What is a Kidney?

Böbrek         The urinary system consists of the kidneys that produce the urine, the ureters that transfer the urine from the kidneys to the bladder, the bladders that stores the urine, and the urethra, which is a tube that expels the urine out. The kidneys are two bean-shaped organs, located on both sides of the backbone, filtering out the wastes and excess water in the blood, and removing them out of the body via the urine. They also regulate the amount of salt and other substances in the blood. Kidneys also produce the hormones that strengthen the bones and create the red blood cells.

What is a Kidney Stone?

Böbrek Taşı Nedir         Kidney stone disease constitutes the most painful condition among urological diseases. Most kidney stones leave the body without any intervention. Studies have discovered several factors leading to the formation of stones in the kidneys and identified measures to prevent it.

How is a Kidney Stone Formed?

        A kidney stone is a hard substance consisting of crystals. There is a handful of chemicals that are discharged from the body along with the urine. These chemicals can be removed from the body without being crystallized thanks a special system. If this system malfunctions, crystals are deposited on each other, forming hard stones. Most kidney stones contain calcium. Less common forms of kidney stones are those that are formed due to infections in the urinary tract. Other types are the uric acid and cystine stones.

Who Develops Kidney Stones?

        Genetic predisposition is crucial. Those who have urinary tract infection, congenital kidney diseases, and metabolic diseases stemming from excessive functioning of the parathyroid gland are more likely to develop kidney stones.

        The excess calcium taken via food is removed in the urine. Excessive use of vitamin D, infections in the urinary system, occlusions of the urinary system and gout may frequently lead to the formation of kidney stones. Kidney stones may be seen after the long-term inflammatory diseases of the intestines and intestine operations.

What are the Symptoms of a Kidney Stone?

        Most kidney stones are expelled without major symptoms. The first symptom would be an extremely sharp pain like the labor pain. This pain is the result of the obstruction of the urine flow by a stone. A cramp-like sharp pain is felt below the abdomen and near the related kidney. Nausea and vomiting are common. Pain is the result of the muscles of the ureter contract in order to push the stone toward the bladder. There may be blood in the urine. Urination is frequent and accompanied with a sense of dysuria. If the condition is accompanied with fever and shivering, this indicates inflammation of the urinary tract and kidneys. A physician should be consulted immediately.

How is a Kidney Stone Diagnosed?

        Silent stones are asymptomatic. They are coincidentally detected during imaging done for other purposes. With additional imaging methods, significant information is obtained on the location of the stones in the kidneys and urinary tracts and their sizes. The best method for detecting kidney stones is unenhanced (contrast-enhanced) tomography. Contrast-enhanced tomography or pyelography provides extensive information on the functioning of kidneys.

How are Kidney Stones Prevented?

        Formation of a kidney stone is a sign that other stones may form in the future. Laboratory and spectrometric analysis of the stones excreted is crucial in determining their types.

        Most stones are excreted in the urine without requiring any surgical intervention. Daily intake of 8 glasses of water is recommended. It is useful to ensure that at least 2 liters of urine should be excreted on a daily basis. Drinking 1-2 glasses of water late at night is an important measure to prevent the reformation of the stone. This is because less urine is produced at night as the kidneys tend to retain water due to nocturnal secretion of diuretic hormones. This effect may be reversed if we wake up at night and drink 1-2 glasses of water. Contrary to what is widely believed, prohibition of calcium-rich foods such as milk, cheese and yogurt does more harm than good. Excessive intake of vitamin D and use of antacids are among risk factors.

        In sum, the effectiveness of drinking water as much as possible in preventing kidney stones has been demonstrated. In cases of some calcium and uric acid stones, stone formation may be eliminated by turning acidic urine into alkaline.

How is Kidney Pain Eliminated?

        Pains in the left part of the body may be mistaken for appendicitis. The priority should be urgent relief of the pain. Severe pain in the kidney actually does not indicate a life-threatening condition. However, patients who are not aware of this may act in panic. They may lose liquid due to nausea and vomiting. As an emergency measure, liquid is injected intravenously. Analgesic and anti-emetic drugs are given intravenously.

        Ultrasonography examination is conducted to see if there is occlusion in the urinary tract. Blood tests are performed to check there is an inflammation of the urinary tract. If inflammation or occlusion is not the case, then a therapy that would facilitate the excretion of the stone is implemented. For the most of the cases, the stones sized below 7-8 mm are excreted in the urine. If inflammation or occlusion is not the case, the pressure in the upper urinary tract must be urgently lowered. This can be done by placing a tube to reduce the pressure either at the lower area or from the kidneys.

        In primary care, analgesics are injected intravenously (IVD) or given through intramuscular injection (Ketorolac). In addition, Metoclopramide is administered against vomiting. If the pain continues, morphine sulfate that affects central nervous system, i.e., the brain, may be given. Later, the orally administered tablets of paracetamol or ketorolac should be given for 5-7 days in order to ensure the excretion of the stone and relieve the pain. To reduce the acute kidney pain, anti-diuretic drugs that decrease the urine formation may be given. To this end, sprays may be applied to the hose during the night. The use of antibiotics is not necessary unless there is the inflammation of the urinary tract.

Treatment of Kidney Stone Disease

        For the most of the cases, the stones sized below 8 mm are excreted in the urine without intervention. Surgical intervention may be needed for the stones with greater sizes. The size of the stone in the kidney or in the urinary tract and its location inside the kidney are important factors for treatment options.

        Open and closed methods are used for dealing with kidney stones. The success of kidney stone operations relies more on the experience of the surgeon on any technique than on the type of the technique used. Another factor that affects success is the excessive amount of stones.

Breaking up Stones with Extracorporeal Shock Wave Lithotripsy (ESWL)

        The ESWL procedure is an ideal method for breaking up the stones sized below 2 cm without compromising the integrity of the body. In this procedure, high-energy sound waves are aimed at the stone externally. This breaks up the stone into smaller pieces which are excreted in the urine. This procedure should not be used in case of pregnancy and hemorrhage disorder.

Closed Surgery of Kidney Stones

        For the last 20-25 years, open surgical methods have been replaced with endoscopic interventions. In closed procedures, the size of the stone and its location inside the kidney are crucial for the clearing of stones. It takes longer to clear larger stones and repetitive interventions may be needed. This implies extra exposure to anesthesia and increased associated complications. In endoscopic methods, pressurized water is used to ensure better view of the operation area. Pressurized water may lead to life-threatening complications, including fever, hemorrhage, etc. When stones in the thin ureters are cleared using this procedure, the ureter may be injured and even completely ruptured away. Depending on the experience of the surgeon, the closed procedure may be left unfinished due to much or little kidney hemorrhage. As the stones cannot be removed in a single piece, they are broken up and removed as small pieces. This is one of the key risks of the closed procedure.

        That is, several operations may be needed to remove bigger stones, and, in addition, it has more complications compared to the open procedure. For this reason, the open procedure has still merits in dealing with big kidney stones.

Ureteroscopy:

        In this technique, a small endoscope is used to enter the bladder and then, the ureter to have access to the stone. The stones sized 1 cm in the ureter and 2-2.5 cm in the kidneys are broken up with laser or hydrostatic pressure tools. There are two types of ureteroscopes: rigid and flexible. The stones that cannot be fully broken up are removed using special basket catheters.

Percutaneous Nephrolithotomy

        In this technique, a needle is sent into the kidney from the low back region. A thin wire is inserted into the needle and a round and long casing is sent over it. This access path is used to perform endoscopy. This larger stones can be broken up and removed using breaking devices.

Use Percutaneous Nephrolithotomy along with ESWL

        In addition to the foregoing, there are also developments in removing the stones using smaller-sized tools in the new generations of ureteroscopy and nephlithotomy. In the ultramini percutaneous nephrolithotomy, smaller and thinner cases are used to have access to the kidney. Kidney stones are removed also in children.

Open Surgery of Kidney Stones

        The kidneys and urinary tracts are located at the back of the peritoneum, or in medical parlance, in the retroperitoneal region. There are the stomach, the spleen, the liver and the bowels inside the peritoneum. These organs are covered with the peritoneum. This membrane is further covered with a layer of strong, transverse muscles that form the abdominal wall. In the standard open surgical procedure, these strong muscles of the abdominal wall have to be cut down in order to have access to the kidney. It may take some time before the patients who have undergone this procedure to resume their normal physical activity and work. In the procedure we employ, we preserve the integrity of the abdominal wall as we do not incise the abdominal muscles using a different method. After reaching the kidney, there are three methods for removing the stones.

        A renal pelvis is formed by the combination of 7-8 channels inside the kidney. In our technique, a small-sized incision is used to have access to the pelvis region without compromising the integrity of the kidney, and stones are removed. However, this method may not be suitable for removing the stones in the 7-8 channels collecting the urine for the pelvis. In such cases, the parenchyma of the kidney should be incised as well. After that, the stone located deeper inside can be cleared off. Damage to the kidney may occur while removing the stone. Due to these serious complications of the open procedure, there have been considerable developments in endoscopic interventions. Yet, endoscopic procedures, too, fail to provide perfect results. The excessive stone load is a major disadvantage. What is crucial is the experience of the physician.

The open procedure we use:

        In our technique, three layers of muscles in the lateral and front wall of the abdomen are not incised. When these muscles are cut down, this significantly affects the patient’s recuperation process. These three muscles join to each other at the back to form a thick envelop. This is like a point of entry. This special region is used for incision, but it should be remembered that incision in this region requires technical fineness and experience. Thus, the internal and external integrity of the patient’s body is preserved. An incision of 4-6 cm allows direct and ideal access to the kidney. This also allows access to the renal pelvis. With an incision into the renal pelvis, the stone can be removed from the kidney as a whole. The stones located inside the channels called calyces that collect the urine deeper inside the kidney can be easily removed with a flexible endoscope. Sometimes, it may be necessary to perform a radical incision of 2-3 cm on the kidney parenchyma to have access to the stone. In this case, the incision is parallel to the kidney veins and no damage is given to them. The procedure is completed successfully. The incised pelvis is closed and stitched in a waterproof manner. A small drainage tube is placed. Having been cleared of his/her stones completely, the patient can be discharged from the hospital in 1-2 days. In just one week, the patient can resume his/her life without needing any other intervention. This is called open, minimal invasive surgery. With only a small-sized incision of 4-6 cm on the skin, the patient can regain his/her daily strength for daily activities in a short time without serious damage to his/her internal integrity, unlike the endoscopic methods. In more complicated and challenging cases, the incision may be extended upwards for 2-3 cm to ensure a successful operation that would not compromise the integrity. Even the patients having stones in both kidneys can undergo the operation in supine position to be cleared off the stones in both kidneys. Some stone pieces may rarely be left inside the kidney and they can be broken down using high-energy shock waves called ESWL and they are excreted in the urine.

        In the technique we have been implementing for many years, no damage is given to the body except the scar from the incision of 4-6 cm on the skin. Stones are removed as a whole. In addition, when needed, a flexible systoscope may be inserted into the renal pelvis to remove the remaining stones. The related videos and images are given below.

Images of Kidney Stone Operation