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Oganes E. Dilanyan
Urologist, MD, PhD
+7(499)344-03-03

Kidney Stones

In this article

Kidney stones are the main sign of a complicated and multifaceted condition known as kidney stone disease. There are more than 200 reasons that cause the formation of kidney stones and correct treatment includes not only the removal of the kidney stone but also removing the cause.

Kidney stones in men and women

Specific features: almost in all cases a dormant underlying kidney infection is present. Very often there is a risk of developing a kidney colic or purulent pyelonephritis. In some cases, the dysfunction is so severe that lifelong dialysis or kidney transplant may be required. If you tell anyone that up to 40% of patients on long term dialysis waiting for years for a kidney transplant “just had kidney stones” they would not believe you. Meanwhile chronic renal failure can go side by side with kidney stone disease especially in the presence of large coral shaped kidney stones.   

Kidney Stones: treatment

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Unfortunately, only surgery can help the patient lower the risk of all the side effects of kidney stones such as kidney colic, acute pyelonephritis and chronic kidney failure. 

Ultrasound lithotripsy for kidney stones without surgery or remote ureteral lithotripsy is the treatment of choice in most cases.

Laser surgery for kidney stones removal is carried out through the urethra or a small puncture in the side. This is done endoscopically without any incisions. This method is more effective than surgery or lithotripsy.  

Most old school urologists have a special shelf in their office that contains a collection of a hundred or more kidney stones of various shapes and sizes and most peculiar colours. Some of them are even cut in half and their beauty may even take your breath away. But the feeling of awe is soon replaced with the feeling of horror. All these stones were removed by means of surgery and sectional kidney dissection.  

Behind every single stone is serious illness, surgery and often a damaged dysfunctional kidney. Endoscopic and laser surgery options were not available 30-40 years ago and every patient with kidney stone disease had to be subjected to complicated open surgery. The consequences of these surgeries were huge scars, incurable post-operative hernias and shrivelled up dysfunctional kidneys.

“I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.”
Hippocratic Oath

What causes kidney stones?

Origins of kidney stones.

Ask any urologist where kidney stones come from and they will screw their face into a smile and start telling you all about it but then would just give up as this conversation would be too long.  Open a few patients’ notes and kidney ultrasound reports and you will see “small kidney stones”. Every 7th person in Russia will be hospitalised for kidney stone surgery or treatment of complications at least once in their lifetime. Approximately half of those patients will have large kidney stones causing constant recurrent infections and disrupting kidney function.

Kidney stone disease – is always a signal that the body, an amazing machine that is capable of maintaining its own health, is malfunctioning. Low quality drinking water, disruption in urinary outflow and infection are just a few reasons of kidney stone forming. 

What can be the consequences of kidney stones?

...— Where have you been all this time? – I ask, frowning and looking at a kidney CT scan results. The kidney is practically dead. It is not producing any urine, has minimal blood supply and slightly below the kidney, in the ureter there is a large kidney stone measuring around 4cm in size.  
— Well…the pain stopped so I just assumed everything was fine.
Background. The patient had a few kidney colic episodes a year and a half ago. They never got to see a urologist and attempted to treat the condition using information they obtained online about dissolving kidney stones with medication. And the result? Nerve endings were permanently damaged and died off, the pain went away and the kidney has been blocked by a kidney stone that has grown into the ureter. And a very good question, can the kidney be saved?

“Kidney stone removal is only half of the job. The second half is to find the reason for the stone forming”.
From a lecture about kidney stone disease

"Dissolving" oxalate and urate kidney stones

Let’s think for a moment why a special area of urology is isolated and devoted to treating kidney stones exists all over the world and whole departments dedicated to treating kidney stone disease exist in hospitals? Why not prescribe some widely advertised kidney stone dissolving medicine to all patients with kidney stones or ureter stones and be done with it? Why invent expensive equipment for laser lithotripsy of kidney and ureter stones, create thin and flexible endoscopes for ureter and kidney access via the urinary tract that allow removal of the stone without open surgery?
One huge problem about kidney stone disease is that there are over 200 reasons that can lead to forming of kidney stones and practically all of the stones are different from one another in terms of composition. And the task for any good urologist is not only the removal of the kidney stones but also to identify the reasons that caused the stones and to treat the initial “system failure” which caused the stones to form in the first place.  
Also, in the vast majority of cases all those “stone dissolvers” simply do not work. Or to be precise they practically never work. Just think about it, the medication capable of dissolving the stone would first dissolve… the kidney itself.

“The task for any good urologist is not only the removal of the kidney stones but also to identify the reasons that caused the stones to form”

Kidney stones: diagnosis

Modern diagnosis of kidney stones has quite a few methods on offer. Often the patient simply cannot understand the need for all this. Lots and lots of tests, investigations and x-ray exposure, what for?

Urinary system ultrasound

Ultrasound scan of the kidneys, bladder and the prostate allow us to identify the stones and to some degree answer the question about the reasons of the stones forming in the kidneys. Often kidney ultrasound is the first test that the patient with kidney stone disease is subjected to.

General urine test

The presence of stones in the kidneys means increased risk of infection. General urine test allows us to identify the infection and determine the degree of inflammation. It also allows us to assess the composition of the stone as the crystals present in the urine are characteristic for specific types of kidney stones.

CT scan

In modern practice Ct scans help answer several questions at once. They help determine the density of the stone, the possibility of remote lithotripsy, help assess the condition of the ureters and if it would be possible for the stone chips too be passed through them. It also helps us see if there are any anomalies present that can mean contraindications to laser surgery.

Biochemical blood test

Several parameters of this test allow us to determine the reasons for forming of the stones and possible disruption of kidney function. For example, increased levels of uric acid can point to gout and increased creatinine levels indicate poor filtration function.  

Urine Culture

Urine culture allows us to determine the type of pathogen and its sensitivity to certain antibiotics which makes it possible to prescribe specific antibacterial agents without unnecessary risks to intestinal flora by using strong broad-spectrum antibiotics.   

Chemical composition of the stone

This test is carried out following the removal of the kidney stone and is paramount in terms of diagnosis of the condition that lead to the stone forming in the first place. In the vast majority of cases this test allows us to prevent future stone formation. 

“A big surgeon is recognised by the big cut. Consider me a small surgeon and give me a good endoscope”.
An extract from a speech by one of modern laparoscopic surgery pioneers.

Kidney stone disease: treatment in men and women

Modern concept of kidney stone disease treatment assumes the use of endoscopic surgery in most cases thus avoiding the cuts as well as pain and long post-operative recovery period. In the vast majority of cases total time of patient admission is no longer than 3-4 days after which they can resume normal activities. One can safely say that the times when a huge incision and a week stay in hospital were required in order to remove a kidney stone are long gone.  The shelves showcasing huge kidney stones are also gone. Now the stones broken down using a laser or ultrasound waves and the urologist has nothing but a handful of sand a keepsake if they are lucky. 
Unfortunately, remote lithotripsy using ultrasound waves is not indicated in 100% of cases but is the method of choice in many cases and is widely used by us.

Modern technology also allows us to perform chemical analysis of the stone (or rather the handful of sand that is left for the urologist) and based on the information obtained we can then work out a specific diet and lifetime changes for every patient which will help them avoid further kidney stone formation in the future.

Therein lies the correct way of treating the patients with kidney stones: first – the removal of the stone and second – prevention of secondary stone formation of new stones. Otherwise the patient becomes chronically ill and will have to spend time admitted to hospital every six months in order to remove or break up the new kidney stones. 

“…And the words of the Hippocratic Oath are once again relevant “I will not cut for stone, even for patients in whom the disease is manifest”
O. Dilanyan.

Surgical options for Kidney Stone removal. Breaking up the stones using laser, ultrasound and laparoscopic surgery.

Basically, all interventions concerning kidney stones can be described by one word “Lithotripsy” which is when the stone is broken into small particles. The additional word used with this term usually describes the way of surgical access.

Remote lithotripsy of kidney stones

Remote breaking up of the stones uses an ultrasound wave that passes through the stones and breaks it into small pieces which are then passed out of the body naturally. We use this method when we are sure that the pieces will be evacuated from the urinary tract without any problems. 

Ureter lithotripsy

An endoscope is inserted into the kidney via the urinary tract. The surgeon can see the stone on the screen, then places a laser fiber next to the stone and breaks it into dust. There are no incisions, risk of bleeding or any other risks that are usually associated with “big surgery”, such as ugly scars and pain.
 

Laser lithotripsy

We use this method in the presence of multiple kidney stones. Fiberscope allows us to break down with a help of a laser and remove all of the stones from the minor calyx and renal pelvis via the urinary tract.   Fiberscopes are also used for breaking down coral shaped kidney stones.  

Percutaneous lithotripsy of kidney stones

The point of this procedure is to insert the endoscope through a 5mm puncture, breaking down the kidney stones with the help of a laser and removal of the fragments. The advantages of this procedure are minimal trauma. The absence of an incision lowers the chance of complications such as pain, ugly scarring, risk of inflammation and longer recovery period. 

Mini percutaneous lithotripsy

This newest method is successfully used in most European clinics. The main difference compared to the standard percutaneous lithotripsy is a smaller puncture which is no larger than 2mm and this allows to insert the endoscope and break down the stones using a laser. The majority of patients are discharged on the following day and go back to work a day later without any discomfort. 

Laparoscopic lithotomy

Sometimes a developmental anomaly of the urinary system or a urethral stricture can cause the stones to form. In this case immediate removal of the stone and anomaly or stricture correction is required. Unlike most clinics we do not offer open surgery for these cases but offer to remove the stones laparoscopically. Today laparoscopy is the acknowledged gold standard for kidney surgery 

Modern laser surgery and use of endoscopic technologies allows us to perform the surgery…without surgery.

...One year after the surgery

— Hello doctor, do you remember me? — My patient is standing in the doorway smiling.
— How could I forget – I frown. Please come in Valeri. 
I really could not possibly forget him. A complicated laparoscopic surgery that lasted nearly 4 hours, surgical removal of narrowed ureteropelvic junction containing an embedded stone.  Yes, I did allow him home 4 days later and yes, he did not have any inflammation or pain but we did have huge doubts that the organ will start functioning again after a break of one year and a half. And here he is, in my office.  
—    Have you had a scintigraphy? Let me see.
Kidney function is almost 40%. Almost 40%! Kidney function deficit is only 10%. It would seem that this is the case when God was on the patient’s and surgeon’s side. 

Information for foreign patients:

If you require kidney stone surgery in Moscow please contact us. We will arrange your hospital admission on the day of your arrival and carry out all necessary tests and perform the surgery as soon as possible. You will be able to return home 3 or 4 days later.

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