Dec
6
Managing Stone Disease Effective approaches to kidney care
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Kidney stone disease is common in the United States, affecting one in 10 people and accounting for seven to 10 of every 1,000 hospital admissions. The incidence of stone disease is highest in patients between 30 and 45 years of age, while the condition declines in patients over 50. Treatment selection for stone disease depends on many factors, including the size and type of stone and the existence of underlying medical conditions.
Kidney stones are hard deposits of minerals that do not dissolve completely in the urine and grow slowly in the kidneys. Factors contributing to kidney stone formation include high levels of urine calcium, oxalate, or uric acid. Dehydration or low levels of urine magnesium, pyrophosphate, and citrate, in particular, also favor stone formation.
Approximately 85% of kidney stones are caused by urine hypercalciuria and mainly consist of calcium deposits, especially calcium oxalate. Calcium phosphate stones occur in patients with hormonal or metabolic disease, such as renal tubular acidosis or hyperparathyroidism.
Risk Factors
Risk factors for developing kidney stones include inadequate fluid intake, dehydration, reduced urinary flow and volume, and increased levels of calcium, oxalate, uric acid, or other urinary chemicals. Other risk factors are low levels of urinary citrate and conditions that block or reduce urine flow. Medical conditions that increase risk include hyperparathyroidism, gout, hypertension, colitis, renal tubular acidosis, Crohn’s disease, and medullary sponge kidney. Poor diet may also increase the risk.
Performing a Diagnosis
Diagnosis of stone disease is based on medical history, physical examination, and imaging tests. Urine should be tested for hematuria or bacteriuria. Blood tests indicated include creatinine for kidney function, blood urea nitrogen and electrolyte for dehydration, calcium levels for hyperparathyroidism, and a complete blood count for infection.
The noncontrast computed tomography (CT) scan is the most frequently used imaging technique for diagnosing a kidney stone attack. Although a CT scan may miss small kidney stones, it can detect medical conditions with symptoms similar to stone disease. If detected, stones can be imaged with an abdominal x-ray to assess their size, shape, and orientation.
Ultrasound is preferred for patients who are pregnant, but it may not detect small stones. Most kidney stones can be located using intravenous pyelogram (IVP), which requires injection of a contrast agent followed by a series of x-rays. Only patients with normal kidney function can undergo IVP, and there is a small risk for allergic reaction to the dye. The IVP procedure can be lengthy if kidney blockage is severe.
Retrograde pyelogram is the most reliable means of imaging kidney stones but may require anesthesia. This technique is used when other imaging methods are unsuccessful.
Prevention and Treatment
Prevention strategies depend on individual risk factors and the type of stone present. Recommendations may include lifestyle modifications, such as increased fluid intake and dietary changes, as well as treatment of underlying medical conditions. Some patients should limit intake of meat, salt, and foods with high levels of oxalate.
Approximately 85% of kidney stones are small enough to pass during urination, usually within 72 hours of symptom onset. Most stones measure 4 mm or less in diameter, and about half of those measuring 5 mm to 7 mm will pass on their own. The best treatment for these stones is to drink up to two or three quarts of water per day, stay physically active, and wait. Walking is useful for helping stones to pass. Painkillers help with the pain associated with passing a stone.
Urinating through a strainer may be recommended so the stone can be recovered and analyzed. The mineral composition of the kidney stone will dictate treatment and future preventive measures. Medications, such as diuretics, and dietary restrictions, such as reduced calcium, are not generally required but may be prescribed. Stones that are not treatable with more conservative measures may require removal using the minimally invasive surgical procedures offered at Urology Associates of North Texas.
Minimally Invasive Surgical Procedures
Extracorporeal shock wave lithotripsy (ESWL) is the usual way to remove stones measuring up to 1.5 cm, which are located in any part of the urinary system. The patient is partially submerged in a tub of water or placed on a cushion during the procedure. The shock waves are moderately painful, so the procedure is performed with sedatives or anesthesia. The physician uses x-rays to monitor the location and status of the stone as shock waves pound the stone for about one hour. Each shock wave produces a loud noise, so patients must wear earplugs.
In many cases, the stone will begin to crumble after 200 to 400 shock waves. The sand-like particles that remain after treatment are easily passed in the urine. Side effects of ESWL include blood in the urine for a short time after the procedure, minor bruising on the back or abdomen, and discomfort with the passing of the stone fragments. Repeated ESWL treatments may be needed to completely break up some stones. This procedure should not be used to treat pregnant women or to remove struvite stones.
Percutaneous nephrolithotomy is recommended when ESWL is not effective or when the stone is very large. The surgeon inserts a nephroscope through a small incision in the patient’s back and into the back of the kidney. An ultrasonic probe or laser, fed through the nephroscope, is used to break up the stones for extraction. Percutaneous nephrolithotomy is performed under general anesthesia, and patients usually stay in the hospital for one to two days, with an additional recovery time of one to two weeks. Because all stones and fragments are removed through the nephroscope during the procedure, this surgery is recommended for people whose jobs or health conditions require that they be stone free.
Ureteroscopic stone removal is used to break up or remove stones lodged in the lower third of the ureter and is usually performed on an outpatient basis under general or local anesthesia. The surgeon passes a small ureteroscope through the bladder into the ureter to snare the stone. In some cases, the surgeon will shatter the stone using ultrasound, laser, or a technique called electrohydraulic lithotripsy. To relieve swelling and help with healing, the surgeon may place a small stent in the ureter for two to three days.
Parathyroid surgery is indicated when the stone is caused by overactive parathyroid glands. Usually a small benign growth in one of these glands causes it to be overactive, increasing the body’s calcium level. Removing the growth on the parathyroid gland cures the kidney stone problem in these patients.
Nov
26
by Nicole Achs Freeling
When treating her young urology patients for problems like bedwetting and bladder infections, Urology Associates of North Texas pediatric urologist Leslie McQuiston, MD, a top expert in the field, finds it helps to have a mother’s perspective.
“I’m a mom, so I understand how moms worry,” says Dr. McQuiston, who recently gave birth to her second son. “I take care of every little person I meet just like I would my own two boys.”worry,” says Dr. McQuiston, who recently gave birth to her second son. “I take care of every little person I meet just like I would my own two boys.”
Such a quality is placing female urologists like Dr. McQuiston in increasingly high demand. Yet, in this dominantly male field, female urologists “are still few and far between,” says Urology Associates of North Texas urologist Diane West, MD, whose practice centers mostly on adult women and men.
But the numbers appear to be on the rise, driven largely by patient demand. Many people — men, women, and children alike — find women easier to talk to about their most intimate health issues. Of the eight female urologists who are in private practice in the North Texas area, six are on the Urology Associates of North Texas staff.
Marie-Blanche Tchetgen, MD, whose areas of expertise include urinary incontinence and other voiding dysfunctions, as well as female pelvic floor reconstruction, is one of these dedicated physicians. Dr. Tchetgen has practiced at Urology Associates of North Texas since 2002.
Putting Patients at Ease
“People are dealing with a lot of embarrassing problems,” Dr. West says. “You really have to be able to talk to them and make them comfortable.” Women may not want to discuss things like leakage, incontinence, and sexual dysfunction with a male physician. They may also feel uncomfortable getting a pelvic exam from a man.
Male patients, meanwhile, are getting more comfortable with the idea of a female physician. Dr. McQuiston recalls the first year she conducted a prostate screening clinic with another physician, who was male. His line was a lot longer, as many of the men were willing to wait to see him.
“Then the guys coming out of my room would talk to those in line and say, ‘Hey, that wasn’t so bad.’ The next year, my line was the longer one and the guys would say, ‘I’m waiting for her,’” says Dr. McQuiston.
Not Just a Guy’s Problem
Having more women in the field does more than provide greater choices for patients. It is also helping push to the forefront urological health issues, which had not been widely known or discussed in the past.
“Incontinence never used to be discussed (at conferences), and now it’s a major topic,” Dr. West says. “This is now becoming true of urinary tract infections (UTIs) and similar complaints.”
People often think of urology as centered on problems of the prostate and male reproductive system. But this is a largely false perception. There are a number of common urological problems that affect women, and as they gain greater attention, more treatment methods are developed to deal with them.
Women are much more likely than men to get UTIs. Some experts estimate that 43% of women between 14 and 61 years old have had at least one UTI. Serious infections can cause kidney problems and, in pregnant women, premature labor.
Just like men, women are increasingly seeking medical advice for sexual dysfunction. Some of the causes — mainly pelvic pain and discomfort during intercourse — may be due to urological problems. Women have also caught up to men in terms of incidence of kidney stones.
But perhaps the most common problem for which women see a urologist is incontinence. Women make up about 80% of the estimated 13 to 19 million Americans who experience this problem, which can affect people of all ages but is estimated to affect one in six people over 40 years old.
The number of treatment options for addressing this highly curable condition has greatly expanded and includes lifestyle changes, medication, and surgery. But many people never seek medical help.
For some patients, a female physician may make the difference between a highly debilitating medical condition and never seeking treatment.
Balancing Work and Family
Dr. West was the only woman urologist in private practice in the North Texas area when she began. She says her practice flourished almost immediately. “There is a demand, and being a woman was a big benefit when starting.”
But choosing urology was not just good for her professionally. It is also extremely rewarding emotionally.
Dr. West decided to go into urology in medical school when she discovered she enjoyed it more than many other areas of surgical specialty.
“To my surprise, I really enjoyed doing the rotations,” she says. “The urologists were all happy. Urologists are said to be a more laid-back group than many other specialists. That may, in part, be because the work they do generally has positive outcomes,” Dr. West says.
Urology is fairly straightforward in that most of the conditions have known causes. Kidney stones, incontinence, bladder infections, and even most of the cancers urologists see are treatable and curable.
Dr. McQuiston and Dr. West agree that, although most female medical students do not consider urology, it is an excellent field for women.
There are fewer emergencies than in other surgical specialties like general surgery, orthopedics, and neurosurgery, making it easier to keep regular hours and maintain a reasonable balance between work and home life.
“When I’ve worked with female medical students, they’ve often said to me, ‘I never would’ve thought of being a urologist until I met you,’” McQuiston says. Now, perhaps, more of them will.
Women Urologists of UANT
Tracy W. Cannon-Smith, MD
S. Alexis “Alex” Gordon, MD
M. Melanie Haluszka, MD
Leslie McQuiston, MD
Marie-Blanche Tchetgen, MD
Diane C. West, MD