What should I do if I have urinary stones? Prof. Xiang He: 5 treatments for different stones

Professor He Xiang, master tutor, chief physician of urology of Zhejiang Provincial People's Hospital, executive deputy director of the Institute of Urology of Hangzhou Medical College, specializes in minimally invasive surgical treatment of urinary stones. He is a member of the Lithotripsy Group of the Urological Surgery Branch of the Chinese Medical Association, the Chairman of the Urology and Andrology Committee of the Zhejiang Rehabilitation Medicine Association, the Vice Chairman of the Urological Stones Committee of the Chinese Health Science and Technology Promotion Association, the Member of the International Urolithiasis Alliance (IAU), the Member of the Chinese Urological Stones Alliance (CUC), the Deputy Leader of the Prostate Group of the Urology Committee of the Chinese Association of Integrative Traditional and Western Medicine, the Member of the Urology Committee of the Association of Maritime Medicine and the Deputy Leader of the Urological Ultrasound Group. Member and Secretary General of the Lithotripsy Group of the Urology Branch of the Chinese Medical Doctor Association, Member of the Standing Committee of the Urological Surgeons Branch of the Zhejiang Medical Doctor Association, Member of the Urology Branch of the Zhejiang Medical Association and Deputy Leader of the Lithotripsy Group, Member of the Urogenital Tumor Committee of the Zhejiang Anti-Cancer Association, Editorial Board Member of the Chinese Journal of Urology, Winner of the "Diamond Cup Award" of the Urology Branch of the Chinese Medical Association.

With the increasing attention to health, the cognitive needs of readers for various diseases are also increasing sharply, but now the science of diseases on the Internet is uneven, and many times ordinary readers are difficult to distinguish between true and false. In order to let everyone hear the most authentic authoritative voice from the clinical frontline, Zhejiang Medical Online specially opened a column of "Zhejiang Medical Experts", inviting top experts from various departments of hospitals in Zhejiang Province to personally write articles for our readers, including disease etiology, comparison of advantages and disadvantages of treatment methods, applicable populations of different treatment methods, disease prevention, etc.

Today, we askEd He Xiang, chief physician of the Department of Urology of Zhejiang Provincial People's Hospital, to talk about urinary system stone diseases.

Urinary stones are a common health problem and refer to stones in the kidneys, bladder, ureters, and urethra. In our country, about 5.8% of adults suffer from urinary tract stones, and the incidence is higher in the south than in the north. Especially in the summer, the human body sweats more, drinks less water, and urinates less, which is the season of high incidence of stones.

There are many factors that affect the formation of stones, including age, sex, race, genetic and environmental factors, eating habits, and specific diseases (such as hyperparathyroidism). Abnormal metabolic status of the body, obstruction of the urinary tract, infections, foreign bodies and the use of drugs are common causes of stone formation.

What are the symptoms of stone disease?

1. The most typical symptom of stone disease is "renal colic". Renal colic is paroxysmal, with unbearable pain, sweating, and sometimes radiating downward to the abdomen, bladder area, and lower back, accompanied by nausea and vomiting. Renal colic is an unforgettable experience for every patient with stones.

2. Urinary tract obstruction / infection. Urinary tract infection or anauria due to stone obstruction is a common emergency in urology. Acute urinary tract obstruction is popularly understood as "urine blockage", and patients have reduced or even no urine output. Stones are also susceptible to complicated urinary tract infections, and patients can have frequent urination and acute dysuria, which can lead to fever, sepsis, and even septic shock in severe cases that are life-threatening. At these times, it is necessary to seek medical attention in time to relieve stone obstruction, which can prevent complications such as urinary sepsis, septic shock, and renal failure.

3. Hematuria. Many stones are not fixed in place, and with the friction of the mucous membrane by the person's exercise, mucosal damage and inflammatory infection will lead to bleeding in the urine, which can be manifested as gross hematuria or microscopic hematuria (positive urine occult blood on urinary tests).

How can I detect stones?

Imaging is the preferred test for the detection of stones, as follows:

1.B ultrasound: ultrasonography is the preferred method for children and pregnant women when suspecting urinary tract stones. Its advantages are simple, economical, non-invasive, can find stones above 2 mm, and at the same time understand the degree of expansion of hydrops in the urinary system. The bladder and prostate can also be observed for triggers and complications of stone formation. However, ultrasound can be affected by the intestine, and the accuracy of examination for the lower and middle ureters and small stones is less accurate.

2. Urinary tract X-ray plain film (KUB): it is commonly understood as "filming", which can find about 90% of X-ray positive stones (some special component stones such as uric acid stones are negative stones, X-ray examination is not visible), can roughly determine the location, form, size and quantity of stones, and the examination is convenient and fast. However, KUB examination cannot determine the hydrops in the urinary tract, which has a greater impact on pregnant women and children, and there are certain limitations.

3. CT sweep: CT examination resolution is high, can find 1mm size of stones, can clearly show the shape and size of stones including negative stones, judge urinary system obstruction, is the preferred examination for patients with renal colic.

4. CT enhancement + three-dimensional reconstruction (CTU examination): CTU combines CT sweep with intravenous urography, which can accurately determine the presence, size, number, location, obstruction and water accumulation of stones, and can reflect the secretion and excretion function of the kidneys. It is the preferred test for patients with large, severely obstructive stones.

Different stones have different treatments

Urinary stones, the most common treatments include extracorporeal shock wave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy lithotripsy. The success rate of surgical treatment depends on the experience of the surgeon, the size, location, composition of the stones, and the specifics of the patient.

1. Medication

Stone excretion: The possibility of spontaneous discharge of ureteral stones is related to the size and location of the stones, and most stones with a diameter of less than or equal to 4 mm can be spontaneously discharged. For stones with a diameter of more than 4 mm, the spontaneous discharge rate is gradually reduced, stones with a diameter of more than or equal to 10 mm are unlikely to be spontaneously discharged, and ureteral stones in higher positions are not easy to pass. Α receptor blockers (tamsulosin, etc.) are usually used clinically to relax ureteral smooth muscle and reduce ureteral wall tension to assist in stone removal.

Liths: Stones composed of pure uric acid that can be chemically dissolved by oral medication under the guidance of a physician. Oral fossil dissolving drugs are based on alkaline sodium citrate, potassium bi citrate sodium or sodium bicarbonate to alkalinize urine to achieve the purpose of dissolving uric acid stones. However, drug lysis of stones is often more effective against kidney stones, and there is less urine accumulation in the ureter, so the effect of ureteral stone lysis is poor.

During drug treatment, the patient's renal colic symptoms may recur, and the effect depends on the composition, location, size and other factors of the stone, and the patient needs repeated outpatient follow-up, and the efficacy is not accurate.

2. Extracorporeal Shock Wave Gravel (ESWL)

Extracorporeal lithotripsy utilizes high-energy shock waves generated by discharges that are conducted through water and can be directly focused on kidney/ureteral stones with the assistance of fluoroscopy. Soft kidney tissue changes in tissue density compared to hard stones so that energy is released on the surface of the stone, thus crushing the stone. This method requires no surgery, is convenient and fast, and can be done on an outpatient basis, which is favored by many stone patients.

Extracorporeal lithotripsy is suitable for smaller kidney stones, but the efficacy is not accurate, affected by many factors, such as the patient's body shape, the composition of the stone, the ureteral stone drainage conditions, etc. Larger stones even require multiple in vitro lithotripsy to achieve the desired effect.

Patients with post-lithotripsy in vitro may have recurrent symptoms of low back pain. Some patients have thin ureters, and small gravel cannot be discharged together, just like "thousands of horses crossing a single wooden bridge", completely blocking the ureteral path, at this time urgent surgery is needed to relieve the obstruction.

There are also many "contraindications" to in vitro lithotripsy, such as renal insufficiency, urinary tract infections, coagulation dysfunction, pregnant women, serious cardiovascular and cerebrovascular diseases and diabetes, skeletal deformities, and severe obesity.

In short, extracorporeal lithotripsy is a "double-edged sword", the majority of patients must be under the guidance of professional urologists for extracorporeal lithotripsy, after the lithotripsy should pay attention to observation and follow-up, timely treatment of complications.

3. Ureteral (soft) microscopic surgery

Ureteral (soft) microscopic surgery is the most common surgical method in stone surgery, and it is also a "minimally invasive surgery" in the popular sense, the operation is carried out entirely in the cavity, and the damage to the surrounding organs is small. Surgery to crush or remove stones by tools such as holmium laser under endoscopic direct vision is more effective than that of in vitro lithotripsy, and is suitable for the treatment of ureteral stones and kidney stones.

Ureteroscopic surgery is generally indicated for the surgical treatment of stones in the middle and lower ureters. Ureteral soft mirrors are surgical instruments that can be bent and are suitable for the treatment of high stones. For kidney stones under 2 cm, various ureteral stones, and stones after extracorporeal shock treatment, ureteral (soft) microscopic surgery is recommended.

The advantages of ureteral (soft) surgery are that the efficacy is accurate, the stone clearance rate is high, the number of surgeries is small, and the vast majority of patients only need one treatment to obtain a high stone clearance rate. The disadvantage is that it needs to be performed under anesthesia and is invasive, with a risk of surgical complications.

4. Percutaneous nephrooscopic surgery

Percutaneous nephrooscopic surgery is popularly understood as "hole in the waist", which is a high-tech, high-skilled, high-risk minimally invasive surgical method, and the operation has high requirements for the operator and surgical instruments. For kidney stones larger than 2 cm, percutaneous nephrolitoscopic surgery is the preferred method, especially for the surgical treatment of "staghorn" kidney stones, basically replacing the traditional open surgery (open surgery).

Surgery directly into the kidneys, in the waist to establish a channel, the passage is thick and thin, small as a straw, as large as a pen holder, the use of gravel tools include holmium laser, air pressure ballistic gravel, ultrasonic gravel and so on. Compared with ureteroscopy, lithotripsy is more efficient, faster, and has a higher rate of stone clearance, but there is a corresponding risk of peripheral organ damage and a higher risk of bleeding, and the postoperative recovery time is longer.

5. Laparoscopic/open surgery

Laparoscopic or open surgery may be considered if some patients have complex stones, contraindications to end-of-chamber surgery (ureteroscopic surgery, percutaneous nephrolitoscopy), or patients who have failed endooperative surgery, and who need to treat both kidney stones and narrowing of the ureteral or renal pelvisal junction. Laparoscopic/open surgery has a relatively long recovery time compared with endoluminal surgery, the possibility of postoperative adhesion stenosis, and the overall safety and reliability are lower than those of endoluminal surgery.

Most people get calcium oxalate stones

China's urinary stones are mainly calcium stones, most of which are calcium oxalate. In addition to common calcium stones, there are uric acid stones, infectious stones, and drug-induced stones.

Many metabolic, anatomical, and dietary factors can precipitate calcium stones, and the prevention of stones should begin with changes in lifestyle habits and dietary modifications, which need to be done:

1. Drink more water, it is recommended to drink 2.5L-3L per day;

2. Control the balance of dietary calcium and oxalic acid;

3. Limit the intake of sodium salts, light diet;

4. Limit excessive intake of animal protein;

5. Weight loss (maintain BMI at 11-18);

6. Increase the intake of fruits and vegetables, coarse grains and dietary fiber;

7. Control the intake of vitamin C (the daily intake of calcium oxalate stones does not exceed 1g);

8. Limit the diet of hyperpurines and eat less offal of animals.