ENDOUROLOGY

        This is an endoscopic urological procedure done for any disease involving urinary tract. There are lot of kidney and kidney related diseases which can be treated with endourology. The common disease affecting the urinary tract which requires endoscopic management is stone disease. The urinary stones can affect kidney, ureter, urinary bladder and urethra. There are various reasons for stone formation. The common causes are genetic, diet, decreased water intake, hypercalcemia and metabolic changes.

        The stones can present in the kidney and in case of small stones there may not be any symptoms. But the presence of large stone can cause pain or may increase the possibility of developing infection. The stones present in the ureter can cause severe pain in case of stone bigger than 4mm in size. The ureteric stone of less than 4mm in size goes with urine spontaneously even without symptoms. But bigger stones may pass off with urine with severe pain. Large stones, usually bigger than 6 mm may not go out with urine and may require Endo surgical management.

SYMPTOMS OF KIDNEY STONES

        1. PAIN WHILE PASSING URINE

        2. BACK PAIN RADIATES TO LOWER AND FRONT PART OF ABDOMEN

        3. PERSISTENT URGE TO URINATE

        4. PINK, BROWN OR RED URINE

        5. NAUSEA AND VOMITING

        6. FEVER WITH CHILLS IN CASE OF INFECTION

          The most common presentation of urinary stone is severe intermittent pain abdomen and pain radiating from “loin to groin” is the classical description of the pain. This pain is usually associated with severe vomiting. This pain is usually associated with burning micturition. Fever can be there in case of infection. Blood in the urine (Haematuria) is another presentation of urinary stones.

          The classical clinical presentation gives suspiciousness to any clinician. The presence of loin to groin pain, vomiting with blood in the urine is almost diagnostic of urinary stone.

INVESTIGATIONS FOR KIDNEY STONES

        1. PLAIN X RAY KUB

        2. ULTRASONOGRAPHY OF ABDOMEN AND KUB

        3. CT ABDOMEN WITH INTRAVENOUS UROGRAPHY

        4. URINE ROUTINE EXAMINATION

        5. URINE CULTURE AND SENSITIVITY

        There are various diagnostic techniques to make a diagnosis of urinary stones. Plain x ray of KUB (Kidney Ureter Bladder) area will give an idea about the urinary stones. About 90% of kidney stones are radio opaque. The presence of radio opaque shadows along the course of the urinary track gives an idea about the presence of stone in the kidney or ureter.              

        Today the screening test for the diagnosis of urinary stone is ultrasonography of KUB area and abdomen. This will give an idea about the presence of stone, site of stone, presence of obstruction and magnitude of obstruction. This has added advantage of identifying any other intra-abdominal pathology like gall stone disease, acute appendicitis, ovarian pathology and any other disease related to pelvic organs. Once the stone disease is confirmed then the next investigation of use will be computerised tomography with intravenous contrast (IVU-INTRA VENOUS UROGRAM). This investigation usually localises the site and size of the stone along with magnitude of proximal obstruction which is very important to decide about the future course of treatment. There are other investigations like MRI of abdomen has added value in the diagnosis and the treatment kidney stones.

        The commonly done blood investigations are blood leukocyte count, blood sugar, blood urea and serum creatinine. Urine culture and sensitivity will be useful in case of associate fever to optimise the antibiotic management. Serum calcium estimation is important to rule out the possibility of hypercalcemia.

 COMPOSITION OF URINARY STONES.

         Approximately 80% of kidney stones are composed of calcium oxalate and calcium phosphate. The other common components are uric acid, struvite and cystine. The common calcium stone is calcium oxalate, is a natural substance present in food having vegetables, fruits, chocolates, liver and nuts. Intestinal bypass procedures and metabolic disorders are also reasons for calcium containing kidney stones. Uric acid stone can occur in individuals not drinking adequate water, people consuming high protein diet and people having gout. Struvite stones are more common with prolonged urinary tract infection. The cystine stones are common in individual who excrete many amino acids which occurs as a hereditary disorder.

CAUSES OF KIDNEY STONES

        Lack of sufficient water intake or dehydration.

        Insufficient urinary drainage

        Foreign bodies in the urinary tract

        Urinary infections

        Metabolic diseases like hyper-parathyroidism and cystinuria.

        Diet with high calcium and oxalates. Also increased vitamin D and decreased vitamin A are the reasons for kidney stone formation 

MANAGEMENT OF URINARY STONES.

        The treatment protocol in the management of urinary stone depends on the site, size and magnitude of obstruction. The presence of stone in the urethra, urinary bladder and ureter are managed by cystoscopy or ureteroscopy techniques. The presence of stone in the kidney is managed by ureteroscopy or combination of ESWL (Extracorporeal Shock Wave Lithotripsy) with ureteroscopy. Another important technique used in treating kidney stone is PCNL (Per cutaneous nephro lithotomy). Infrequently used another minimally invasive technique is laparoscopic uretero-lithotomy or pyelolithotomy. 

CYSTOSCOPY

        Cystoscopy is a procedure that uses a cystoscope to look inside the urethra and urinary bladder. Cystoscope is a long, thin optical instrument with an eyepiece at one end, a rigid or flexible tube in the middle, and small lens or camera and light at the other end of the tube. The rigid scope is an angled scope which is connected to the camera system and passed in to the urinary bladder through urethra. The bladder will be filled fluid which distend the bladder. Then detailed examination of urinary bladder can be done. The presence of stone in any part of urethra and urinary bladder will be seen and can be retrieved using baskets. The larger stones may require crushing instruments like lithotripter.  The lithotripter can be mechanical or LASER. The presence urinary bladder tumour or other abnormalities can be seen and biopsy can be taken from the same area in case of any suspected area of disease.

INDICATIONS FOR CYSTOSCOPY

        1. Frequent urinary tract infections

        2. Blood in the urine (Haematuria)

        3. Urinary retention

        4. Abnormal cells in the urine

        5. Suspected cancer of the urinary bladder

CAN DIAGNOSE

        1. Urinary stones- solid pieces of material in the bladder formed by high concentration of minerals in the urine.

        2. Abnormal tissue, tumour or cancer in the urethra or bladder

        3. Stricture or narrowing of the urethra usually due to enlarged prostate in man or due to scar tissue due to recurrent urinary tract infection.

        4. Other congenital abnormalities ureterocoele or ureteric diverticulum can be seen.

PROCEDURE DONE ARE

        1. Remove the stone from bladder and urethra.

        2. To take biopsy or treat the tumours of the urethra or bladder

        3. To remove stent from the ureter

To perform retrograde pyelography- it is a radiological study of urinary system to know about the urinary flow, urinary obstruction like stone or tumours of urinary system.

COMPLICATIONS OF CYSTOSCOPY

        Mucosal injury to urethral and urinary bladder can happen although rare. Bleeding is another complication related to cystoscopy.

URETEROSCOPY

        This is visualisation of ureter and kidney using long angled scopes similar to cystoscopy. The ureteroscope is long and thinner than cystoscope. The ureteroscope with camera system is passed into the urethra, then advanced into the urinary bladder. After this both ureteric orifices will be identified. The triangle area connecting urethral orifice and both ureteric orifice is known as trigone of urinary bladder. After identifying both ureteric orifices, the required ureteric orifice can be entered under vision. While passing through the ureter, the presence of stones and other abnormalities can be identified. In case of stones present in the ureter can be extracted. If the stones are bigger, then lithotripter can be used to crush the stone. After removing the stone, a stent will be placed across the ureter. Various types of stents are there. The commonly used stent is plastic double pigtail stent which prevents slippage from the ureter.

INDICATIONS FOR URTEROSCOPY

        1. To see and treat the ureteric stone.

        2. To see, remove or take biopsy from the ureteric tumours.

        3. To treat the ureteric block like strictures

COMPLICATIONS OF URETEROSCOPY

        1. Injury to urethra, bladder and ureter.

        2. Ureteric perforation

        3. Bleeding

                   In case of carefully done ureteroscopy the complications are almost nil. 

NEPHROSCOPY

        Nephroscopy is a procedure to examine the inside of kidney and to treat certain conditions of urinary tract. This procedure is done with a small instrument called nephroscope. The thin, tube part of the nephroscope is inserted into the skin through small incision. The nephroscope has channels within it that provide a source of light, a telescope and an irrigation system (Water system to flush the operation site). Apart from visualisation of kidney, the nephroscope uses ultrasound or a laser probe to break apart the target (For examples, kidney stone). Once broken, the pieces are suctioned out through one of the channels of the scope or pulled out through the scope with graspers. Nephroscopy is a less-invasive procedure that reduces the need for traditional open surgery.

        The nephroscopy is mainly used in removing kidney stones. This is called percutaneous nephrolithotomy or PCNL, a small incision is made in the skin and nephroscope is passed and the kidney stone extraction procedure will be performed.

INDICATIONS FOR NEPHROSCOPE.

        To remove kidney stones 

        To treat kidney cyst

        To remove small kidney tumours

        To remove foreign bodies, like retained stent

        To treat pelvi-ureteric junction block

        This procedure is done under anaesthesia usually under general anaesthesia. After anaesthesia, patient will be in head down and lateral position. The operating site will be up. After anaesthesia, under cystoscopic guidance, a catheter will be placed in the ureter and contrast will be injected to study the kidney. Under fluoroscopic guidance a needle will be passed in to the kidney as required. Then this tract will be dilated and a tube (sheath) will be passed into the kidney. This sheath allows the nephroscope to visualise the kidney directly. This nephroscope allows to perform the planned procedure like breaking the kidney stone in pieces and removal (PCNL). At the end of this procedure a ureteric stent will be placed across the ureter to drain the urine so that the hole made in the kidney will close very fast. The stent will be removed two to four weeks after the procedure.

        Usually, a course of antibiotic will be given. Occurrence of fever with chills or presence of blood in the urine are important symptoms to have a consultation with the treating doctor.

        Neproscopy is a simple procedure which avoids traditional surgical procedure. The complications related to this procedure are bleeding, infection, injury to kidney and injury to urinary bladder. 

LAPAROSCOPY AND KIDNEY STONE REMOVAL

        Laparoscopy is a one of the advancements in the field of surgery. Laparoscopic is a minimally invasive technique used to treat abdominal surgical conditions and it requires small incision (Key Hole) to perform the procedure. Most common surgical condition affecting the kidney, ureter and urinary bladder is stone disease. Most of the stone disease can be treated with endourological techniques in which there will not be any incision. The procedures are performed through natural orifice like urethra. But all the stones may not be able to treat through endourology. So other techniques available are PCNL and laparoscopic technique. Both are hybrid techniques in which endourology and procedure along with key holes are used.

        In PCNL, using ureteroscopy and nephroscopy the stones present in the kidney are retrieved. In laparoscopic technique, large stone present in the ureter or pelvis of the kidney can be removed along with ureteroscopy to place a stent across the ureter. The recommended techniques to remove kidney stones are through ureteroscopy, cystoscopy and PCNL. Lithotripter and ESWL are complimentary techniques to break the kidney stones. The laparoscopic technique is used if the kidney stones cannot be removed with above mentioned techniques.

        Laparoscopic surgery can be done trans-peritoneally or retroperitoneally. The commonly done technique is trans-peritoneal approach in which the procedure is done under general anaesthesia. The patient will be in a lateral position in which area of operation will be up. Three to four trocars are used. The position of the stone will be identified before surgery. As per the site of the stone, trocars will be placed and the stone retrieval will be done. The stone removal is commonly from pelvis of the kidney or ureter. The stone will be removed after dissecting the particular area like ureter or pelvis of the kidney. The ureter or pelvis of the kidney will be opened and the stone will be removed. After removing the stone, the opened area will be closed by laparoscopic suturing. The end of the procedure is to leave a stent in the ureter through ureteroscopy. 

        The advantage of the procedure is that open procedures like open uretero-lithotomy or pyelo-lithotomy can be avoided in cases where endoscopic technique is not possible for large stones present in the ureter or pelvis of the kidney.

        The anticipated complications are difficulty in retrieving the stone, bleeding and post operative urine leak. In case of technical difficulty in retrieving the stone, the procedure can be completed by proceeding to open surgery. In case of post operative urine leak, it subsides spontaneously because of the stent in the urinary system.