New laser op to clear those painful kidney stones faster
KIDNEY stones are common and can cause excruciating pain. David Calver, 67, a semiretired accountant from Hampshire, underwent a new minimally invasive procedure to treat his, as he tells OONA MASHTA.
EVERY couple of years since 2002 I would have constant bowel pain for one to two days. It was a dull ache, with waves of sharp spasms. Sometimes it was so bad I had to take painkillers and lie on the floor with my legs bent and feet pressed against the wall. I would do this until the shooting pains passed, although the dull ache persisted.
The first time it happened, I went to A&E. I had an ultrasound scan that didn’t reveal anything, and I was discharged after seven days with no diagnosis.
The subsequent two or three times I had the pain over the next 18 months I would go to my GP and be given painkillers, which would ease the pain. After a couple of days, it would go away.
After that I didn’t bother seeing my GP. Though the problem recurred about ten times, lasting a maximum of two days, I just put up with the pain.
But two years ago, when the pain started again, I did go back to my GP. I was 64 then, and was concerned that it could be something life-threatening.
He sent me for a blood test to check my calcium levels, which turned out to be abnormally high.
I was then given a bone density scan and the results indicated I had brittle bones (although they weren’t so bad that I needed treatment at that point). This surprised me, as I wasn’t feeling pain from that.
I was told that one of the four parathyroid glands in my neck, which control blood calcium levels, was malfunctioning and inflamed. It wasn’t clear why.
As a result, too much calcium was being released in my blood instead of diverting to my bones.
As well as my brittle bones, this explained the abdominal pain, as it had caused kidney stones (your blood is filtered by the kidneys). I don’t know why my initial scan hadn’t spotted this.
Most of the time, people can pass microscopic stones in their urine without even knowing, but when the stones are bigger they can get stuck, causing pain. F IRST, I needed to have the faulty parathyroid removed. This was done in June 2016 using a keyhole procedure. My surgeon, Bhaskar Somani, also explained that one stone they could see on the ultrasound was so big — 2cm in diameter — I would need surgery for that, too.
Mr Somani was using a new operation employing a laser to blast the stones from the inside. He said it was better than the standard technique for big stones, using ultrasound to break them up.
The new technique needs a smaller incision, so you’re less likely to bleed, and recovery is faster. This sounded good to me.
The laser surgery, which took an hour-and-a-half under general anaesthetic in July 2016 was fast, painless and left no scar. I had no discomfort directly after surgery and I went home the next day.
Since the treatment, I haven’t had any pain — it’s a real relief.
A test in December 2016 showed that my calcium levels were normal, and I’ve not needed treatment for brittle bones. I am so happy my issues have been resolved.
THE SURGEON
Bhaskar somani is a consultant urological surgeon at University hospital southampton nhs Trust. KIDNEY stones occur when waste products removed from the blood form crystals. Over time, these turn into hard stones that may be too large to pass out naturally.
These can be extremely painful and lead to infections, as waste products are unable to pass through the blockage, causing a build-up of bacteria.
The main cause of kidney stones is dehydration, but the risk also increases in people who have diabetes, high blood pressure or are overweight. As in David’s case, they can also be caused by a faulty parathyroid gland.
Patients who have large kidney stones feel severe pain across the lower abdomen. This usually comes in waves and is sharp at times, but may settle between the episodes. In these cases, people who turn up at A&E suffering from this pain will have a CT scan of their kidneys to detect whether there are any stones.
In people with smaller stones, we use a shockwave treatment called lithotripsy.
This is a non-invasive procedure in which sound waves break up the stones, so the patient can pass the fragments out themselves.
It can, however, be ineffective in many obese people, because the shock waves have farther to go to reach the stone.
For very big stones, we advise keyhole surgery — percutaneous nephrolithotomy (PCNl) — to remove them. This takes two-anda-half to five hours and there is a risk of complications. Five per cent of patients need a blood transfusion as the kidneys have such a rich blood supply. The operation involves inserting a tiny telescope-like device — a nephroscope — through a hole of about 1-1.5 cm in the patient’s back, just below their ribcage, down to the kidney, so we can see the stone on a screen. The stone is then broken up using ultrasound that’s administered via the nephroscope. We remove this but leave a drainage tube in place until the patient is discharged, to help the kidney.
The patient spends two to five days in hospital. It’s an invasive procedure so they will need to be monitored after.
But hospitals are now using the ultra-mini PCNl, an improved, much more minimally invasive form of this procedure which uses a laser to destroy the stone rather than ultrasound. The laser is quicker than ultrasound: the operation lasts from about 90 to 150 minutes instead of up to five hours. There is also no drainage tube because the fragments of stone are broken into much more tiny pieces by the laser.
With the new procedure, there is also less risk of bleeding or the need for a blood transfusion, because it involves a smaller incision — 4.5 mm compared with 10-12 mm — and uses smaller instruments. It means a reduction in post-operative pain, so less pain relief is needed and the hospital stay is only one day.
The procedure itself is essentially similar to the standard one, except we insert a laser to break up the stone. After surgery, I advise my patients to drink plenty of water to help flush the stone fragments out of the body. They will need fewer painkillers, as the laser makes the fragments so tiny that they won’t cause much pain.
A minority of people with very large stones may still need the standard technique, but the smaller, less invasive PCNl can deal with most stones.
Although we advise patients to take it easy for the first few days before resuming work, sport and social activities, people can return to these more quickly than after a normal PCNl.
WHAT ARE THE RISKS?
n THERE is a risk of bleeding with the ultra-mini PCNl, but it is less than the standard technique.
n THE procedure may not be suitable for patients with very large stones (stones that completely fill the kidney).
n OlIVER WISEMAN, a consultant urologist at Cambridge University Hospitals NHS Trust, says: ‘We have been using this technique in suitable patients in Cambridge for more than two years with good results. The theory is that the procedure should lead to less damage to the kidney and a lower risk of blood loss, together making for a shorter hospital stay. ‘However, it is not suitable for very large stones in the kidney as these take longer to break down.’