are there any contra-indications for this treatment?There are certain factors that would prohibit lithotripsy treatment such as:  

·         If you weigh over 120 Kg,

·         If you have had blood-clotting problems or pregnancy.

There may be other factors that your doctor will take into consideration before performing the procedure.What are the alternatives to treatment of kidney stones?

The majority of small stones within the kidney are fragmented by lithotripsy. However, a proportion of smaller stones and most large stones need other treatment methods using telescopes passed through the bladder or through a keyhole operation. Decisions regarding the best treatment option will be taken based on the size and position of the stone and the structure of the kidney.

What preparation do you need before attending lithotripsy?

1. If you are taking a substance used to prevent clotting such as Aspirin, Warfarin and Clopidrogel, please discuss this with your Urologist prior to appointment.

2. If you have a pacemaker please let your treating Urologist know.

3. Continue other routine medications.

4. Do not eat anything 4 hours prior to the procedure (you can drink freely). If you are diabetic, please take normal diet as suggested.

5. Arrange someone to pick you up after the procedure from the lithotripter unit , as you will not be able to drive for 24 hours.

How is the procedure (ESWL) performed?

The procedure is done as an out-patient and it takes about an hour. A few tests will be performed beforehand, such as an x-ray to determine the size and location of the stones, routine urine test, blood pressure and an electrocardiogram if there are any risk factors. After signing a consent form, you will be positioned on the Lithotripsy table and monitoring equipment will be connected. A needle may be inserted in a vein in your arm to administer painkillers.

The position of the stone will be located using an X-ray or Ultrasound scan. After confirming the position of the stone, painkillers will be given and the treatment started. You must lie still during your treatment. You will be able to request more medication if you experience any pain. After the treatment finishes, you will rest in the recovery area. You will be discharged home when you are comfortable and your observations are stable. Please allow approximately 2 hours for your visit.

Will there be any pain afterwards?

Some minor abdominal discomfort is common after the procedure. You will be prescribed some painkillers after treatment.

It is common for you to pass a small amount of blood in the urine for a few days after treatment.  You may also experience some bruising on your back and excessive need to urinate. You will be warned to watch for symptoms of infection such as fever and excessive pain. It is very important to drink plenty of water afterwards to help flush out the stone fragments after treatment.. If you get symptoms of infection or if the pain is severe and persistent, please get in touch with your GP or attend the accident and emergency department in your local hospital.

How long do you need to stay off work?

Office based work can be resumed within a day or two depending on how comfortable you are. Heavy physical work has to be avoided for at least 48 hours. Due to the sedative effects of the medications given, driving should be avoided for 24 hours after the procedure.

Following Lithotripsy, stone fragments may pass in the urine and may result in pain. For this reason, always keep painkillers available .

When do you come back for follow up treatment?

Fragmented stones may take a few weeks to pass in the urine. You will be asked to return for follow up in the clinic. For large stones, more than one treatment may be necessary. On follow up visits, fragmentation and clearance of the stone will be checked by X-rays and further action planned based on the results.

PERCUTANEOUS NEPHROLITHOTOMY (PCNL)

 This leaflet tells you about the procedure known as percutaneous nephrolithotomy (PCNL) and serves to explain what is involved and the possible outcomes and complications. It is not meant to replace informed discussion between you and your consultant but can act as a starting point for such a discussion. You will be seen in a pre-assessment clinic a few days before the operation and have blood tests, Chest X-ray and ECG (echocardiogram) if needed. You might also have an X-ray to check the size and position of the kidney stone either in the pre-admission clinic or on the day of the operation. You will also be required to produce a fresh mid-stream urine specimen. bring all your medication or a list of medication, and inform the doctor about all or any new medical problems. It is especially important to let the doctor know if you are on Warfarin/ Clopidrogel/ Aspirin as this may need to be stopped before the operation. You will be advised appropriately and admitted 4 days earlier if you are on Warfarin for special preparation before the operation. If for some medical reason you are considered unfit, the operation may have to be deferred until you are fit enough and this may require consultation with other medical colleagues. allergies to medication or have had an allergy to the dye used to take special X-rays in the past. woman of child bearing age it is important Insert own Trust logo pregnant. If in doubt we may need to perform a pregnancy test. This is important to avoid any inadvertent radiation exposure to a baby in the womb during the X-ray. There will be a catheter in your bladder to drain your urine. Your urine may be coloured with blood or bluish-green dye used during the procedure. The catheter will be removed once you are up and about or when the consultants are satisfied with your progress.

How is the operation performed?

While you are under the general anaesthetic the surgeon will examine your bladder with a long, thin, semi-rigid or flexible telescope and pass a small tube up to your kidney, which has the stone. This is used to pass a mixture of a coloured dye and X-ray dye to the kidney making it easier to see during the operation.

You will then be placed face down on the operating table and the consultant will make one or more small incisions into your back. This is done using special metal or balloon dilators (see diagram). This enables the consultant to pass a telescope into your kidney. The stone or stones in the kidney are then removed either intact or in pieces after breaking them with special instruments. X-rays will be taken during and at the end of the procedure to ensure that all accessible bits of the stone have been removed from your kidney.

What can I expect after the operation

• There will be a tube in your back connected to a drainage bag to allow the kidney to drain a mixture of blood and urine. The blood in this tube will gradually clear in a day or two. Occasionally further X-rays may be necessary before this tube is removed. Removing the tube does not usually require any painkillers or sedation.

• There will be a drip in one or both of your arms to give intravenous fluids until you are able to drink and eat normally. This may sometimes be used to give a blood transfusion if required.

• You may be given antibiotics post-operatively either orally or through the drip in your arm.

• You will be prescribed and given appropriate painkillers after the procedure.

 

What are the risks?

 

Chest Infection might arise if you are a smoker or if you have pre-existing breathing or chest problems. It is

 

What are the alternatives?

Problems and complications specific to this operation only are listed here. This does not cover every possible complication but covers the more common or serious. Complications may result from anaesthesia and should be discussed with your anaesthetist.) or locate the kidney stone may make it impossible to proceed with the operation. Bleeding either during the operation or post-operatively via the tube in your kidney and the bladder is common but soon settles. Heavy bleeding is uncommon (less than 1% of patients experience this). Rarely, the consultant may have to abandon attempts to remove the stone and take active steps to control the bleeding. This might take the form of open surgery or using X-ray techniques to selectively control the bleeding. In very rare circumstances patients have had to have the kidney removed because of uncontrolled bleeding. Infection of the bladder is common although all patients are given antibiotics before and after the operation. Some stones have bacteria trapped within them which are released during the operation. Severe infection occurs in less than 1% of patients. Injury to the lung or chest cavity may lead to the collection of fluid or blood in the chest or lung which may require a separate tube temporarily to let it settle.important you stop smoking before the operation and inform the consultant if you have had a recent chest infection. Abdominal distension (bloating) may occur after the operation because of leakage of fluid used during the surgery or due to bowel distension. This usually settles in a day or two. During this time the amount you drink should be reduced. Injuries to other organs such as the bowel, liver or spleen are very rare and usually settle with conservative management or may rarely require other surgical procedures. This may however prolong your stay in the hospital.

The consultant will usually discuss with you before the operation alternative ways of treating the kidney stone. This might require an alternative procedure whilst still under the anaesthetic or a different procedure on another occasion.

Before the operation

Stop smoking a week or two before the operation: this reduces the risk of chest infection and clots in your legs.

After the operation

What will happen after discharge?

Depending on the outcome of your operation you will either be given an outpatient appointment or if you require further treatment the consultant will discuss this with you and schedule this appointment.

Maintain a high fluid intake (4 – 6 pints per day): this will help clear the blood in your urine and flush out stone fragments and reduce the risk of constipation.

It is important that you make a list of all medicines you are taking and bring it with you to all your follow-up clinic appointments. If you have any questions at all, please ask your surgeon, or nurse. It may help to write down questions as you think of them so that you have them ready. It may also help to bring someone with you when you attend your outpatient appointments

.

Dietary advice for people with kidney stones

Drink a minimum of 4 pints of water per day, enough to keep your urine a clear colour at all times.

Your consultant may provide you with a more in depth diet sheet if necessary.

• Eat no more than 2 potions of meat a day (red meat, chicken and fish).

• Dairy products are good for you in moderation.

• Reduce foods containing Oxalates (a chemical that combines with calcium in urine to form the most common type of kidney stone) for example spinach, rhubarb, nuts berries, chocolate, and wheat bran.

• Reduce your salt intake, on and in your food.

• Eat lots of fruits and vegetables: besides being part of a good diet it also helps to reduce constipation, straining to open your bowel may increase the risk of bleeding.

• Try to get active as soon as possible after the operation to reduce the chances of pneumonia and clots in your legs.

• Avoid, if possible, heavy lifting or straining for 4 weeks after the operation.

• Do not drive until you feel comfortable making an emergency stop.

• You may see some blood in your urine for up to 2 weeks after the operation. If this persists or you have sudden appearance of blood contact your GP or alternatively contact the Urology ward to which you were admitted. You should be directed to come to the A & E department of the hospital to be assessed by an appropriate member of the Urology team.

• If you develop high fever or chills, contact your GP or the Urology ward to which you were admitted.

• Get some gentle exercises: the fitter you are the easier your postoperative recovery.

 

 

URETEROSCOPY FOR DIAGNOSIS OR TREATMENT OF KIDNEY STONES It is not meant to replace informed discussion between you and your consultant but can act as a starting point for such a discussion.

This leaflet tells you about the procedure known as Ureteroscopy and serves to explain what is involved and what the possible outcomes and complications are.

Ureteroscopy is likely to be a pre-planned operation and you should have plenty of time to discuss it with your consultant so you have sufficient explanation before you agree to the operation.

Why do I need this operation? What are the benefits?

Your surgeon would have explained to you why you require this procedure, which can either be used for diagnostic purposes, or for treating a kidney stone. If you have a kidney stone it may be in the ureter (the tube which drains urine from the kidney to the bladder) or in the kidney.

This operation is performed using either a long, thin, semi-rigid or flexible telescope. This is passed up the natural urinary passage (urethra) into the bladder and up to the stone or the problem in the ureter or kidney. The procedure requires a general anaesthetic with a hospital stay usually of 1 to 3 days. You may be able to go home the same day (this will depend on your individual circumstances and will be discussed with you by your consultant).

What can I expect before the operation?

How is the operation performed?

While you are under the general anaesthetic the consultant will examine your bladder with a long, thin, semi-rigid or flexible telescope and then pass a small guide wire up the ureter beyond the kidney stone. Sometimes it will be necessary to stretch the opening of the ureter into the bladder. The surgeon will then pass a long, thin, semi-rigid or flexible telescope up the ureter to the stone. If the kidney stone is small enough to be extracted intact it will be removed with a special basket. If however the stone needs to be broken up, this will be done using either a laser or a small vibrating probe. If fragments can then be removed they may be sent for analysis.

Sometimes it is necessary to leave a stent (this is a long thin plastic flexible tube which extends from the kidney to the bladder) in the ureter if it has not been possible to fragment the stone or if the ureter looks inflamed. This will be left inside you temporarily and be taken out in a few weeks or left in until further treatment of the stone is necessary. The stent may cause pain, frequent desire and urgency to pass water or blood in your urine for a few days.

You will be seen in a pre-assessment clinic a few days before the operation and have blood tests if needed. You will also be required to produce a fresh, mid-stream urine specimen. medication or a list of medication to the pre-assessment, and inform the doctor about all or any new medical problems. allergies to medication or allergy to the dye used to take special X-rays in the past. woman of child bearing age it is important to let the doctor or the nurse know if there is any possibility of your being pregnant. If in doubt we will perform a pregnancy test. This is important to avoid radiation exposure to a baby in the womb during the procedure.You may have a catheter in your bladder to drain your urine. Your urine may be coloured with blood. The catheter will be removed once the consultants are satisfied with your progress. Failure to reach the stone, in which case a stent might be left in and the consultant will discuss further management at a later date unless an alternative procedure has been discussed with you beforehand. Damage to the ureter is uncommon and might lead to the need for a stent. Very rarely an open procedure to repair the damage may be necessary. Bleeding in the urine usually settles in a few days but can last for 2 or 3 weeks. Infection of the bladder is common although all patients are given antibiotics to minimise this risk. Some stones have bacteria trapped within them which are then released during the operation. Severe infection occurs in less than 1% of patients.important you stop smoking before the operation and inform the doctor if you have had any recent chest infection. Stopping smoking before the operation will also reduce the risk of clots forming in your legs. Maintain a high fluid intake (4 – 6 pints per day): this will help clear the blood in your urine and flush out stone fragments and reduce the risk of constipation. Drink a minimum of 4 pints of water per day, enough to keep your urine a clear colour at all times.

What can I expect after the operation?

What are the risks of this operation?

(Problems and complications specific to this operation only are listed here. This does not cover every possible complication but covers the more common or serious. Complications may result from anaesthesia and should be discussed with your anaesthetist.)

 • Chest Infection might arise if you are a smoker or if you have pre-existing breathing or chest problems.

What are the alternatives?

If there are complications you may need a stent leaving in until your consultant has discussed further management with you or you may need an open procedure.

After the Operation

What sort of follow up/ after care will I get?

Depending on the outcome of your operation you will either be given an outpatient appointment or, if you require further treatment, the consultant will discuss this with you and schedule this appropriately.

It is important that you make a list of all medicines you are taking and bring it with you to all your follow-up clinic appointments. If you have any questions at all, please ask your surgeon, or nurse. It may help to write down questions as you think of them so that you have them ready. It may also help to bring someone with you when you attend your outpatient appointments

Dietary advice for people with kidney stones

• Eat no more than 2 portions of meat a day (red meat, chicken and fish).

• Dairy products are good for you in moderation.

• Reduce foods containing Oxalates (a chemical that combines with calcium in urine to form the most common type of kidney stone) for example spinach, rhubarb, nuts, berries, chocolate and wheat bran.

• Reduce your salt intake, on and in your food.

• Try to get active as soon as possible after the operation to reduce the chances of pneumonia and clots in your legs.

• Do not drive until you feel able to make an emergency stop.

• You may see some blood in your urine up to 2 weeks after the operation. If this persists contact your GP or alternatively contact the Urology ward to which you were admitted.

• If you develop high fever or chills contact the Urology ward to which you were admitted.

• You may have an intravenous drip until you are able to drink and eat normally.

• You will usually be given antibiotics when you are anaesthetised and if needed post-operatively as well to prevent infection.

• You will be prescribed and given appropriate painkillers after the procedure.

• It is important to bring all your

• Please tell the doctor if you have any

• You might have a further X-ray of your abdomen on the day of the operation to check the latest position of your stone.

A percutaneous nephrolithotomy is likely to be a pre-planned operation and you should have plenty of time to discuss it with your consultant so you have sufficient explanation before you agree to the operation.

Why do I need this operation? What are the benefits?

You have been diagnosed as having a kidney stone (or stones) causing some, or all, of these symptoms: pain, infections, bleeding or obstruction of your kidney, which if left untreated, may lead to further symptoms or complications, such as severe infection or loss of kidney function.

This operation (PCNL) is performed to remove large kidney stones using a keyhole approach. This is a major operation despite the term ‘keyhole surgery’. The procedure requires a general anaesthetic and may last 1 to 3 hours with a hospital stay from 4 to 7 days. The success rate of kidney stone clearance ranges from 75% to 100% depending on various factors. The consultant will usually discuss with you if any alternative procedures are possible or may be required after this.

What to expect before the operation?