Urinary Tract and Kidney Stone Surgery

Urinary tract stones (urinary tract stones) are one of the most common urological diseases in our country. Stones in the kidney, renal pelvis, ureter, bladder and urethra are generally known as urinary tract stones. It is a benign (non-cancerous) disease of the urinary system. It occurs in both men and women. It is mostly seen in men. Urinary system stones are seen in the bladder, ureter, renal pelvis, kidney and very rarely in the urethra.

Depending on the location of the stones, their treatment also varies. In the past, most of the stone surgeries were done open, today, thanks to the advancement of technology, stone surgeries are mostly performed with closed methods. Endoscopic kidney surgeries are called endoscopic surgeries and laser is commonly used in these surgeries. We also perform stone surgeries endoscopically and with laser.

In this article, I will talk about endoscopic surgeries of urinary system stones by taking advantage of our own experiences.

Preparation before kidney stone (urinary system stone) surgery

Patients who have urinary system stones and require surgery go through a general evaluation before surgery. If there is an obstacle to the operation, these are corrected and the operation is planned under appropriate conditions. We evaluate the patients we are going to have surgery by doing the following tests beforehand;

• Patients taking blood thinners (aspirin) stop them one week in advance.
• Preoperative general blood tests are taken from the patients.
• Chest X-ray and EKG are taken
• Cardiology consultation is requested if you are elderly and have heart disease.
• Medicines related to other diseases that have been used before can be used as a result of the doctor’s evaluation.
• If the patient has a urinary tract infection, it should be treated before surgery.
• Patients who do not have a disability for surgery do not eat or drink for 5-6 hours before surgery.
• Informed consent form is read to the hospitalized patients and their signatures are taken.

What is the type of anesthesia, the duration of the operation, and the length of stay in the hospital?

Anesthesia varies according to the location of the stone. If there are ureter, renal pelvis and kidney stones, general anesthesia is applied. General or spinal anesthesia is used for urethra and bladder stone surgery. The duration of the operation varies according to the location, size and hardness of the stone. Small and non-hard stones break in a shorter time. Large and hard stones take a little longer to break. The duration of the operation can vary from 1 hour to 3-4 hours on average. The length of hospital stay of the patients is related to the course of the surgery. We usually keep the patients in the hospital for one day and discharge them. If there is kidney stone and bleeding, patients stay in the hospital for a few more days.

What are the advantages of endoscopic laser stone surgery?

Laser endoscopic urinary system stone treatment has many advantages over open surgery. These advantages are:

• Shorter hospital stay
• There are no surgical incisions and scars.
• Bleeding is less
• Lower risk of infection
• Return to normal life is faster
• Healing is faster
• Complications are less

Open kidney, ureter and bladder stone surgery

Although open surgery for urinary system stones was performed much more frequently in the past, it is performed extremely rarely today. We also rarely perform open surgeries. We perform our operations with laser and closed method. Open surgeries are more severe surgeries for patients than endoscopic surgeries. Wound healing and prolonged hospitalization are disadvantages of open surgery.

Percutaneous nephrolithotomy surgery

Percutaneous nephrolithotomy or nephrolithotripsy surgery is one of the kidney stone surgeries. Here, an incision of about 1 cm from the skin is made on the back. With special tools, the kidney is entered and the stone is reached. The stones are crushed by laser and taken out. In this method, an x-ray device is used to see the stone. This surgery is called PNL surgery for short. PNL is now used to a lesser extent. Instead, flexible URS is used. Bleeding may occur at the entrance to the kidney with the PNL method, it is necessary to be more careful. After the stones are surgically removed, a catheter is inserted through the skin incision into the kidney and withdrawn in 1-2 days depending on the postoperative situation.

Endoscopic bladder stone surgery

Bladder stones are usually the result of a blockage in the urinary tract after the bladder. It is mostly due to prostate enlargement in older men. Sometimes it can be seen in the form of stones formed in the kidney and ureter falling into the bladder. We mostly make bladder stones with the closed laser method. If it is a result of BPH (benign prostate enlargement), both prostate and stone are operated endoscopically in the same session.

We perform both prostate surgery and stone surgery with the HOLEP method to these patients at the same time. Sometimes, if the stones are very large, they can be removed with open surgery with a small incision.

Endoscopic kidney stone surgery

With this method, the inner parts of the kidney are reached with an instrument called a flexible ureterorenoscope (flexible URS) from the urinary tract without any carcasses in the body. After the location of the stone is determined, it is divided into very small pieces by laser and the stone falls. Small and soft stones break much more easily and in a short time. Big and hard stones take longer time. The average operation time varies between 1-3 hours, depending on the type and size of the stone. If the stone is large and the operation has taken a long time, a double J (D J) catheter is placed in the ureter and can be removed after 1-4 weeks.

Renal pelvis stone surgery

The renal pelvis or pelvis renalis is the upper end of the ureter at the exit of the kidney. Since this area is one of the narrowest areas of the ureter, stone formation is common here. Renal pelvis stones are broken with laser in appropriate cases. We also use the flexible URS method for our patients.

Endoscopic ureteral stone surgery (URS)

The ureter has three anatomical sites of stenosis. These; where the ureter meets the renal pelvis (ureteropelvic region, UPJ), where the ureter crosses the iliac vessels, and where the ureter enters the bladder. Ureteral stones usually form in these narrow areas. Most of the ureteral stones are made by endoscopic method. If the stone is in the lower part of the ureter, rigid URS can also be used. For stones in the upper parts, we generally prefer to break stones with flexible URS. After the stone is seen, it is broken by laser and then excreted in the urine. There is no need to put a ureteral D-J catheter in small stones. The operation is completed in 30-60 minutes.

What are the complications of stone surgery?

In the past, complications were more because stone surgeries were mostly performed with open method. Nowadays, these complications are less common since stone surgeries are mostly performed endoscopically. Complications of endoscopic stone surgeries are as follows;

• Bleeding
• Infection
• Obstruction of the urinary tract
• Injury of urethra, bladder, ureter and kidney
• Urethral stricture (in the late period)
• Ureteral stenosis (in late periods)
• Neighboring organ injury (intestinal and vessel, liver, spleen injuries can be seen, albeit rarely, during PNL surgeries)

Is a double J catheter inserted in patients after stone surgery?

Ureteral catheter is inserted in some patients after stone surgery. This is called a double J catheter or a ureteral catheter. One end of this catheter is in the kidney and the other end is in the bladder. The purpose of inserting a catheter is to prevent postoperative blood clots or small stone fragments from blocking the ureter or injuring the ureteral wall. The catheter remains for varying times depending on the condition of the surgery. It is usually withdrawn in 2-4 weeks. These catheters do not have any side effects.

Will there be bleeding from the urine after urinary system stone surgery?

It is normal to have light bleeding from the urine and dark urine in the early stages after urinary system stone surgeries. In cases of excessive bleeding, patients should definitely call their doctor. We advise our patients to drink plenty of water against bleeding, not to use blood thinners, and not to do excessive sports. Patients with high blood pressure should be more careful in this regard. Patients with high blood pressure have a higher risk of bleeding. If patients are taking blood pressure medication, they should use them regularly.

Is there any erection problem after stone surgery?

There is no erection problem (hardening problem) as a result of stone surgeries. Although there are erection problems due to surgical pain and stress in the early postoperative period, these are temporary. The operation does not have a negative effect on the direct erection mechanism. Patients can have intercourse a few days after the operation if there is no pain. Having a D-J catheter is not an obstacle to sexual intercourse.

What should be considered after kidney stone surgery?

There are some issues that patients should pay attention to after stone surgery. Things to do especially in the early postoperative period;

• If there is no problem after the surgery, the patients are taken to their rooms after they wake up.
• They do not eat or drink orally for 4-5 hours, they are fed only intravenously.
• Painkillers for pain and antibiotics against infection are started.
• After 5 hours, patients take water and soft foods by mouth
• They start walking slowly for 5-6 hours
• It is not appropriate to do heavy sports or lift too much weight for 4-6 weeks after discharge.
• It is appropriate for them to drink plenty of water after the surgery (2-3 liters per day).
• Blood thinners such as aspirin should not be used.

When should a doctor be called after surgery?

Complications of endoscopic surgeries are extremely rare. If patients follow the recommendations after discharge, a serious problem is usually not seen. Although rare, there may be some conditions that the doctor should see. Post-operative patients should definitely call their doctor in the following cases;

• If there is very severe pain
• If high fever, nausea and vomiting occur
• If there is serious bleeding in the urine
• If there is an inability to urinate
• Bleeding from the surgical site (open surgery, after PNL)

In summary; Urinary system stone surgeries are performed using endoscopic and laser technologies today. We have been performing our surgeries with this method for a long time. Open stone surgeries are extremely rare. Complications after laser stone surgery are very few. Patients return to their daily lives earlier.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY

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