Introduction:

Lithotripsy is a medical procedure that uses shock waves to break up stones in the kidney, bladder, or ureter. After the procedure of lithottripsy, the tiny pieces of stones pass out of the body of the patient in urine of patient. Extracorporeal shock wave lithotripsy (ESWL) is the most common type of lithotripsy. "Extracorporeal" means outside the body. The patient will wear a medical gown and lie on an exam table on top of a soft, water-filled cushion. Patient will be given a mild sedative or pain medicine before the procedure starts. Antibiotics is also given before the procedure starts to prevent infection.

High-energy shock waves, also called sound waves, will pass through the body until they hit the kidney stones. The patient may feel a tapping sensation when this starts. The waves break the stones into tiny pieces. Often, he or she will be given general anesthesia for the procedure. Patient will be asleep and pain-free. The lithotripsy procedure should take about 45 minutes to 1 hour. A tube may be placed through the bladder or back into the kidney. This tube calld "Double J Stent" will drain urine from kidney until all the small pieces of stone pass out of your body. The tube may be put in place before or after your lithotripsy treatment.

Lithotripsy is used to remove kidney stones that are causing Bleeding, Damage to your kidney, Pain and Urinary tract infections.

Risks of Lithotripsy:

Lithotripsy is usually safe. Ask your doctor about these possible complications.

• Bleeding around kidney, which may need a blood transfusion
• Kidney infection
• Pieces of the stone block urine flow Kidney
• Pieces of stone are left in body
• Ulcers in stomach or small intestine
• Renal failure, Kidneys may not work as well, or they may stop working, after the procedure

Ureteroscopic Lithotripsy (URS):

This is endoscopic treatment of ureter stones using a mini-scope. Under general anaesthesia, the scope is passed via the urethra into the bladder and up the ureter. Using a laser or lithoclast probe, direct contact is made on the stone to break it into smaller pieces. These tiny stone pieces will pass out on their own. Sometimes a wire basket is used to extract the stone pieces. This surgery takes 30 mins on average and can be done as a day case under general anaesthesia. Occasionally, a double-J (DJ) stent may need to be inserted after the procedure if there is any injury to the ureter wall or if there is gross swelling of the kidney caused by the stone. The success rate for stones lodged in the lower ureter is near 100%. For stones lodged at the mid- to upper ureter, there is a chance they may float up into the kidney beyond the reach of the scope. If this happens, then a DJ stent is inserted and the stone then managed by ESWL.

The advantages of this method over ESWL is that even hard stones can be broken and the ureter opening is simultaneously dilated by the scope to facilitate subsequent stone passage. Ureteroscopy (URS) involves the use of small telescopes that are inserted through the bladder and into the opening of the ureter. The telescope allows visualization of stones in the ureter and/or kidney. Depending on the size of the stone and the diameter of the ureter, the stone may be fragmented and/or removed. The most common method of fragmentation is performed using a laser. The laser is passed through a tiny channel in the telescope and used to fragment the stone into smaller pieces. One benefit of this treatment is the ability to directly visualize the fragmentation process. Moreover, stone fragments can be collected for analysis by passing a stone basket through the telescope and capturing the fragments for removal.

The holmium laser is considered the safest, most effective and versatile of all ureteroscopic lithotripsy devices for breaking up stones. It has several advantages over other types of lasers. It can transmit its energy through a flexible fiber, which allows its use in both the ureter and the kidney. It is much less likely to cause damage when used within the ureter, and it has the ability to fragment all stones regardless of their composition. The holmium laser also produces significantly smaller fragments compared with other ureteroscopic devices.

Passage of the ureteroscope may result in swelling of the ureter. Therefore, it may be necessary to temporarily leave a small tube inside the ureter called a stent. The stent travels from the kidney, down the ureter and into the bladder. Occasionally, a thin string attached to the end of the stent will be left exiting the bladder. This will aid future removal of the stent once the swelling subsides. The stent may also assist in the passage of any residual stone fragments. It is not uncommon for some patients to experience some discomfort from the stent. As with ESWL, a minor amount of blood is expected in the urine while the stent is in place. URS is usually performed as an outpatient procedure, requiring use of anesthesia.

URS can be used safely in pregnancy and may be the favored approach in patients with bleeding disorders, on blood thinners or who are morbidly obese. In addition, patients with stones in an abnormally formed kidney may be treated best with URS. URS is considered safe and effective, but, as with any procedure, risks exist. They include perforation of the ureter and formation of scar tissue that narrows the diameter of the ureter. These adverse events are encountered more frequently when a stone is found lodged or embedded in the wall of the ureter. If perforation occurs, an attempt will be made to place a temporary stent within the ureter to allow the area to heal. In the event that a stent cannot be safely placed, a small tube may need to be placed into the kidney to direct urine away from the damaged area. Fortunately, scar tissue formation in the ureter is rare, occurring in less than one percent of cases. However, when it happens, obstruction to the flow of urine may result. Obstruction can cause pain and may damage the kidney if allowed to persist. Additional intervention is often necessary to treat the narrowed area.

Ureteroscopy (URS) involves the use of small telescopes that are inserted through the bladder and into the opening of the ureter. The telescope allows visualization of stones in the ureter and/or kidney. Depending on the size of the stone and the diameter of the ureter, the stone may be fragmented and/or removed. The most common method of fragmentation is performed using a laser. The laser is passed through a tiny channel in the telescope and used to fragment the stone into smaller pieces. One benefit of this treatment is the ability to directly visualize the fragmentation process. Moreover, stone fragments can be collected for analysis by passing a stone basket through the telescope and capturing the fragments for removal.

The holmium laser is considered the safest, most effective and versatile of all ureteroscopic lithotripsy devices for breaking up stones. It has several advantages over other types of lasers. It can transmit its energy through a flexible fiber, which allows its use in both the ureter and the kidney. It is much less likely to cause damage when used within the ureter, and it has the ability to fragment all stones regardless of their composition. The holmium laser also produces significantly smaller fragments compared with other ureteroscopic devices.

Passage of the ureteroscope may result in swelling of the ureter. Therefore, it may be necessary to temporarily leave a small tube inside the ureter called a stent. The stent travels from the kidney, down the ureter and into the bladder. Occasionally, a thin string attached to the end of the stent will be left exiting the bladder. This will aid future removal of the stent once the swelling subsides. The stent may also assist in the passage of any residual stone fragments. It is not uncommon for some patients to experience some discomfort from the stent. As with ESWL, a minor amount of blood is expected in the urine while the stent is in place. URS is usually performed as an outpatient procedure, requiring use of anesthesia.

URS can be used safely in pregnancy and may be the favored approach in patients with bleeding disorders, on blood thinners or who are morbidly obese. In addition, patients with stones in an abnormally formed kidney may be treated best with URS.

Complications:

• Bloody urine which should clear up in a few days.
• Perforation of the ureter, if this happens, urine leak and pain results. A DJ stent will need to be inserted to prevent further urine leak and promote healing of the ureter.
• Stone migration, because pressurized water is used during the endoscopy, this may push the stone up and beyond the reach of the ureteroscope. If this happens, a DJ stent is inserted and alternative method, i.e. ESWL is resorted to.

Conclusion:

It is concluded as URS is considered safe and effective, but, as with any procedure, risks exist. They include perforation of the ureter and formation of scar tissue that narrows the diameter of the ureter. These adverse events are encountered more frequently when a stone is found lodged or embedded in the wall of the ureter. If perforation occurs, an attempt will be made to place a temporary stent within the ureter to allow the area to heal. In the event that a stent cannot be safely placed, a small tube may need to be placed into the kidney to direct urine away from the damaged area. Fortunately, scar tissue formation in the ureter is rare, occurring in less than one percent of cases. However, when it happens, obstruction to the flow of urine may result. Obstruction can cause pain and may damage the kidney if allowed to persist. Additional intervention is often necessary to treat the narrowed area.

World Laparoscopy Hospital, Cyber City, DLF Phase II, Gurugram, NCR Delhi, 122 002, India
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