Lithotripsy (ESWL) & Lithotomy (PCNL) Producedures

Kidney stones are primarily an aggregation of crystals development by deposition of different chemicals. An article by Dr. N. Subramanian indicates that this usually happens in patients who are susceptible to stone formation. Kidney stones are amongst the most common emergency conditions in urology occurring more frequently in adults. Affecting around 3-5% of the world population, it is seen more in men. Various inhibitors in the urine ususally prevent the formation of these stones, but in some people, this protective mechanism fails or is overwhelmed by other stone forming chemicals. The most common stone is calcium in combination with oxalates and phosphates. It usually happens in patients who are susceptible to stone formation. Contrary to popular perception, dietary intake of calcium does not increase the risk of stone formation unless there is a family history or conditions like Gout and increased activity of parathyroid gland. In some cases they damage the kidney. The most common symptoms are: pain, urinary infection, fever, blood in urine, urinary frequency and burning.

Diagnosis: An Ultrasound Scan, X-Ray. A CT scan: A most accurate method, Blood and Urine Tests and Stone analysis.
Non-Surgical treatment: Stones that are 4mm or smaller pass through the urine and will not require treatment other than pain relievers.Medicines such as Tamsulosin help in passing the stones through the Ureter. Potassium Citrate helps in reducing recurrences. Those having high uric acid will benefit from Allopurinol.
Surgical treatment: Extra Corporeal Shock Wave Lithotripsy (ESWL) is the non evasive option for breaking kidney stones using shock waves delivered externally with precise mechanisms to focus the energy on the tones without damaging the surrounding structures. This is an OPD procedure and does not need anesthesia or hospitalisation.
Percrutaneous Nethro Lithotomy (PCNL) involves removal of the stones from the kidney through an endoscope introduced via small puncture hole at the back, called keyhole surgery.
Extracorporeal shock wave lithotripsy (ESWL) has replaced percutaneous nephrolithotomy (PCNL) much as the latter replaced open surgery, but a place exists in clinical practice this day for PCNL as well as open procedure and it is important for surgeons and urologists to be familiar with this technique of PCNL. Indications for PCNL. Renal calculi greater than 3 cms in diameter. Stone with composition inappropriate for ESWL.

Complete or partial staghorn calculus. Renal malformations like infundibular stenosis, pelvi - ureteric Junction obstruction. Cystine calculi greater than 1.5 cm. Failure of ESWL. Body habitus unsuitable for ESWL.
An ideal patient for PCNL is one who has two functioning kidneys and 2 cm stone in one of the kidneys with extrarenal pelvis with mild to moderate hydronephrosis. PCNL procedure has advantage of short hospital stay, small stab wound scar and negligible pain in the post operative period. Even today in good centres doing large stone work 10% to 15% require PCNL either by itself or together with ESWL. The patient needs to undergo pre operative workup as required in open operation and urine infection if present to be covered by prior antibiotics, the PCNL procedure is done with help of imaging facility like "C" Arm or fluoroscopy and under general anaesthesia. The kidney and upper ureter can also be entered through a small incision in the back through which a telescope, called a nephroscope is introduced. This operation is called percutaneous nephroscopy. Again, lasers, and grasping instruments can be introduced through these video-nephroscopes to allow for the treatment of large kidney stones or the incision of scar tissue that obstructs the outflow of urine from the kidney.
Laparoscopy is the newest and most sophisticated technique of minimally invasive surgery. This technique uses small cylindrical tubes called trocars to enter the abdominal cavity. The trocars allow entry of a video-telescope, called a laparoscope, to view the entire abdominal cavity and its contents from inside the patient. Accessory small trocars allow the introduction of fine instruments necessary to perform surgery. In laparoscopy several small keyhole incisions (usually 1 to 2 centimeters in size) are used in place of a significantly larger and more painful incision. The patient undergoes a similar operation by laparoscopy as by open incision. The advantages of laparoscopy include less pain, a more rapid recovery, a decreased hospital stay, and a quicker return to normal activities.