When Would You Need Surgery for Small Ureteric Stones?

When Would You Need Surgery for Small Ureteric Stones? : Ureteric stones can vary in size, with small ureteric stones typically being less than 4 to 6 millimeters (mm) in diameter. While small stones often pass on their own, certain situations may necessitate surgical intervention. This article delves into when surgery is required for small ureteric stones, with a focus on diagnosis and treatment options.

Understanding Ureteric Stones

The most common types of ureteric stones are calcium oxalate, but stones can also be composed of uric acid, cystine, or struvite. Small ureteric stones are those that are typically less than 4 to 6 mm in size.

Causes and Risk Factors

Several factors can contribute to the formation of ureteric stones:

• Dehydration: Inadequate fluid intake can lead to concentrated urine, increasing the risk of stone formation.
• Diet: High intake of oxalate-rich foods, salt, and animal proteins can promote stone development.
• Genetic Predisposition: Family history of kidney stones increases the likelihood of stone formation.
• Medical Conditions: Conditions such as hyperparathyroidism, gout, and urinary tract infections can predispose individuals to stone formation.

Symptoms

Small ureteric stones may remain asymptomatic but can cause a range of symptoms if they move or obstruct urine flow:

• Pain: Sudden, severe pain in the back or side, radiating to the lower abdomen and groin.
• Hematuria: Blood in the urine, making it pink, red, or brown.
• Nausea and Vomiting: Often accompanying severe pain.
• Frequent Urination: Increased urge to urinate or urination in small amounts.
• Dysuria: Painful or difficult urination.
• Fever: Due to associated infection secondary to urinary obstruction.

Diagnosis of Ureteric Stones

Accurate diagnosis is crucial for determining the appropriate treatment for ureteric stones. The diagnostic process involves a combination of clinical evaluation, imaging studies, and laboratory tests.

Clinical Evaluation

The diagnostic process begins with a detailed medical history and physical examination. Physicians will inquire about the onset, duration, and intensity of symptoms, as well as any family history of kidney stones or relevant medical conditions.

Imaging Studies

Imaging is essential to confirm the presence, size, and location of ureteric stones:

• Ultrasound: A non-invasive, first-line imaging modality that can detect stones and assess the kidneys and bladder. However, ureteric stones are difficult to trace specially around mid portion of the ureter by ultrasound alone. In such cases, advanced imaging modality such as CT may be needed.
• Non-Contrast CT Scan: The gold standard for diagnosing ureteric stones, providing detailed images of the stones and urinary tract.
• X-Ray (KUB): An X-ray of the kidneys, ureters, and bladder can reveal radiopaque stones, although it may miss radiolucent stones.
• Intravenous Pyelogram (IVP)/ or CT Urography: An older imaging technique using contrast dye to visualize the urinary tract and detect obstructions.

Laboratory Tests

Laboratory tests help assess the patient’s overall health and identify any underlying conditions:

• Urinalysis: To detect hematuria, crystalluria (crystals in the urine), and signs of infection.
• Urine Culture: To identify any bacterial infection.
• Blood Tests: To evaluate kidney function and whether any systemic infection is present. Also to detect metabolic abnormalities, such as hypercalcemia or elevated uric acid levels.

Treatment of Small Ureteric Stones

Treatment for small ureteric stones aims to relieve symptoms, facilitate stone passage, and prevent complications. While many small stones pass spontaneously, some situations require surgical intervention.

Conservative Management

For small stones, conservative management is often the first approach:

• Hydration: Increasing fluid intake to produce at least 2 to 3 liters of urine per day, which can help flush out the stones.
• Pain Management: Nonsteroidal anti-inflammatory drugs (NSAIDs) or other analgesics to manage pain.
• Alpha Blockers: Medications such as tamsulosin can relax the muscles in the ureter, facilitating stone passage.
• Diuretics: Are used to increase the formation of urine.
• Steroids: Are used to reduce inflammation around stone, facilitating its easy passage.

Indications for Surgery

Surgery may be required for small ureteric stones in the following situations:

1. Persistent Pain

If conservative measures fail to relieve severe pain, surgical intervention may be necessary. Persistent, intolerable pain despite medication warrants consideration for surgical removal.

2. Obstruction

Stones causing significant obstruction of urine flow can lead to hydronephrosis (swelling of the kidney due to urine buildup), impaired kidney function, or recurrent infections. Surgery is indicated to relieve the obstruction and prevent renal damage.

3. Infections like infected Hydronephrosis /Pyonephritis

Infections due to obstructing stones can lead to pus formation in the kidney. Urgent surgical removal of the stones are necessitated to prevent kidney damage.

4. Non-Progressive Stones

Stones that remain in the same position for several weeks or months without signs of passing may require surgical intervention to avoid complications and provide symptom relief.

5. Pregnancy

Pregnant women with ureteric stones pose a special case. If conservative management fails and there is a risk to maternal or fetal health, surgical intervention like URS/ DJ Stenting may be necessary.

Surgical Treatment Options

Several surgical options are available for the treatment of small ureteric stones:

Ureteroscopy (URS)

Ureteroscopy is a minimally invasive procedure where a thin, flexible scope (ureteroscope) is inserted through the urethra and bladder into the ureter. The stone is then visualized and removed or fragmented using laser lithotripsy. URS is highly effective for stones located in the lower and mid-ureter.

Prevention of Ureteric Stones

Preventing ureteric stones involves addressing the underlying risk factors and making lifestyle changes to reduce the likelihood of recurrence:

• Hydration: Drinking plenty of water to produce dilute urine and prevent stone formation.
• Dietary Modifications: Reducing intake of salt, oxalate-rich foods (such as spinach, nuts, and chocolate), and animal proteins. Increasing consumption of citrate-rich foods like lemons and oranges can help prevent stone formation.
• Medications: For patients with recurrent stones, medications such as thiazide diuretics for calcium stones, allopurinol for uric acid stones, and potassium citrate for certain types of stones may be prescribed.
• Regular Monitoring: Patients with a history of ureteric stones should have periodic check-ups to monitor kidney function and assess for any new stone formation (usually 6 monthly sonography is sufficient).

Conclusion

While small ureteric stones often pass spontaneously with conservative management, surgery may be necessary in specific situations such as persistent pain, obstruction, recurrent infections, non-progressive stones, or during pregnancy. Accurate diagnosis through clinical evaluation, imaging studies, and laboratory tests is essential for determining the appropriate treatment approach. Surgical options like ureteroscopy, ESWL, PCNL, and in rare cases, laparoscopic or open surgery, provide effective solutions for removing obstructing stones. Postoperative care and preventive measures are crucial to ensure recovery and reduce the risk of recurrence.

Best Hospital for Treatment of Ureteric Stone and Renal Stones in Jaipur – Institute of Urology, C Scheme

The Institute of Urology stands as a pinnacle of advanced medical care in the heart of Jaipur city, specializing in the treatment of ureteric stones, kidney stones, and a wide array of other urological conditions. Harnessing the power of cutting-edge diagnostic and therapeutic technologies, the institute offers comprehensive solutions ranging from sophisticated imaging techniques to innovative treatments such as laser lithotripsy, percutaneous nephrolithotomy, and ureteroscopy.

Their team of exceptionally skilled urologists Dr. M. Roychowdhury and Dr. Rajan Bansal, utilizes minimally invasive procedures to ensure effective stone removal with minimal discomfort and expedited recovery. By merging state-of-the-art equipment with a patient-focused approach, the Institute of Urology provides unparalleled care, establishing itself as the premier destination for those seeking expert management of kidney stones, ureteric stones, and other urological concerns.

We have also started the facility of online consultation so that you can discuss about your problems in detail with our experts from the comfort of your home. Please remember to keep ready all the investigations that you’ve had done so far so that it is helpful for the specialist to guide you precisely about the next course of action. At Institute of Urology, we strictly abide by the International protocols so that we keep up with the latest and best of what the advancements in the medical field has to offer.

Our doctors can be reached Monday to Saturday during working hours.
Dr. M. Roychowdhury – 9929513468/ 9829013468
Dr. Rajan Bansal – 8601539297

References

1. Preminger, G. M., Tiselius, H. G., Assimos, D. G., Alken, P., Buck, A. C., Gallucci, M., … & Sarica, K. (2007). 2007 guideline for the management of ureteral calculi. European Urology, 52(6), 1610-1631.
2. Türk, C., Petřík, A., Sarica, K., Seitz, C., Skolarikos, A., Straub, M., & Knoll, T. (2016). EAU guidelines on diagnosis and conservative management of urolithiasis. European Urology, 69(3), 468-474.
3. Assimos, D., Krambeck, A., Miller, N. L., Monga, M., Murad, M. H., Nelson, C. P., … & White, J. R. (2016). Surgical management of stones: American Urological Association/Endourological Society Guideline, PART II. Journal of Urology, 196(4), 1161-1169.
4. Scales Jr, C. D., Smith, A. C., Hanley, J. M., & Saigal, C. S. (2012). Prevalence of kidney stones in the United States. European Urology, 62(1), 160-165.
5. Pearle, M. S., Goldfarb, D. S., Assimos, D. G., Curhan, G., Denu-Ciocca, C. J., Matlaga, B. R., … & Preminger, G. M. (2014). Medical management of kidney stones: AUA guideline. Journal of Urology, 192(2), 316-324.