kidney stone fragments from a 1.1cm stone blasted with laser during a ureteroscopic procedure
Kidney Stone Treatment is not the same for all
Just the other day we had a few kidney stone cases at the hospital. These were causing all sorts of pain, infections and kidney problems in our affected patients. It was time to get them out surgically since they would not budge on their won due to their size. We use different treatment as appropriate per patient. This, even if the stone is in the same spot or of the same size. One of our cases in particular, required us to blast the stone with a laser and remove it in pieces.
What happens at times with the kidney stone
You can always have an expectation on what will happen to the stone and what the next steps will be. We blasted the kidney stone. The stone was broken into several small pieces instead of being pulverized or breaking into just a few. We proceeded to carefully remove each of them. Then we make sure kidney, ureters and bladder are clear of them. We leave some kidney stone fragments to flow out on their own, when appropriate. However at times pieces left alone may cause problems in the future. As in the case of our patient the other day, we removed them to prevent further problems.
We recommend that any person with a potential kidney stone to visit a doctor. If left untreated, a kidney stone could cause more than pain. Some patients may suffer from blocked ureters and/or urinary retention and even severe infections. We can remove many kidney stones. If that is not an option then we’ll use other methods, including laser blasting.
In that note we wish patients all over the best of recoveries. Come back for your follow up visit!
T. Greene, MD
Kidney Stones in 2013
Thirty years later, I came down with yet another kidney stone. Having experienced one back in ‘84 was enough for me to cringe at the possibilities. However nowadays we have more advanced medications like alpha blockers which can help facilitate passage of small stones. We used Toradol for pain, which is non narcotic. In the process of diagnostics, we used a CT scan, which are easier and quicker to perform and do not require IV contrast. CT scans also provide more information to help with the treatment process. Once the stone was found treatment was decided. We had some options. One of which was ESWL (Extra-corporeal Shock Wave Lithotripsy) which was not available back in 84. This procedure is non invasive.
However for my stone, a urethral stone extraction was done. Today’s instruments are more advanced and much smaller. This helped reduce pain and trauma during the procedure. This was carried out at an out patient facility. After the extraction was performed a stent was placed in. This was a more tolerable experience due to the softness and flexibility of today’s Stents. Additionally, the stent was removed in only 3 days.
All in all, treatment for kidney stones has advanced vastly. From medications to instrumentation we have great options to help you with this problem in an efficient and effective manner.
Ms. X is a middle aged woman with two children. Ever since the delivery of her last baby, she developed urinary leakage. It happened when she coughed or had a heavy cold. Over the last three years, she recalls that the leakage got worse. Not only did she have a problem when she had a cold, but she leaked during her workouts, or even if she tripped off the curb or suddenly dashed for the subway. The constant leaks had a great impact in her active lifestyle and self esteem. She begun to wear a pad every day, and sometimes she wore a heavy pad. Ms. X said that she felt a heaviness and pressure in her pelvis, usually by the end of the day.
Her gynecologist recommended that she have a consultation with our office regarding treatment. On examination, she was found to have a dropped bladder, which would account for the heavy feeling in the pelvis. Urine squirted out of her urethra when she was asked to cough during the pelvic examination. Her problems were fairly clear to us by the end of the consultation.
A Urodynamics test at our office was done to determine how we could best help her. Once her problem was better defined we scheduled outpatient surgery. During that session we would correct both the dropped bladder and the urinary incontinence problem. She took off two weeks from work post surgery to allow her to rest and heal.
Since the surgical procedure she feels great with resolution of both of her problems. Ms. X is no longer experiencing leakage during her day to day activities. She now enjoys her workouts and has had no need to wear pads. Her quality of life and self esteem have improved greatly. She indicated in our last visit that she is ready to get out there are start dating. Unfortunately, we can’t help her in that department!
Kidney Stones in 1986
Having experienced kidney stones twice in the past 30 years (see A Kidney Stone, a patient’s perspective) has given me some good insights, which I share with our patients at the New York offices from time to time. There are many aspects involved with diagnosis and treatment of kidney stones. Fortunately, our diagnostic and treatment options have improved significantly. Over time the art and science in treating kidney stones has improved vastly. I say art since not all stones are treated in the same way.
When I suffered my first kidney stone attack in 1984 diagnostic and treatment options were limited. During that episode the pain was unforgettable. It was like nothing I had ever experienced. At the time the mainstay of pain management consisted of narcotics which carry significant side effects. Patients where prescribed Percocet and/or morphine which did dull the pain caused by kidney stones but carried side effects of nausea, dizziness and constipation. The diagnostic options at the time of my first attack consisted of plain x-ray and intravenous pyelography (IVP). IVPs are rarely done today. This type of x ray was time consuming and and required an injection of dye into the bloodstream to locate the stone. X-rays do however deliver significant radiation exposure.
In 1984, I was unable to pass my stone (3-4mm) which was located in my left ureter (tube which transports urine from the kidney to the bladder) and caused intense and constant pain. There was no form of medical therapy at that time. My treatment consisted of a surgical procedure called ureteroscopy and stone extraction. At that time the instruments were large and cumbersome. During this procedure, the doctor inserts the ureteroscope through the urethra, into the bladder and then into the affected ureter. There he uses the instrument to visualize and grasp the stone to remove it. In some cases, the doctor has to break the stone into smaller fragments and remove them one at a time. The smallest pieces are to pass normally during urination. I underwent this procedure which lasted 2-3 hours and I was kept in the hospital for 3 days. The pain from the procedure was severe. After the procedure an ureteral stent was inserted to keep the ureter open and allow urine to flow from the kidney into the bladder. The ureteral stent was kept in place for one week. It left me with significant sympthoms. After it was removed, I slowly returned to my normal day to day activities.
In hindsight, the progress we have made over the last 30 years in treating kidney stones is amazing . Im glad we at New York Urological in Manhattan have access to much advanced methods for treatment today. I’ll be discussing my most recent experience in my next post for comparison of all aspects; from diagnosis through treatment. We know how it feels and understand that prompt and efficient treatment are the key to a better experience.
We just can’t escape the constant chatter regarding the two extremes: screen everyone vs. screen no one. We were recently discussing a blog which likened the dangers of PSA screening to the harm caused by performing prostate biopsies on prisoners in the early 60’s without their consent. These men had terrible consequences: rectal injury, incontinence, impotence etc. as the anatomy of the prostate and its surrounding structures was not well known until the late 80’s. This comparison is extreme and clearly the situation regarding lack of informed consent is completely inappropriate and a whole different problem. As urologists, we first discuss PSA’s potential benefits as well as limitations. While it is true that PSA is not the be all and end all, it most definitely plays an important role in diagnosis and follow-up, as does the DRE (digital rectal exam). While this exam is unlikely to be the highlight of your day it is helpful and we do notice subtle changes over the years as we come to “know you and your prostate”. There are many factors that we take into consideration before recommending biopsy to patients. These include the absolute PSA value when making comparisons across age groups and race; rate of rise (velocity); doubling time; density of PSA when taking into account the size of the gland; free % of PSA; genetic markers; family history and changes in the exam. While true that a high value on one occasion should not automatically prompt a biopsy, if repeatedly elevated more information may often be better. When a cancer is diagnosed, we consider the patient’s co-morbidities and life expectancy before making recommendations regarding: to treat or not to treat and if treatment is recommended, how to treat.
We believe that physicians and patients alike should have all of the information that is safely (and biopsy is still relatively safe when given appropriate antibiotics) and readily available to them in order to make educated decisions. Patients are empowered by more information and it often guides their medical decisions. While we understand that not every high PSA reading requires immediate biopsy and not all biopsy proven cancers require intervention, we do believe that a patient and their doctor have a “right to know” if they are harboring a cancer. Clearly, the hope is that more specific markers will become readily available to determine those patients whose prostate cancer is destined to have a negative effect and therefore those to whom treatment is recommended. There are already complex genetic tests available though not frequently used at present.
Many like to say that “only 3 out of 100 men diagnosed with prostate cancer will die from their disease”, but they fail to mention the potential symptoms. Urinary complaints with possible gross blood in the urine as the disease progresses, bone fractures or SRE’s (skeletal related events), or metastases can precipitate a miserable existence. We have all seen extreme cases where a man may awaken unable to walk due to lower extremity muscle weakness due to spinal cord compression. This often requires emergent surgery. In the “DONT SCREEN PSA” side, many also ignore the fact that there was not one urologist, medical oncologist or radiation oncologist on the US Preventive Services Task Force Panel that came up with the recommendation D status against PSA testing in anyone. How did psychiatrists, pediatricians and nurses end up on the panel? These are independently assigned panels, but they are not comprised of physicians who treat the specific disease processes on which they’re expected to comment. Many are also unaware of proper interpretation of the data. Task forces have been known to be wrong, and if not wrong, sometimes change their opinion based on data outcomes. This is apparent in the recent change of the USPSTFP panel which recommends a yearly low dose CT scan of the chest in smokers who are 55-79 yo and who are high risk. This was defined as having “a 30 pack year smoking history”, meaning they smoked a pack per day for 30 years, or 2 packs per day for 15 years,etc. The National Lung Cancer Society and American Cancer Society generally support this and recommend that “a thorough discussion be held regarding the pros and cons of and serious consideration be given” to annual CT Chest scanning. All involved in these recommendations readily acknowledge the risks of radiation and detection of many false positive lesions. These findings may even lead to further imaging and/or procedures that have their own associated risks. Despite this, CT scans should still be considered as it has become clear over the last eight years that this policy saves lives.
It is also very clear when comparing populations in the pre and post PSA era that screening has saved lives, even when done every second or even fourth year, as shown in numerous studies. This is apparent if one reads and is able to correctly interpret the data of multiple large trials from the USA and Europe which have recently matured and provide compelling evidence. Unfortunately, one of the three largest randomized controlled trials (Goteborg trial) that looked at prostate cancer specific mortality, was excluded from the USPSTF’s consideration. Not only do we know that the risk of mortality is decreased, but one must not ignore the even greater benefit earlier detection has had on decreasing the risk of metastatic disease. Metastatic disease at diagnosis has decreased by 75% in the USA since PSA was introduced. We should not take this for granted.
There is no doubt that PSA testing should be used judiciously and that it is our responsibility as physicians to be aware of the data, understand it and present it to our patients in a clear and concise manner. A list of the pros and cons of any test and/or intervention should be provided. While we definitely need better tests for diagnosis and for assessing the degree of risk the disease may pose to the individual patient, the constant push to eliminate PSA is absurd. There is admittedly “over-diagnosis, under-utilization of active surveillance, and over-treatment”, but this does not eliminate the value of screening.
Many female patients come to us with similar urinary related concerns. Some of these may be affecting you as well. Follow these posts as we address many of these issues. Please note these Q&A are not treatment advise but simplified answers to general issues that affect many women alike. If you or anyone you know has some or any of these symptoms, please call for appointment or visit your preferred doctor. Ladies, don’t your lifestyle be defined by your urinary problems.
Q: Are female incontinence and urinary frequency an inevitable part of aging?
A: Although female incontinence, urinary frequency and urgency are more common in women as they get older, not every woman will leak urine as she ages. If you feel that you are going to the bathroom more often or that you need a pad because of urinary leakage, treatments are available to help manage your bladder.
Q: How can I prevent incontinence and do I have to take medication? Are there holistic treatments for this problem?
A: Urinary incontinence cannot be prevented but it can be managed if the problem is interfering with your quality of life. The first line intention is behavior modification, which includes urinating at fixed interval (for example, every two hours), managing fluid intake based on the availability of a bathroom, and kegel exercises. If these efforts fail to control the leakage, medication is available.
As both a practicing urologist and a kidney stone patient at New York Urological Associates in Manhattan, I can truly sympathize with and have great empathy for our patients who suffer with kidney stones. The old cliché that passing a kidney stone is worse than childbirth is often used to describe the event. However, not having given birth, I won’t attempt to diminish the discomfort of delivering a baby.The pain is serious though.
I developed my first stone approximately 30 years ago at the age of twenty. This was truly an event I will never forget. At that time (1985) I was a college student and an active athlete. I was hit in my side while playing lacrosse and had lingering pain for several days. I was eventually referred to a urologist after blood was discovered in my urine. At that time CT scans were not yet being used for routine evaluation and I underwent an Intravenous Pyelogram (IVP), now that seems like an ancient test. This test involved infusing a contrast agent into a vein and then taking multiple x rays of the kidneys, ureters and bladder. To my and the urologists surprise, I had a small stone stuck in my left ureter. Treatment for small kidney stones at that time was limited to either trying to pass it, albeit painfully or having a “new” procedure called ureteroscopy. In the mid 80’s there was no medical treatment available nor was shock wave treatment developed yet. Since I was unable to pass the stone , I underwent a ureteroscopy and had it successfully removed. Kidney Stone treatment technology has advanced and now many stones can be treated with non- invasive modalities such medical expulsive therapy (i.e Flomax) or with Extracorporeal Shock wave lithotripsy (ESWL). Some stone types such as those that contain Uric Acid can now be dissolved with medical therapy. My stones, however, are calcium oxalate and not amenable to medical dissolution.
Unfortunately I have had recurrences and more recently had to undergo another ureteroscopy, stone extraction, this time requiring a ureteral stent. (A ureteral stent is a thin tube inserted into the ureter to allow passage of urine from the kidney to the bladder while the ureter heals.) Fortunately , the stent is temporary usually removed after several days. Mine was in for 4 days and was not the most enjoyable time. Going through these experiences has allows me to sympathize with our patients at a different level. I can give them first hand information about what to expect during and after the procedure.
In the event that you, a loved one or friend develops a kidney stone, we at New York Urological Associates truly understand the pain and are here to provide you with expert, compassionate, empathetic and efficient care.
Many male patients wonder if there are any treatments for ED (Erectile Dysfunction) in the event that the usual pills do not work for them.
The answer? Yes, there are several other treatment options that are available for men when pills such as Viagra, Levitra and Cialis are not effective. The process starts with an evaluation and examination at our office to assess your problem. Some specialized tests may be required to check the nerves and the blood vessels and blood flow in the penis and these can be done in the office. Using this approach we will determine where the problem lies and what options would work the best to treat it. We have been able to to successfully customize treatment and return 90% of our patients with ED to satisfactory function.