Dr. Khumukcham Somarendra
M.B.B.S, M.S.(Surgery), M.Ch.(Urology)
Consultant Urologist, Department of Urology, RIMS Imphal.

Urinary tract stones or urolithiasis is a common ailment in our population. The recurrent nature of this condition leads to overall increase in the number of people suffering from this disease. Within one year of a stone episode another 10% of the patients develop another stone ,and 50% of them will have stone recurrence within the next 10 years.

The disease may be manifested as severe pain, blood in urine, whitish turbid urine, burning sensation while passing urine, fever or even kidney failure in a later stage. Sometimes they are silent and found out incidentally during a routine check-up.

Stone formation is multifactorial with both Intrinsic factor and environmental (extrinsic ) factors playing important roles and also the main reason for it being a condition which is difficult to control. Younger age, male sex, anatomical abnormalities and genetic predisposition are important intrinsic factors while hot climate, excess food, high animal protein ,inadequate fluid intake ,limited exercise, high salt intake and low calcium diet are important preventable extrinsic factors.

Urine is a supersaturated solution of various solutes of calcium, oxalate, uric acid crystals etc and its ability to hold more solutes than pure water as a clear solution is by virtue of the body temperature, urine pH and presence of various inhibitors of aggregation e.g. citrate, Mg, glycosaminoglycans, Tamm Horsfall proteins etc. The urine normally shows aggregation of crystals when collected overnight and exposed to the cold atmospheric conditions which the quakes misinterprets the sediments to be due to dissolution of patients stone from their treatment regimen.

Type of stones:

  1. Calcium oxalate stone (60-85%)
  2. Uric acid stone (5-10%)
  3. Struvite (infection) stones (2-20%)
  4. Cystine stones (1%)

Treatment: The armamentarium for management of Urolithiasis has developed rapidly with introduction of technological advances in the recent times. It ranges from a simple watchful waiting to more complicated surgical interventions using different technology & energies as enumerated below:

  • Conservative or watchful waiting: it is meant for asymptomatic small stones which may be passed along the urinary stream sometimes unknowingly. Urinary alkalisers as in case of acidic urine in uric acid stone, pain killers, antibiotics and increasing fluid intake are the mainstay of the conservative approach. It is against the popular belief that any stone can dissolved by medicines.
  • Medical Expulsive Treatment (MET) e.g. some drugs relaxes the urinary smooth muscles and helps in expediting the smaller stone (<6mm size) passage along the narrow tract.
  • Non- invasive e.g. Extracorporeal Shock Wave Lithotripsy (ESWL) or Shockwave lithotripsy or Lithotripsy is an useful technology where stones are broken down using shock pulse wave into smaller fragments and allowed to pass along the urinary stream. It is suitable only for moderately small size (<1.5cm) normal urinary tract anatomy, without infection or bleeding tendency and not during pregnancy.
  • Surgical intervention:
    • Endoscopic procedures like Ureterorenoscopic Lithotripsy (URSL), Retrograde Intrarenal Surgery (RIRS) ,Cystolithotripsy (CLT) ,DJ Stenting etc. URSL is an endoscopic removal of impacted Ureteral stone without any incision
    • Percutaneous nephrolithotomy (PCNL) is a keyhole surgical technique for removal of kidney stone by making a small tract of the size of little finger from the back. It is a very popular technique but still has the risk of bleeding in larger tract sizes.
    • Laparoscopic procedures are gradually replacing open surgery with reduction of significant morbidity in terms of Pain , Hospital stay etc.
    • Open surgery still remain as an unavoidable choice for some complex cases where stone burden and kidney status does not allow the minimally invasive options and where kidney salvage is the priority.
  • Removal of kidney along with the stone in case of renal failure or irreversibly damaged kidney. All the above techniques may be considered individually or in combination to achieve the goal of a stone free status of the kidney.

Dietary Recommendations for Kidney Stone Patients:

  • Dietary Modifications:
    • Foods Recommended:
      1. Fruits and Vegetables provide Magnesium, Potassium, fibre, citric acid that is associated with reduced stone risk e.g. lemon, Pineapple, banana, apples, watermelon, Carrots, etc
      2. Dietary calcium: Low calcium intake is paradoxically associated with an increased risk of stone formation . It is advised to make sure that 1000mg of calcium supplementation per day along with the meal is taken
    • Foods to be restricted
      1. Carbonated drink/high salt and sugar intake. High salt intake induces hypercalciuria leading to stone formation
      2. Restrict high oxalate and uric acid food e.g. dark chocolate, tomato ,Brinjal, pumpkin, Mushroom, cashew nuts, liver,tea, Coffee etc.
      3. limit intake of animal proteins High intake of animal proteins causes increased urinary excretion of calcium,reduced pH,high urinary uric acid and reduced urinary citrate, all of which predispose to stone formation.
  • Fluid Recommendations: Low fluid intake is the single most important risk factor for recurrent stone formers .Thus fluid intake of 2.5 to 3 L/24 hrs is the single most important dietary recommendation for all stone formers . The fluid intake has to be evenly distributed throughout the day to prevent episodic supersaturation of urine leading to stone formation
  • Lifestyle Modifications: Like in many other ailments it is always protective if a person maintains healthy weight and healthy lifestyle principles. Metabolic syndrome is a risk factor where there is association of obesity, Hypertension, Diabetes Mellitus, Hyperuricemia and sedentary lifestyle. Regular exercise , avoidance of substance abuse, healthy diet and fluid intake and Medical check up benefits in the management and preventing Urolithiasis and other health related issues.

Reproduced from “Leeklam – A Biennial publication of Kakching Khunou Educational Forum, June 2019 Vol. III, Issue I”