Treatment

Kidney Stones

Extracorporeal Shock Wave Lithotripsy (ESWL)

Extracorporeal shock wave lithotripsy (ESWL) is a minimally invasive technique for the treatment of lithiasis, generally up to 1 cm, in renal and/or proximal ureteral location. This treatment is based on the use of shock waves that pass through the skin avoiding surgical intervention.

The lithotripter available at ROC Clinic has a powerful electromagnetic wave generator -the most widespread worldwide- effective and durable. It has integrated localization and tracking systems that allow it to locate the stone and fragment it effectively. With the latest generation lithotripters, all stones present in the urinary tract can be treated with the patient lying on his back.

Most stones can be effectively treated by this method. However, its main disadvantage is that once the stone is fragmented, it must be eliminated naturally through the urinary tract.

This treatment lasts approximately 60 minutes and requires sedation, and does not require hospitalization. It does not usually require placement of a double J ureteral catheter prior to ESWL.

Ureterorenoscopy

Ureterorenoscopy (URS) is an endoscopic technique that involves the introduction of an instrument through the urethra until it reaches the bladder. Once in the bladder, the ureter (the tube that carries urine from the kidney to the bladder) is ascended to identify the stone in order to fragment it by laser and subsequently extract the fragments.

Currently, Holmium-YAG laser is considered the first choice treatment for ureteral calculi, especially in the middle and distal third. It is one of the most widely used procedures in the management of lithiasis, together with ESWL, since it is resolutive and has few adverse effects.

This procedure requires anesthesia (either general or spinal) and a variable length of hospitalization, usually 24 hours. Usually, after the procedure, it is necessary to place a double J ureteral catheter to avoid the appearance of colic in the immediate postoperative period.

Retrograde Intrarenal Surgery (RIRS)

Retrograde intrarenal surgery (RIRS) is a minimally invasive endoscopic procedure used to treat kidney stones. It allows treatment of stones of varying size inside the kidney using flexible instruments with an integrated high-definition camera and a high-powered light source at the tip.

This technique uses a high precision and high power fragmentation source, such as the Holmium laser, which allows fragmentation to be performed with excellent results.

In addition, in certain cases, suction sheaths are used during the procedure, allowing continuous removal of the fragments resulting from lithotripsy. This improves surgical visibility, reduces surgery time and facilitates a more complete removal of the debris.

RIRS is performed under general anesthesia and requires subsequent admission and discharge within 24 hours. After the procedure, it is necessary to place a double J ureteral catheter to avoid the appearance of colic in the immediate postoperative period.

Percutaneous surgery

Percutaneous nephrolithotomy (PCNL) is a minimally invasive surgical procedure used to remove large or complex kidney stones. The term "percutaneous" means "through the skin". This technique is used in cases of:

• Large stones impossible to expel on their own (more than 2 cm in diameter).
• They cause severe pain or block the flow of urine.
• They are in a location that is difficult to reach with other procedures.
• They have not responded to other treatments, such as shock wave lithotripsy or ureteroscopy.

The procedure is performed under general or spinal anesthesia. A small incision is then made in the back and an image-guided needle (ultrasound or x-ray) is used to create a conduit to the kidney. A nephroscope, a thin instrument with a camera and light, is inserted to locate the stone. Once located, it is fragmented by a laser fiber and the fragments are removed by suctioning or clamping through the nephroscope.

In many cases, an aspiration sheath is used during the procedure to facilitate continuous fragment removal, reduce operative time and improve visibility during the procedure, which contributes to a more efficient and safer extraction.

Placement of a catheter (optional): In some cases, a small catheter may be placed in the kidney to drain urine and prevent fluid accumulation while the incision heals.

Postoperative: After the procedure, a double J ureteral catheter can be placed to drain urine and prevent fluid accumulation while the incision heals, thus avoiding the appearance of cramping in the immediate postoperative period. It is also usually necessary to place a drain that comes out of the kidney (nephrostomy) and requires hospitalization for 48-72 hours to monitor the development of possible complications.

Combined Endoscopic Intrarenal Combined Intrarenal Surgery (ECIRS)

Combined endoscopic intrarenal endoscopic surgery (ECIRS) is a surgical technique that embodies the highest excellence in the endourological treatment of lithiasis, since it involves total mastery of the operating room and requires a large amount of high-tech surgical equipment (lasers, rigid and flexible endoscopes, intelligent operating rooms).

In this endourology technique, a combined antegrade and retrograde approach to the upper urinary tract is fully exploited. The synergistic teamwork of a group of experienced surgeons provides a safe and effective minimally invasive procedure for the treatment of all types of urolithiasis.

Similar to PCNL, in this surgical technique a puncture of the kidney is also performed under ultrasound and X-ray control. An anterograde tract is created and dilated until a tube of variable caliber is placed, through which the stones are fragmented and extracted. On this occasion another surgeon will be added who, simultaneously and retrograde, will reach the renal cavities not accessible by the anterograde trajectory to complete the lithofragmentation.

Today it is the technique of choice, in the hands of experienced surgeons, since it allows the treatment of highly complex lithiasis. Due to its versatility, the patient can be left free of lithiasis.

This treatment is performed under general anesthesia. After the intervention, a double J ureteral catheter is usually placed and, depending on the caliber of the percutaneous access, a nephrostomy. It also requires hospitalization for 48-72 hours.

Morphological analysis of the calculus, life habits and dietary recommendations.

Once the urinary lithiasis has been resolved, and in cases in which debris can be recovered, a morphological analysis of the stone must be performed in a laboratory. This is a test that allows the composition, structure and shape of the stones to be studied once they have been removed from the body. This information is key to identify their metabolic or dietary origin and to try to prevent future recurrences.

When no calculi or lithiasic material is retrieved, the composition of the calculi can be assessed by their radiological characteristics and urinary determinations and the mascroscopic appearance during surgery.

What does morphological analysis provide?

By means of a macroscopic and microscopic visual examination (and, in some cases, complementary techniques such as spectroscopy or X-rays), it is possible to determine: the type of calculus (calcium oxalate, phosphate, uric acid, cystine, etc.), its internal structure (monolayer, multiple layers, nucleus), its possible relationship with metabolic alterations, infections or dietary habits and whether the origin is genetic, dietary or infectious.

Why is morphological analysis of calculus important?

The information obtained allows the urologist to personalize preventive treatment, correct dietary habits or pharmacological treatments, carry out a more effective follow-up and avoid the formation of new stones, which is one of the great challenges in patients with recurrent lithiasis.

• Increase fluid intake.
• Decrease the amount of animal protein and salt.
• Decrease the intake of foods rich in oxalates (rhubarb, beets, okra, spinach, Swiss chard, sweet potatoes, nuts, tea, chocolate, black pepper and soy products).

At ROC Clinic we perform a morphological analysis of the lithiasis and offer a consultation with a nutritionist to identify and correct dietary habits that are favoring the appearance of stones, adapting the diet to the type of stone.