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Ureteroscopy |
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 Introduction to the Urinary System |
Do I have to get admitted for the procedure ? |
| How does the Urinary System work ? |
Before the surgery |
| What is a Ureteral Stone ? |
Inside the operating room |
| What are the signs of this problem ? |
About the surgery |
| How can Ureteric Stones be treated ? |
After the procedure |
| Treatment options for ureteral stones |
How can I prevent Ureteral Stones ? |
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| Introduction to the Urinary System |
The organs, tubes, muscles, and nerves that work together to create, store, and carry urine constitute the urinary system. The urinary system consists of two kidneys, two ureters, the bladder, and the urethra. |
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| How does the Urinary System work ? |
You know that the body needs energy to carry out the various functions and this energy comes from the food we take. After your body has taken what it needs from the food, waste products are left behind in the blood and in the bowel.The lungs excrete carbon-di oxide and takes in oxygen,the skin also is responsible for excreting a certain amount of fluid wastes from our body in the form of sweat.So it is not only the urinary system which gets rid of the wastes from the body but the above mentioned systems also help the body to do the same and all these systems work together by co-ordinating with each other. Adults eliminate about one and half litre of urine in a day. The amount depends on many factors, the major ones being the amount of fluid one drinks,and foods a person consumes and how much fluid is lost through sweat and breathing.
The kidneys are bean-shaped organs about the size of your fists. They are near the middle of the back, just below the rib cage.
The kidneys filter the blood flowing through them using tiny filtering units called nephrons. The kidneys on an average filter about 180 litres per day.So you can understand the tremendous pressure on the kidneys in producing urine. From the kidneys, urine travels down two thin tubes called ureters,leading away from each kidney to the urinary bladder. The ureters are about 24 – 30 cm long and the thickness is about 3 mm.The muscles in the walls of the ureter constantly tighten and relax to empty the urine from the kidneys. Small amounts of urine are emptied into the bladder from the ureters about every 10 to 15 seconds.
The urinary bladder is responsible for storing the urine produced and for letting it out at regular intervals. It sits in your pelvis and it stores urine until you are ready to go to the bathroom to empty it. It swells into a round shape when it is full and gets smaller when empty. If the urinary system is healthy, the bladder can hold up to 450 – 500 ml of urine comfortably for 2 to 5 hours.
The nerves in the bladder tell you when it is time to urinate (empty your bladder). As the bladder first fills with urine, you may notice a feeling that you need to urinate.As the bladder fills with more and more urine over a period of time,sensation to urinate becomes stronger. At that point, nerves from the bladder send a message to the brain that the bladder is full,and your urge to empty your bladder intensifies.After the brain has received the signal,it sends back an message to the urinary bladder whether it can let out the urine or not.For example,if you feel like passing urine when you are in a important meeting,you will be able to control your desire to urinate or the urge to pass urine to some degree until it is convenient to pass urine.This is because the brain has given a signal to wait for some time till it is convenient to pass urine.
When it is convenient, the brain signals the muscles of the urinary bladder to tighten which would help to squeeze the urine into the urethra through which the urine is taken out from the body.
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| What is a Ureteral Stone ? |
Urinary stones are gravel like collections of various substances within the urinary tract.Stones nearly always form in the kidney, where they may remain without symptoms and do not require treatment. However, they may cause obstruction or break loose and try to pass with the normal flow of urine through the urinary tract. More commonly, a stone will enlarge or move and cause pain and obstruction.A ureteral stone is a kidney stone that has moved down into the ureter. The stone begins as a tiny grain of undissolved material located where urine collects in the kidney. When the urine flows out of the kidney, this grain of undissolved material is left behind. The material deposited is usually a mineral called calcium oxalate. Other less common materials that may also form a kidney stone are cystine, calcium phosphate, uric acid and struvite. Over time, more undissolved material is deposited and the stone becomes larger. Most stones enter the ureter when they are still small enough to move down into the bladder. From there, they pass out of the body with urination. Some stones, however, have grown larger by the time they leave the kidney. They may become lodged in a narrow part of the ureter, causing pain and possibly blocking the flow of urine. These stones may need to be treated. |
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| What are the signs of this problem ? |
The pain of trying to pass a kidney stone has been described as the most severe pain that a person may experience. It has been described as being worse than child birth.The pain often begins suddenly as the stone moves in the urinary tract causing irritation and blockage.Typically,the person feels a sharp and twisting type of pain in the area of the kidney or in the lower abdomen which may spread to the groin. The pain may be steady or come in waves and may be associated with nausea, vomiting, and blood in the urine. An acute attack is a true medical emergency because of the severe symptoms.
Occasionally, stones do not produce any symptoms. But while they may be "silent," they can be growing, even causing damage to the function of the kidney. If the stone is too large to pass easily, pain continues as the muscles in the wall of the tiny ureter try to squeeze the stone along into the bladder.If the stone is in the lower end of the ureter,at the point where the ureter enters the opening of urinary bladder,one may feel the need to urinate more often or feel a burning sensation during urination. In a man, pain may move down to the tip of the penis. If fever or chills accompany any of these symptoms, then there may be an infection. You should contact your urologist immediately in this case.It has been found out that small stones produce lot of trouble to the patitent.Stones as small as 2 mm have caused many symptoms while those as large as a pea have quietly passed. |
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| How can Ureteric Stones be treated ? |
Treating kidney stone disease depends largely on the size, position and number of stones in your system. Luckily, the majority of small stones of about 5 – 6 mm in diameter that do not cause infection, blockage or symptoms will pass if you simply drink plenty of fluids every day. Consuming about 2 .5 to 3 .5 litre of water increases urine production, which eventually washes kidney or other stones out of the system. Once they have passed, no other treatment is necessary. The doctor usually asks one to save the passed stone(s) for testing. A cup or tea strainer can be used for this purpose. However, recent studies have suggested that the majority of stones (95 percent) that are capable of spontaneous passage will pass within six weeks.
Surgery should be reserved as an option for cases where other approaches have failed or should not be tried. Surgery may be needed if a stone:
- does not pass after a reasonable period of time and causes constant pain
- is too large to pass on its own
- blocks the flow or urine
- causes urinary tract infection
- damages kidney tissue or causes constant bleeding
- has grown larger over the period of time
(It can be found out from follow up X-rays or ultrasound )
Until recently, surgery to remove a stone was very painful and required a lengthy recovery time (four to six weeks). Today, treatment for these stones is greatly improved and many options do not require major surgery.
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Treatment options for ureteral stones |
- Shock wave lithotripsy
- Endoscopic lithotripsy
- Endoscopic removal
- Open surgery
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| Do I have to get admitted for the procedure ? |
After deciding whether you need to get admitted, the doctor will ask you to do some blood tests and urine tests.In addition,you may have to get X-rays and ultrasound examination to see where the stone is present in the urinary tract.If the stone is found to be in the lower portion of your ureter, then you may have to take up Ureteroscopy. You have to get admitted for the procedure as it would help in proper planning of the surgery.It would be better if you bring your relative with you to get the things required for the surgery and to help in other things.The anaesthesia doctor will come and see you regarding the same the day before surgery.Mostly, an X- ray will be taken in the morning of the day of surgery to see if you have passed the stone.If you have passed the stone, then surgery is not required. |
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| Before the surgery |
1. The doctor who is taking care of you will come and see you .He will explain to you about the surgery.If you have any doubts or questions regarding the same,you can communicate your feelings to the doctor without hesitation.
2. As any medical procedure whether minor or major is associated with some amount of risk,you have to sign a consent form ,expressing your consent for the surgery.
3. You will be kept fasting for a few hours before the surgery and all jewels and other sacred threads will be removed.It is very esential that you have to co-operate regarding this aspect as all these things increase the risk of infection. Other foreign items like dentures,contact lenses etc. has to be removed.Your nails will be trimmed too.
4. Your private area will be cleaned and shaved on the day before the surgery and you will be given enema or other drugs which help you to pass motion freely because your bowels have to be empty before the surgery.
5. Depending upon the instructions given by your doctor,the the nurse who is responsible for taking care of you in the ward will give injections to prevent infection and other test injections.
6. If you have any heart problems or hypertension,you may have to get fitness from the cardiologist regarding fitness for surgery.If your sugar levels are not under control,then it has to be brought under control before the surgery.
7. Provided all this is done , you will be made a gown from the hospital.You will also be provided with a cap and special slippers to be worn in the operation theatre.
8. After, this you will be shifted to the operation theatre and the sister in the operation theatre will see if you have all the necessary things for the surgery.
9. Finally,the anaesthesia doctor will make a check if everything is fine and shift you inside the operating room.
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| Inside the operating room |
1. Once you are inside the operating room,you will be made to lie on the surgery table and anaesthesia will be given.Usually,it is given through a injection into the spinal cord.
2. After the anaesthesia has been given, you will be made to lie on your back with your knees raised and apart.
3. The lower part of your body will be undressed and the doctor or the nurse involved in the surgery will wash the area around the urethra with antiseptic solution and will place sterile towels around the area.
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| About the surgery |
Ureteroscopy was developed in the 1970s and came into wide use during the 1980s. Before then, a type of treatment called "blind basketing" was often used. A basket-like device was passed — blindly, with no viewing instrument — through the urethra and bladder and into the ureter to pull out the stone. This type of "blind" treatment risks injury to the ureter and is less effective than other methods used today.
Ureteroscopy is an endosopic procedure i.e there is no need for cutting or removing tissues and hence no scars are left on your body after the procedure.It is done by the introduction of an instrument into your urinary passage through the urethra and urinary baldder into the ureter without an incision.,called the “URETEROSCOPE” .
These instruments allow the doctor to view a ureteral stone directly. They also have small working channels through which various devices can be passed to remove or fragment the stone. Once the stone is identified,it can be removed tollaly or if it is too large to be removed as such,it can be broken down into smaller fragments using appropriate devices and can then be removed.After the stone has been removed,a stent (a synthetic tube which is left in between the kidney and the urinary bladder) is left in the ureter for a few days after the treatment to allow healing. It is possible for the stent to be provided with a nylon suture attached at the distal end which would allow removal of the same without any intervention.The stent can be left inside the system for about 2 weeks to 2 months.It is very important for this stent to be removed because if it is left in the urinary system for a longer time, it can become a stone by itself.A urinary catheter is kept after this through your urinary passage to drain the urine. The majority of ureteroscopic procedures can be performed as day surgery and most individuals can return to work within one to two days following the procedure.
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| After the procedure |
Once the surgery is over, you wll be shifted to the recovery area where you will come out of the anaesthesia and your temperature will be checked for a few minutes.Once you are stable,you will be shifted to the ward.Do not get alarmed by seeing blood in your urine collecting bag after the surgery.As you keep taking water , during the course of the day,it will become normal.Usually,you can have your normal food 3 hours after the surgery.
If a stent has been placed in your system,a check up X- ray will be done to see if it is in proper position.The catheter will be removed on the first or second post operative day and you will be treated on anti-biotics and pain killers after the surgery.If everything is fine and you are comfortable, you can be discharged on the second or third day following Surgery. You will be asked to come for review after 2 weeks to see your progress after surgery.A decision about stent removal can be made at that time.You will also be given medicines which prevent stone formation.
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| How can I prevent Ureteral Stones ? |
1. A good first step for prevention is to drink more liquids — water is the best. If you tend to form stones, you should try to drink enough liquids throughout the day to produce at least two litres of urine in every 24-hour period.
2. People who form calcium stones are usually told to avoid dairy products and other foods with high calcium content. However, recent studies have shown that foods high in calcium, including dairy foods, help prevent calcium stones.
3. If you are at risk for developing stones, your doctor may perform certain blood and urine tests to determine which factors can best be altered to reduce the risk. Some people will need medicines to prevent stones from forming.
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