dr ajay prakash

Mankind has been affected by urinary stones since centuries, and has been the silent cause of renal failure. Even in the 4th century BC, Hippocrates (father of modern medicine) notes the presences of the renal stone together with renal abscess and he wrote in his Hippocratic oath “… I will not cut, even for stone, but leave such procedures to the practitioners of the craft.” The speciality of urology has been recognized ever since. And the surgeons who treat urinary stones and other urinary diseases are called Urologist.

Urinary stone constitute one of the commonest diseases in our country and pain due to stones is known as worse than that of labour pain. In India, approximately 5 –7 million patients suffer from stone disease and at least 1/1000 of Indian population needs hospitalization due to stone disease.
Thus, the disease is as widespread as it is old, particularly in countries with dry, hot climate. These “stone belt regions” of the world are located in countries of Middle East, North Africa, the Mediterranean Regions, North Western state of India and Southern State of USA and areas around the great lakes.
In India, the “stones belt” occupies parts of Maharashtra, Gujarat, Punjab, Haryana, Delhi and Rajasthan. In these regions, the disease is so prevalent that most of the members of a family will suffer from kidney stones sometime in their lives. Surgery for removal of urinary stones forms one of the commonest operations in hospitals in these regions.
The kidneys are solid; bean shaped, reddish brown-paired structure, which lie behind the abdominal cavity one on either side of the vertebral column. This kidney acts like the filter organ, which removes the waste products from the blood, which forms urine.
About 180 litres of blood, which run through these nephrons (functional unit of the kidney), are reduced to urine by the process of filtration, reabsorbtion, and secretion by the nephrons. The urine enters the pelvis of the kidney where it collects and continues down the ureters to the bladder. In the urinary bladder urine is temporarily stored and is finally eliminated from the body. Human being on an average excrete about 1 to 1.5 litres of urine per day
Stone formation :
Stones can be formed any where in the urinary system, like kidney, ureter, and bladder. The process by which the stone formation occurs is Supersaturation of urine. Here is simple example illustration the formation of the stone.
Supersatuaration theory :
Imagine a glass of water containing little salt .If you add some more salt, it dissolves. When you add more and more salt, a stage is reached when the water is no longer able to dissolve the salt added to it. This is because the solution is supersaturated with the salt. Above this point, any little amount of salt added to the solution will start precipitating. This is exactly the mechanism by which stones form except that the solution is urine and the chemical composition of the salt is different.
Natural History :

Virtually all stones are formed in the kidneys, initially as small particles. These particles grow within the kidney to varying sizes, often filling up the whole kidney as a branched stone (the staghorn calculus). Sometimes they move out of the kidney when relatively small, and then migrate down the ureter into the bladder. Some stones less than 5 mm in size pass out spontaneously, but occasionally they migrate down the ureter & they may block the ureter causing obstruction to the flow of urine. This results in pain, which may be very severe (ureteric colic). Nausea and vomiting can also be associated with the colic pain. Some stones reach the bladder, and lodge there, growing larger and larger. Rarely they block the urethra causing a painful retention of urine.
Types of stone:
There are various types of urinary stones, but the most common ones are

Symptoms:
Stones in the kidney or ureter do not cause any symptoms until and unless they obstruct the urinary passage. The nature and the location of the pain can vary from person to person depending upon the size of the stone, the position of the stone within the urinary tract, and the damage it causes to the urinary system. “It should be however remembered that the size of the stone does not interrelate with the severity of the pain.”

Stones can be diagnosed with following symptoms:

Investigations :
A through physical examination is very important to understand the site and nature of the pain. It would also give the doctor an idea as to whether the pain is likely due to a stone within the urinary system or due to other reason.
To diagnose stone formation:

To plan treatment once stone is diagnosed :
1.Blood test to look for normal functions of the kidneys

2.Intravenous Urography. This is the specialized test were series of X- ray are taken after injecting the special medicine, a dye - Contrast, which has radiopaque property. The kidneys excrete these contrasts and kidneys are out lined on X rays and serial films are taken. This is a very useful test. It gives lot of information including size and shape of kidneys, function of kidney – comparative and individual, presence of obstructive uropathy, delineates the anatomy of kidney, ureter & bladder etc.

Metabolic tests may have to be done to look for any defects in your body, which may be responsible for stone formation. This is very important, as it is not only sufficient to treat for the stone but to find out why stone has been formed. The recurrence of stone formation can be prevented. Therefore, an appropriate treatment can be given so that one does not form stones again.

Treatment:
It has been said that once a stone former, always a stone former. Once a stone has been diagnosed, the choice is between expectant treatment and more aggressive forms of treatment, such as transurethral, percutaneous, or open surgeries or the relatively new extra corporeal modalities. Although some stones may pass spontaneously and unless complicating conditions arise, surgical intervention may not be necessary. Thus, identification of stones that are likely to pass is of utmost importance.
The primary decision is whether to apply surgical treatment or wait. Removal of stones by any methodology is necessary when there is evidence of:

Various general and specific medical measures are used to treat the stone disease. A significant percentage of patients will at sometimes or the other require intervention for the recovery of the stone.
1.Conservative-Management:

Most stones of small size pass spontaneously in the urine without any need for intervention. The probability of a stone passing down spontaneously will depend upon the size of a stone, its location, shape etc. Such patients are treated symptomatically with: