Stone Disease

Urinary tract stones

Anyone who has passed stones or gravel from the urinary tract knows that this period can be very painful. Until the 1980s, urinary tract stones were a major health problem. Most patients underwent surgical procedures and suffered kidney loss. Technological advances have made this disease no longer a major health problem. Treatment and follow-up of stone disease should be carried out by urologists.

How do stones form in the kidney?

Scientific research to date has provided sufficient information about the chemical and physical structure of stones; however, despite all technological advances, the cause still has not been fully clarified. Kidney stones are caused by an imbalance of the salts and minerals normally present in urine. Stones form when very small crystals formed inside the kidney come together and adhere to one another. For these small crystal particles to form, the substances that make up stones must be present in sufficient amounts in the urine and precipitate. Essentially, a kidney stone results from crystals that precipitate in the urine adhering to and accumulating on the inner surface of the kidney. Normally, there are substances in urine called inhibitors that prevent this crystallization and precipitation. These inhibitors may not be present in sufficient amounts in every person, and this leads to stone formation. Another cause is whether the urine is acidic or basic. If these crystals and sand that form are small enough, they pass without lodging in the urinary tract and without causing any problem. Kidney stones are composed of many substances in terms of their chemical structure. The most common type of stone contains calcium and is a calcium phosphate or calcium oxalate combination. These substances are always found in a person's normal daily diet. In addition, other stone-forming substances are also present (uric acid, cystine and infection stones, etc.). These stones form in the kidney cavities and may remain there and continue to grow, or they may leave the kidney and enter the ureter (urinary duct). There are 3 physiological narrowings in this duct; depending on their size, stones may become lodged at these narrowings or pass into the bladder. 90% of stones smaller than 0.5 cm pass on their own; stones larger than 0.5 cm have difficulty passing through the ureter and being excreted.

Who develops stones?

Kidney stones occur 3 times more often in men than in women. Patients who have a kidney stone have a 50% risk of developing another stone within 5 years. Diet plays an important role in the development of stone disease. It is thought that the worldwide increase in stone disease is due to diets rich in protein and carbohydrates and poor in fiber. People who eat diets rich in animal protein excrete more calcium in their urine than normal, and the amount of citrate in urine decreases, which in turn increases stone formation. The amount of water consumed is important: as the amount increases, the risk of stone formation decreases. Likewise, the foods and beverages consumed have important effects on stone formation; some foods lead to stone formation, while others cause existing stones to grow. There are other important factors that cause stones. The answer to who develops stones and why is quite complex. When many factors come together, certain chemical substances increase in the urine, and especially when urine volume decreases, these substances precipitate and form small crystals. After these crystals form, they quickly combine to form stones. In this regard, the most important factor is the amount of fluid taken in. If people prone to stone formation do not drink enough water (at least 2-3 liters per day), urine volume will decrease, urine will become more concentrated, and the substances in the urine will precipitate, leading to stone formation more easily and frequently. Conversely, in people who take in enough fluid and pass urine, these substances are excreted before they precipitate, and the risk of stone formation decreases. Apart from fluid intake, diet, urinary tract infections, diseases, etc. also play an important role in stone formation.

Other factors;

• Stones in other family members,
• Being between 20 and 40 years of age,
• Stones containing brushite,
• Anatomical abnormalities,
• Hyperparathyroidism, renal tubular acidosis, sarcoidosis,
• Use of diuretic, antacid and thyroid medications, use of calcium and vitamins D and C,
• Having a single kidney,
• Low fiber and high meat consumption,
• Not consuming enough fluids,
• Working in hot or cold places,
• Having a sedentary lifestyle or being bedridden,
• Having undergone ileostomy surgery due to Crohn's disease,

What are the symptoms of stone disease?

• Very severe, colicky pain, especially in the flank area
• Nausea and vomiting accompanying the pain
• Blood in the urine
• Frequently recurring urinary tract infections
• Stone disease in the family
• Abdominal pain, loss of appetite, urinary tract infections in children

The most important symptom of stones located in the kidney is flank pain of varying degrees. The pain is often very severe, stabbing in character. Particularly when stones that pass from the kidney into the ureter advance along this duct, very severe pain that interferes with daily activities can develop. The cause of this type of pain is that stones block the ureter, impede urine flow, and increase pressure inside the kidney. The intensity of the pain may increase and decrease from time to time. Pain usually occurs in the right or left flank area and may spread toward the lower abdomen or groin depending on where the stone(s) are located (ureter, bladder, etc.). In addition to pain, fresh bleeding in the urine is another important symptom, and it is especially significant when it occurs together with pain. Nausea and occasional vomiting may also accompany the pain. Stones are also frequently a cause of infection in the urinary tract.

How is it diagnosed?

Although the patient's complaints guide diagnosis, the most commonly used imaging method today for detecting stones is ultrasonography. This simple and practical procedure, which does not pose any difficulty for patients, can detect most stones in the urinary tract. Sometimes patients' complaints may be abdominal pain, stomach pain or groin pain, and this may be confused with other diseases. When making a differential diagnosis of any abdominal pain, urinary tract stones should be kept in mind. If necessary, an intravenous pyelogram (IVP) can be performed to visualize stones and the urinary tract cavities. In recent years, spiral tomography, which has emerged as another practical, fast and comfortable method, can very easily diagnose all stones. It is also necessary to evaluate patients' crystals, bleeding and infection status in urine by having a urinalysis performed.

What are the treatment methods?
A considerable portion of stones (especially those less than 0.5 cm in diameter) pass spontaneously. The treatment plan varies depending on where the stones are located (kidney, ureter, bladder), their number, or their size. Until recently, open surgery was very commonly performed, but thanks to technological advances, in addition to stone fragmentation, modern closed procedures (without making any incision in the patient's body) have been introduced, making stone treatment easier and no longer a difficult matter for patients. Patients can be hospitalized for a shorter period and quickly return to their daily activities.

Shock wave lithotripsy (ESWL)

ESWL is one of the greatest innovations in medicine. Until the last 25 years, stones of any size were treated with open surgery. The first application began in 1980, and today it has established itself as the easiest and least invasive method used in stone treatment. It involves breaking the stone by converting sound waves generated from a source outside the body into shock waves and directing them at the stone.

Ureteroscopy

We can divide the ureter (urinary duct), which lies between the kidney and the bladder, into 3 segments. Stones remaining in the upper ureter are usually fragmented by ESWL and rarely require other surgical intervention. In the treatment of middle and especially lower ureteral stones, the fragmentation success of ESWL is low. Almost all stones lodged in these areas can be treated with endoscopic methods. Without making any incision, under general or local anesthesia, the ureter is entered through the bladder with a thin fiberoptic or metal special instrument (ureteroscope) and the location of the stone is determined. Then, if the stone is small, it is captured with a special instrument and removed; or if the stone is large, it is fragmented with shock waves or laser and the pieces are removed.

Percutaneous stone surgery

Before modern methods were introduced, stones located inside the kidneys were removed by open surgery. Thanks to technological advances and modern approaches, today only a very small proportion (1%) of kidney stones are removed by open surgery. For most stones that cannot be treated with shock wave lithotripsy, or that remain after fragmentation with a high stone burden requiring many ESWL sessions, i.e., stones resistant to ESWL, treatment can be performed endoscopically through a single channel entering the kidney, without open surgery (via a closed route). During this procedure, also called surgical treatment of stones by the percutaneous route, the kidney is entered through a small hole made in the skin, and the stones inside the kidney can be seen directly, and their number and size can be clearly evaluated.

Open surgeries:

With the introduction of the modern, practical methods mentioned above that cause very little harm to the patient, today open surgical (through an incision in the body) procedures are required for only a very small proportion (1%) of stones located in the urinary tract. In centers with the technical equipment and experience, such procedures have been almost entirely abandoned. This method is preferred in patients whose stone is very large and fills almost all of the kidney cavities.

What should stone patients do?

• Absolutely drink enough fluid every day (2-3 liters, 10-15 glasses)
• Adjusting diet in cases of frequently recurring stone disease
• Leading a sufficiently active life (regular walks, exercises)
• Ensuring a lifestyle free from stress
• Repeating urine analysis and ultrasonography examination every 6 months
• Examining blood and urine samples to clarify the causes leading to stone formation in the body and starting the necessary treatment
• Taking the necessary precautions to prevent existing stones from growing and cleaning stones using appropriate methods
• Collecting passed stones for analysis and applying to experienced centers dealing with this subject for examination

Holmium Laser Applications: Holmium laser is frequently used in the treatment of urological diseases, especially stone diseases.

Areas of use of the Holmium laser:

• Primarily for the treatment of kidney, ureteral and bladder stones,
• Upper urinary tract (ureteral) strictures,
• Lower urinary tract (urethral) strictures,
• Urinary tract tumors,
• Can be successfully used in the treatment of superficial lesions of the external genital organs

Closed Kidney Stone Surgeries

Particularly for kidney stones larger than 2 cm, a method called PERCUTANEOUS LITHOTRIPSY or PNL is used. In this treatment, the kidney is accessed with a needle; after this tract is dilated to a thickness of a thin finger, the stones are fragmented with special instruments through a tube placed inside it and removed. The patient stays in hospital for 2-3 days and can return to work immediately afterwards. Closed surgeries performed using laser with newly developed, much thinner instruments are called MINI-PNL.