Nephrolithotomy is a type of surgery that is performed as a result of disorders that occur in the kidney. Prof. Dr. Haluk Kulaksızoğlu from the Department of Urology answered all the questions about renal calculi and nephrolithotomy such as what is nephrolithotomy, how is nephrolithotomy performed, how many days to recover from nephrolithotomy, does renal calculi pass down spontaneously. Here are all things you need to know about renal calculi and nephrolithotomy.
Prof.Dr.Haluk Kulaksızoğlu from the Department of Urology answered all the questions about renal calculi and nephrolithotomy such as how many days to recover from nephrolithotomy, does renal calculi pass down spontaneously at an unprecedented.
Here are all things you need to know about renal calculi and nephrolithotomy.
1- What is nephrolithotomy, how is nephrolithotomy performed?
One of the areas where technology is most frequently involved in daily life is nephrolithotomy. Until very recently, we were talking about an extremely large open surgery when it is said nephrolithotomy Unfortunately in open surgery, the patient's kidney is reached with a serious incision with an almost blind procedure carried out. However, today with the surgeries we called minimally invasive, it is possible to have the patient return to his daily life and work 1-2 days after the surgery by making only a small hole in the patient, or by passing through the urinary tract and without any incision or hole outside. Kidney calculi is a common name, and the surgery can also be performed for the stones in the tract (i.e., ureteral calculi) endoscopically.
Depending on several variables such as the size of the stone, patient’s risk factors (heart disease, use of blood thinner), history of previous surgery, renal function, type of the stone, "percutaneous nephrolithotomy" or a surgery called "retrograde intrarenal surgery-RIRS” completely through the urinary tract can be performed in patients who are determined to undergo surgery. In order to perform these two operations, a trained surgical team and, of course, appropriate surgical instruments are required.
During the percutaneous nephrolithotomy operation, a small hole is opened from the patient’s lateral side close to the his/her back after determining the location of the stone through x-ray guided imaging, and a tube is inserted into that hole and a telescope-like device (called nephroscope) is passed. The stone is broken into small pieces, and the kidney is cleaned by removing those pieces visually again through the tube we placed in the kidney. The tube placed in the kidney is removed at the end of the procedure and another smaller tube called nephrostomy is placed for 1 day to allow the kidney to repair itself. This tube is withdrawn within 1 or 2 days and the patient is discharged to home.
In retrograde intrarenal surgery, the surgery is performed with an instrument called flexible ureterorenoscope, which is a very gentle and thin telescope-like device inserted through the urinary tract. The stone is broken into sand by the laser probe passing through this device and the stone is made disappear. After the procedure, a catheter may be inserted into the kidney this time for the recovery of the kidney, or the patient can be taken to his/her room without any catheter. Since there is no external incision in this type of surgery, the patient may walk to his home after 1 day.
2 - How many days to recover from nephrolithotomy?
The recovery period may vary depending on whether there is an intraoperative bleeding, the function of the kidney, and whether there are additional problems in our patient, such as cardiac trouble, lung disease. However, it is often possible to discharge the patient to home the next day or two days later. The main reason of the increased duration of hospital stay is the pain that the patient may feel during the passing of the remaining stone pieces after surgery and the bleeding that may continue during the recovery time in the kidney which is a very bloody organ. Immediately after the closed surgery, the patient can return to his/her daily life. The patient can take a bath next day and go around.
3- What is the reason for renal calculi?
Different mechanisms are involved in the renal calculi formation. This is because each kidney stone is not the same. Actually, the reason for the kidney formation is several crystals stacked up on top of each other. The precipitation of the crystals can be considered as the lime scale on the tap. Some people are genetically-predisposed to kidney calculi formation. Hereditary kidney stone disease is quite common. The kidney's function is to clean the blood of many waste materials in our body. These waste products are combined with water to form urine and transported to our bladder through the channels in the kidney. If the minerals such as uric acid, cystine, etc., especially calcium, during the filtration process, are more concentrated than the density that the water can carry, they start to precipitate on each other.
Small crystals then combine together and cause stone fromation. Also infections in the urinary tract may increase the precipitation of these crystals.
Sometimes, the increase in the uric acid level in gut disease other than calcium crystals may also cause stone formation. In the same manner, a stone may also form a stone. So when a small stone is formed, it can be easier for crystals to accumulate on this little core structure.
4- What are the symptoms of renal calculi?
The stone, as we all know, typically manifests itself with a pain. Pain is very severe, and nausea, vomiting and abdominal pain can also be added. As the severity of pain, kidney pain which is supposed to be one of the most severe pains is caused by the obstruction of the stone in the urinary tract. Due to the urine that accumulates behind it, the urinary tract is stretched and the pain occurs. Apart from pain, bleeding in the urine is one of the most common complaints. This may be a visible bleeding or incidentally detected in urine analyses carried out for different reasons.
If the blockage due to the stone becomes chronic, there may even be conditions leading to kidney failure. Also, the frequent urinary tract infections can be observed as a finding for the stone. If the stone does not move and allows the passage of urine through the channels, there may not be any complaints.
5- What are the risks of nephrolithotomy?
Since the surgery is performed in the kidney, which is a very bloody organ, some complications may be experienced such as bleeding, urine leakage through the urinary tract, fever and pain due to spontaneous fall of small pieces of stones. There are risks, such as perforation and injury in the urinary canals which are very delicate, and subsequent stenosis when it is not performed by competent specialists. Of course, these surgeries should not be perceived as simple operations.
It is important to evaluate the risk of anesthesia since those surgeries may be difficult and sometimes take long time. During these surgeries, there may be sometimes a requirement to have x-ray imaging. Therefore, you should inform your doctor in order to avoid exposure to radiation for those who have a pregnancy risk.
6- Which methods are used in nephrolithotomy?
There are mainly two approaches such as the removal or fragmentation of the stones in closed kidney calculus operations. If the stone is not very large in size, it is possible to pull out the stone with the instruments grasping the stone that may be considered as a kind of fishnet. However, it is often necessary to first break the stone into small pieces and even reduce its size as small as a sand. Therefore, laser devices, pneumatic or electrohydraulic lithotripsy devices are used in the operation.
7- Does the kidney stone pass spontaneously?
Especially in women, before making a decision on surgery, we evaluate whether the stone may pass by itself or not. With medication, the stones smaller than 1 cm in size are likely to pass. If there is a previous history of expelling kidney stones, the stone may pass a little easier in these individuals. However, it is not so easy to pass even small stones, especially in people with a narrowing in the urinary tract, a malpositioned kidney or the displacement or rotation of the renal structure. These patients may require surgical intervention.
8- How is closed nephrolithotomy performed?
Nephrolithotomy is performed under general anesthesia. In order to be able to choose the appropriate one for the patient from the methods mentioned above, anatomy of the kidneys and the urinary tract should be evaluated throughly. Sometimes the two methods can also be combined together to be used and not as an alternative to each other. The stone may not be in only one kidney or the same area of the kidney. In such cases, it may be necessary to use a combination of those procedures or to open multple holes in the skin.
9 - What do you recommend to prevent the recurrence of renal calculi?
The most important known risk factors are low water intake, urinary tract infections and, if any, metabolic disorders. There are some stone types that we can prevent the recurrence.
Therefore, the mineral composition and 24-hour urine collection test are important in the analysis for kidney stone.
It is very important to emphasize enough the importance of drinking water. The more intense the environment for the minerals converge in, the more likely it is that they will precipitate. For that reason, drinking plenty of water is recommended. Besides that, the easiest way to prevent calcium deposits observed in the majority of kidney stones is to shift the urine acid balance towards the acid side. We can do this by taking vitamin C. Vitamin C, i.e. citric acid, is not stored in the body and is excreted in the urine.
When it is excreted, it shifts the urine PH towards acid. So, the calcium does not precipitate and has protective effects on stone formation. In patients with chronic urinary tract infections, the prevention of this is again involved in the protection of stone formation. Of course, there are also medication we use. These medication can be administered according to the type of stone.
10- How should the diet of a person with renal calculi be?
Recent studies have shown that having a calcium-poor diet in those with stones high in calcium does not compensate too much for stone formation. If there is a problem in calcium metabolism in the kidney, calcium that is not taken orally may come from the bones and cause stone formation again. Therefore, it is necessary to adjust the diet without calcium restriction. Also, protein restriction may be required in those with uric acid stones.
In fact, before giving a decision on diet, the whole body metabolism shouşd be examined in detail and a personalized diet should be prescribed. Dieteticians are helping us about that.