Treatment of urolithiasis (urinary stone disease) abroad
Urolithiasis is a pathological process when calculi or stones appear in the kidneys and the urinary tract. Urinary stone disease is the most common disease of the urinary system. It makes up 3-5% of the population and 10% in certain countries.
Over 50% of patients that are hospitalised in regards to urology related issues is usually as a consequence of urolithiasis.
What causes urinary stone disease?
Urilithiasis is a result of chemical composition that forms stones affecting the pH of urine or decreasing the outflow of urine.
There are various physical and pathological factors causing the illness such as:
- Genetic predisposition
- Male sex
- Ages between 30-50
- Abnormalities of the urinary system structures
- Ileum resection in the anamnesis
- A diet including high amounts of meat
- Vitamins B deficiency
- Hypovitaminosis A
- Hypervitaminosis D
- Excessive intake of vitamin C
- Long-term use of calcium medications
- Insufficient fluid intake
Stones differ in its chemical composition and are caused by different factors. Urate calculi, for instance, appear when purines’ metabolism malfunctions, usually when one is on a meat diet and the body is dehydrated. Phosphate stones form because of a chronic inflammatory processes in the kidneys.
Symptoms of urolithiasis
Urolithiasis is latent in the early stages as the stones are immobile and do not bring any discomfort. Meanwhile, even small stones are able to make a patient feel discomfort if they move.
Normally, a patient can first suspect a disease after the first attack of renal colic which happens when a stone obstructs urine outflow. This malfunction of urodynamics leads to an increased pelvic pressure of the kidney and the expansion of its capsule, which is full of nerve endings.
Basic signs of a renal colic are:
- Sharp and intensive pain in the lower back
- Pain remains even when body position is changed
- Possible pain in the other kidney or its irradiation into the whole abdominal cavity
- Muscle tension of the anterior abdominal wall
- Nausea, vomiting
- Change in heart rate and blood pressure
- Chills, fever
- Blood in theurine
Best variant when colic lasts just few minutes, though it can last for hours or even days. Attack ceases only if a stone will change location, flow out with the urine by itself or be removed surgically.
Diagnostics of urolithiasis
Normally, a primary diagnosis is made when the patient is either in the hospital or upon a visit to a doctor for renal colic. Laboratory tests data that confirm the diagnosis are:
- Urine рН changes
- The appearance of salts in urine
- Macrohematuria (visually conspicuous blood in the urine) or microhematuria (erythrocytes in urine)
- Bacteria and leukocytes excretion with the urine
- Leukocytosis and increased ESR in the blood
A kidney ultrasound or radiography of the abdomen is necessary to establish a diagnosis. Sometimes, both techniques are used at the same time as each has its pros and cons.
Radiography is unable to detect X-ray negative stones, which have a low density, when ultrasound is unable to scan the middle section of the renal duct closed by the intestine.
Computed tomography (CT) is considered the best way to diagnose the illness. Top hospitals own advanced check-up facilities and offer a CT scan to all their patients when some countries CT is optional.
Computed tomography is performed when:
- There is coral nephrolithiasis
- Suspected tumour
- A stone is not visible with an ultrasound scan and radiography but renal colic symptoms are present
It is vital to find out the stone’s chemical composition as some calculi can be split up by certain medications and others respond to breaking with the ultrasound. There are also super solid stones that respond either to the contact or can be surgically extracted.
They do X-ray diffractometry and infrared spectrophotometry to determine the stone’s chemistry.
Other diagnostics techniques are:
- Excretion urography is used to assess renal function
- Retrograde ureterography is used to assess the renal duct patency
- Bacteriological culture of urine is done if inflammatory complications (pyelonephritis) are present
- Aortography is sometimes prescribed to patients with dendritic stones when planning surgical intervention
Treatment of urolithiasis abroad
Both conservative and surgical techniques are used for urinary stone disease treatment. Antispasmodics and pain-killers are prescribed if a patient is suffering from renal colic, but narcotic analgesics may often be required.
Further treatment goal is to remove the calculi one way or another. Urate stones can be decomposed chemically with the help of special drugs that change the pH level of the urine and a patient has to drink a lot of water.
Radical treatment aimed at crushing or removing stones is used if the stones are larger than 1 cm, causes unpleasant symptoms or disrupts the function of the kidney.
Surgical treatment is sometimes used even when the calculi are small, about 4-6 millimetres because of the following indications:
- Ineffectiveness of conservative treatment while symptoms remain
- Accompanying infectious process
- Chronic renal duct obstruction (closure of the lumen)
Radical ways of urinary stone disease treatment are:
- Remote lithotripsy presupposes stones crushing with the help of acoustic waves. They then go out on their own, or the rest of the concrements are removed ureteroscopically (through the urethra). Remote shock wave lithotripsy is used if a stone size is up to 2 cm.
- Contact ureterolithotripsy is used with the access through the urethra when a ureteroscope is inserted. The stone is crushed by various ways (laser, pneumatics, electrohydraulics). The concrements are then extracted from the urethra. Extraction is not required when using laser, because the stone turns into dust, and do not split into fragments.
- Percutaneous lithotripsy is used for large stones, if they have a high density and are not subject to crushing with the help of an ultrasound, or if having infectious complications and pounded stones. This is a surgical operation when the stone is crushed and removed with the help of a tube inserted through a small incision in the lower back. The operation is minimally invasive and rehabilitation period is short.
- Mini-percutaneous lithotripsy is a similar method, but it’s more modern and less traumatic. The tube is smaller, so the diameter of the cut can be only 0.5 cm. The stone is extracted in parts by means of miniature surgical instruments.
Open and laparoscopic interventions are basically banned today. Stones are removed with the help of ureteroscopic methods or by percutaneous lithotripsy in 99% of the cases.
Prognosis for urinary stone disease
Small stones can flow out by themselves without any treatment and the percentage of the spontaneous divergence of concrements, depending on their size is:
- Up to 4 mm – 85%
- Up to 5 mm – 50%
- Up to 6 mm – 10 %
Percentage of renal duct stones retreat which are from 4 to 6 mm large, depending on their location is:
- Upper third of the renal duct – 35%
- Middlethird – 50%
- Lowerthird – 78%
According to the European Association of Urologists, the total probability of stones self-separation 6 mm in size is 60%. According to the American Association of Urologists this number is 75%.
Effective and efficient treatment in German hospitals help to remove all stones in most patients. However, there is a further risk of calculi recurrence that depends on the person’s lifestyle and stones’ chemistry. Risk canreach 70-80% forsomeurinarystonediseasetypes.