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Preventing Kidney Stones After Kidney Stone Surgery

It is a well-documented fact that even after surgical removal of kidney stones, up to 50% of patients may have recurrence within 5 years. Therefore, some preventive measures must be taken in order to avoid kidney stones in the future.In the longer term, a daily urine output of at least 2 liters is advisable in all patients with stone disease. Fluid intake should therefore be about 3 liters per day---more if the climate or the patient’s occupation causes much sweating. Suitable measures should be implied to correct any known cause of stone formation. Preparations containing vitamin D must be avoided, even milk intake has to be reduced.Idiopathic hypercalciuria can be helped by reduction of sodium intake (low salt intake) and by the use of a thiazide diuretic. Reduction of calcium intake is not recommended unless it is very high, as it may lead to a negative overall calcium balance and reduction of bone mass which ultimately makes bones weaker, also reduction of calcium intake causes increased oxalate absorption and excretion.Citrate excretion can be increased by daily administration of potassium nitrate or potassium bicarbonate. Alternatively, lemon juice may be a very good dietary source. Hypokalemia should be prevented as it leads to a reduction in citrate excretion.In patients with recurrent oxalate stones, foods and some liquids rich in this salt, such as rhubarb, spinach, tomatoes, strawberries, chocolate and tea, should be avoided. Persons who have passed several uric acid or urate stones benefit from allopurinol, 100-300 mg daily, depending on renal function. Allopurinol also has a place in treating calcium oxalate stone disease, since urates may contribute by acting as a nidus (nest) for stone formation.Phosphate-containing calculi are formed only in alkaline urine; hence acidifying the urine by giving ammonium chloride may be effective. In contrast, cystine and urate stones may be prevented or sometimes dissolved, by giving sufficient sodium bicarbonate to make the urine persistently alkaline, and ensuring a high urine output of 2-4 liters/day. When these measures fail or are unacceptable to the patient, treatment with D-penicillamine, a chelating agent, in a dose of 1-1.5 gram daily may be tried, although it is frequently associated with significant side effects. In case of struvite stones, which are actually magnesium-ammonium-phosphate stones and quite common in women with recurrent urinary tract infections, protease inhibitors are advised. Frequently, struvite stones are large staghorn calculi, and urine pH is high. These stones are formed due to infection with urease producing organisms such as Proteus mirabilis, Pseudomonas, Klebsiella, Staphylococcus and Mycoplasma but not E. coli. Therefore, struvite stones are also called as Infection stones.

Kidney Stone Surgery (Surgical Procedures for Kidney Stones)

Kidney stones are not always fatal, as they tend to pass out from the body through urine. But surgery has to be done if:

• Infection is present.
• The patient has intolerable frequent bouts of severe pain.
• The patient is anuric (A condition in which there is total absence of urine production)
• If there is Hydronephrosis (Aseptic dilatation of the whole or part of the pelvicalyceal system of the kidney due to partial or intermittent obstruction to the outflow of urine)
• If there is Pyonephrosis (In this condition, kidney is converted into a bag of pus)
  

The treatment of renal stones or calculi can be divided into Non-Operative treatment and Operative treatment.
Non-Operative Treatment.
1-Small stones less than 5mm in size pass off with intake of copious amount of fluids and at times forced diuresis. Intravenous hydration followed by intravenous Frusemide may help pass the stones spontaneously.
2-Extracorporeal Shock Wave Lithotripsy (ESWL) In this procedure, after cystoscopy, a ureteric stent (Double J Stent) is placed into the ureter on the side of a lager renal stone. Shock waves are generated (around 500-1500 shock waves) which blast the stone, getting it crushed, so it comes out by the side of stent.ESWL has 3 advantages as this procedure does not cause incision, nor pain and above all, it is quite safe but its disadvantages are its cost factor and availability.
Operative Treatment

-Endoscopic Procedures

Percutaneous Nephrolithotomy (PCNL) PCNL is often done when stone is quite large. In this procedure, Retrograde Pyelography (RPG) is done, stone is located in the pelvis of kidney. With a small 1cm incision in the loin, the PCN needle is passed into the pelvis of kidney and is confirmed by fluoroscopy. A guide wire is passed through the needle into the pelvis of kidney, now the needle is withdrawn with the guide wire within the pelvis. Over the guide wire, dilators are passed and a working sheath is introduced into the pelvis. A nephroscope is passed into the pelvis and if the stone is small, it is taken out and if big, it may have to be crushed using ultrasound probes and the fragments are removed. Ultrasound or pneumatic energy is used for fragmenting.PCNL has its own complications as it may cause injury to colon and blood vessels, may cause urinary leak that may persist for few days and may cause sepsis.

-Open Procedures

Depending upon the location of the stone, various types of procedures are done which are mentioned below:

A. Pyelolithotomy

B. Nephrolithotomy

C. Extended Pyelolithotomy

D. Pyelonephrolithotomy

E. Partial Nephrectomy

F. Nephrectomy (This is done when kidney is destroyed by pyonephrosis, following obstruction by stone)
-Special Procedures

A. Bilateral Renal Stones: Kidney with better function has to be operated first. 1-2 weeks later, the opposite side is operated.

B. If there is pyonephrosis with a severe degree of fever, pain and tenderness, Nephrostomy is done. If kidney is nonfunctioning, Nephrectomy is done but if kidney is functioning ESWL/PCNL/Open Procedure is done. This is known as Percutaneous Nephrostomy.

However, it must be kept in mind that open procedures for management of stone disease have now become obsolete.