Endourology and Laser Treatment for Stone
Endourology is the specialised branch of urology that deals with the closed manipulation of the urinary tract. It comprises all urologic minimally invasive surgical procedures, and is generally performed with the help of small cameras and instruments inserted into the urinary tract. This facilitates prostate surgery, surgery of tumours of the urothelium, kidney stone surgery, and various urethral and ureteral procedures.
Extracorporeal Shock Wave Lithotripsy (ESWL)
Extracorporeal Shock Wave Lithotripsy (ESWL) makes use of shock waves to disintegrate a kidney stone into small pieces so that they can travel easily via the urinary tract and pass out of the body.
- In this procedure, the patient lies on a water-filled cushion, and the surgeon uses X-ray or ultrasound tests to accurately identify and locate the stone. High-energy sound waves are passed through the body, thus fragmenting the stone into small pieces, which enables them to pass through the urinary tract and out of the body easily.
- The entire process takes only about an hour and is performed using local anaesthesia.
- A stent may be placed in the ureter if you have a large stone, to allow small stone pieces to easily pass without causing ureter blockage
ESWL is generally an outpatient procedure. Following the treatment, stone fragments tend to pass in the urine for a few days, which could result in mild pain.
Why it is Done
ESWL is usually performed on those suffering from kidney stones that are causing pain or blockage of urine. Kidney stones that are between 4 mm and 2 cm in diameter are usually treated with ESWL. It also treats stones in the kidney or in the part of the ureter that is adjacent to the kidney.
However, ESWL is not recommended if the individual is:
- Has a bleeding disorder
- Has infection in the kidney or urinary tract
- Has kidney cancer
- Has abnormally structured kidneys or if there is problem in the functioning of the kidneys
Risks or Complications
- Intense pain caused by the passage of fragments of stone
- Blockage in urine flow
- Infection in the urinary tract
- Bleeding on the outside of the kidney
Retrograde Intrarenal Surgery (RIRS)
Retrograde Intrarenal Surgery (RIRS) is a surgical procedure performed within the kidney using a viewing tube known as a fiberoptic endoscope.
In this procedure, the endoscope is placed via the urethra into the bladder and then passed through the ureter into the part of the kidney wherein the urine gets collected. In this way, the endoscope is moved up to the urinary tract system to a specific position within the kidney.
RIRS is generally performed to remove a stone or a small tumour. The stone can be directly visualized through the endoscope, and then fragmented using an ultrasound probe, evaporated with the help of a laser probe or grabbed using small forceps. It is typically performed under general or spinal anaesthesia.
Advantages of RIRS
Some of the major advantages of RIRS over other surgeries include access to all parts of the kidney that have stones, less pain and bleeding following the surgery, and faster recovery.
RIRS is recommended for patients who are suffering from kidney stones or in certain cases such as narrowing of the kidney outlet or related strictures and tumours.
RIRS is mainly used for treating certain difficult conditions such as:
- Previous treatment attempts that have completely failed
- Large stones that cannot be removed using ESWL
- Strictures or tumours
- Stones in children
- Patients suffering from bleeding disorders
- Patients suffering from gross obesity
- Patients with odd anatomy
Standard percutaneous nephrolithotomy is an extremely effective procedure that helps remove renal calculi. However, it results in significant morbidity.
Mini-percutaneous nephrolithotomy, performed using a 15F or 16.5F ureteroscopy sheath, tremendously reduces the morbidity associated with standard percutaneous nephrolithotomy and simultaneously maintains the effectiveness of stone removal.
Microperc’ (Micro PCNL) is a procedure performed using a 16-gauge needle.
One of the major disadvantages of Extracorporeal Shock Wave Lithotripsy (ESWL) is its unpredictable result. While the prominent limitation of Retrograde Intrarenal Surgery (RIRS) is high-cost, a limitation is its invasiveness and associated morbidity.
Reduction in the tract size helps reduce the invasiveness of the procedure and potential complications. In Microperc or Micro PCNL, the procedure is performed through a 4.85-Fr (16 gauge) tract. The underlying hypothesis of the ‘All-seeing needle’ is that if the initial tract is perfect, then the tract-related morbidity can be substantially reduced. The optical needle also helps eliminate any traversing viscera. Yet another advantage of microperc is that it is a single-step renal access procedure, which results in a shorter insertion. It thus provides a novel standard of obtaining renal access.
Ureteroscopic Removal Of Stone (URS)
Urinary stones present in the ureter, particularly hard stones or those that cannot be treated with ESWL, can be treated using laser. URS is a procedure used to treat stones situated in the middle and lower ureter. This procedure is performed under general or spinal anaesthesia.
A ureteroscope, or a small fiberoptic instrument is inserted through the urethra and bladder into the ureter, which enables the urologist to directly visualise the stone present in the ureter.
While small stones are removed using a specialised stone basket, large ones are disintegrated using a laser or a similar device. A stent may be placed in the ureter for a few days following the treatment in order to facilitate healing and prevent blockage caused by inflammation or spasm. The stent is usually removed 8-14 days after surgery using flexible cystoscope as an outpatient procedure.
Percutaneous Nephrolithotripsy (PCNL)
Percutaneous Nephrolithotripsy (PCNL or PNL) refers to a minimally invasive endoscopic treatment that is used for removing staghorn stones, large kidney stones or multiple stones in the upper ureter.
In this procedure, a puncture is created in the skin through the kidney to the stone and a telescopic port is inserted, without any big incision required. A telescope known as a nephroscope is passed through this port into the kidney to disintegrate the stone and break it into pieces, to remove the debris from the stone. PCNL or PNL is performed under general anaesthesia and real-time X-ray control called fluoroscopy. The surgery may last for 1 or 2 hours.
Prominent advantages of PNL or PCNL include:
- Eliminating the large skin incision caused by pervious kidney surgery for stones
- Removal of all fragments removed during surgery
- Faster recovery and healing as compared to other procedures
- Shorter hospital stay – 2 or 3 days
Percutaneous stone surgery may also be recommended in certain conditions where the ureter below one of the kidneys is obstructed, or in ureteropelvic junction obstructions.