URSL Surgery in Delhi, India

Ureteroscopic lithotripsy (URSL) is a minimally invasive medical procedure designed to treat kidney stones that are lodged in the ureters. The ureters are narrow, muscular tubes, each about 25-30 centimetres long, that transport urine from the kidneys to the bladder. These tubes are integral to the urinary system, as they propel urine using peristaltic waves, which are rhythmic contractions of the muscles in the ureter walls.

When kidney stones enter the ureters, they can cause severe pain, block urine flow, and lead to potential complications such as urinary tract infections or kidney damage. URSL involves the use of a ureteroscope, a thin, flexible instrument equipped with a camera and tools, to locate and treat these stones without the need for large incisions. This procedure allows for precise visualisation and management of stones, making it an effective solution for alleviating the discomfort and health risks associated with ureteral stones.

When a laser is used to fragment stone during URSL, it is called laser URSL. Due to laser usage there is better fragmentation and lesser migration of calculus.

Kidney stones, also known as renal calculi, are hard deposits made of minerals and salts that form inside your kidneys. These stones develop when the urine becomes concentrated, allowing minerals to crystallise and stick together. Common types of kidney stones include calcium oxalate, uric acid, struvite, and cystine stones.

When these stones move into the ureters, they can cause intense pain and a range of other symptoms. The pain, often referred to as renal colic, can be severe and typically occurs in waves as the stone moves through the narrow ureter. This pain is usually felt in the lower back, side, abdomen, or groyne, depending on the stone's location. Additionally, kidney stones can lead to other symptoms such as:

• Hematuria: Blood in the urine, which can appear pink, red, or brown.
• Nausea and Vomiting: Nausea and Vomiting are common reactions to severe pain.
• Frequent Urination: An increased urge to urinate, often accompanied by discomfort.
• Cloudy or Foul-Smelling Urine: Indicating a possible infection.
• Fever and Chills: If an infection is present.

Kidney stones can vary in size, from as small as a grain of sand to as large as a golf ball. Smaller stones may pass through the urinary tract on their own with sufficient hydration, while larger stones can become lodged in the ureter, leading to blockage and requiring medical intervention such as ureteroscopic lithotripsy (URSL) for removal.

Ureteroscopic lithotripsy (URSL) is typically recommended for individuals with:

Small - to Medium-Sized Stones

• Generally Less Than 2 Centimetres: URSL is most effective for stones that are less than 2 centimetres in size. Larger stones might require different treatment approaches, such as percutaneous nephrolithotomy (PCNL) or a combination of treatments.

Stones Lodged Anywhere Along the Ureter

• Upper Ureter: Stones located in the upper part of the ureter, near the kidney, can be successfully treated with URSL.
• Mid-Ureter: Stones in the middle section of the ureter are also accessible and treatable using this technique.
• Lower Ureter: URSL is particularly effective for stones in the lower part of the ureter, close to the bladder, where other non-invasive treatments might not be as effective.

Stones That Have Not Responded to Other Treatments

• Extracorporeal Shock Wave Lithotripsy (ESWL): URSL is often recommended for stones that have not successfully been fragmented or passed following ESWL. ESWL uses shock waves to break up stones, but if this method fails, URSL offers a direct approach to remove or break up the stones using a ureteroscope.
• Medical Expulsive Therapy (MET): For stones that have not passed with the help of medications aimed at expelling them, URSL is a viable next step.
• Conservative Management: When lifestyle changes, increased fluid intake, and pain management have not resulted in stone passage, URSL becomes a necessary intervention.

Here's a breakdown of what to expect before, during, and after the procedure:

Preparing for URSL

Before a patient undergoes URSL, the doctor will discuss their medical history and perform a physical examination. The patient will also likely undergo some tests such as:

• Imaging tests (X-ray, CT scan, or ultrasound): These will help determine the size, location, and number of stones.
• Blood tests: These will assess the patient's overall health and kidney function.
• Urinalysis: This will check for infection or blood in the urine.

The doctor will also provide specific instructions on how to prepare for the surgery, which may include:

• Medications: The patient may need to stop taking certain medications, such as blood thinners, several days before surgery.
• Diet: The patient may be advised to avoid certain foods or drinks before surgery.
• NPO (nothing by mouth): The patient may be instructed not to eat or drink anything after midnight the night before surgery.

During URSL

URSL is typically performed on an outpatient basis, meaning the patient won't need to stay overnight in the hospital.Here's a general idea of what to expect during the procedure:

• Anaesthesia: The patient is given general or spinal anaesthesia to numb the area and prevent pain.
• The Procedure: A thin, lighted instrument called a ureteroscope is inserted through the urethra (the tube that carries urine out of the body) and bladder, and up into the ureter (the tube that carries urine from the kidney to the bladder).
• Stone Removal: Once the stone is located, the doctor can use a laser to break the stone into smaller pieces or a basket to remove it whole.
• Stent Placement: In some cases, a small tube called a stent may be placed in the ureter to help keep it open while it heals.

Post URSL Care

After URSL, the patient will be monitored in a recovery room until awake and stable. They may experience some discomfort or pain after surgery, which can be managed with medication. Here's what to expect during recovery:

• Diet: The patient should be able to resume their normal diet as soon as they feel comfortable.
• Activity: The patient may be advised to take it easy for a few days after surgery.
• Pain Management: The doctor will prescribe pain medication to help manage any discomfort.
• Follow-up Appointment: The patient will need to schedule a follow-up appointment with their doctor within a week or two after surgery to check on healing and remove the stent (if one was placed).

URSL is a safe and effective procedure for removing kidney stones. By understanding what to expect before, during, and after surgery, patients can help ensure a smooth recovery. Be sure to ask the doctor any questions you may have about URSL.

Compared to traditional surgery, ureteroscopic lithotripsy (URSL) offers several significant advantages:

• Minimally Invasive: URSL is performed using a ureteroscope, a small, flexible instrument that is inserted through the natural urinary tract. This eliminates the need for large incisions, significantly reducing physical trauma to the body.
• Lower Risk of Complications: The minimally invasive nature of URSL leads to a lower risk of complications such as infections, bleeding, and scarring compared to traditional open or laparoscopic surgery.
• Shorter Hospital Stay: : In many cases, URSL can be performed as an outpatient procedure, allowing patients to return home the same day. Even when hospitalisation is required, the stay is typically much shorter than with traditional surgery.
• Reduced Healthcare Costs: Shorter hospital stays not only benefit patients in terms of convenience and comfort but also help reduce overall healthcare costs.
• Faster Recovery: Patients undergoing URSL often experience a faster recovery, enabling them to return to their daily activities and work sooner than those who undergo more invasive surgical procedures.
• Less Postoperative Pain: The procedure usually results in less postoperative pain, reducing the need for strong pain medications and allowing for a smoother recovery process.
• Broad applicability: URSL is highly effective for treating stones located at any point along the ureter, from the upper portion near the kidney to the lower section near the bladder. This versatility makes it a preferred option for many urologists.
• Direct Access and Visualisation: The ureteroscope provides direct access and visualisation of the ureter, allowing for precise identification and treatment of stones regardless of their location. This can lead to higher success rates in stone removal.

Overall, URSL represents a significant advancement in the treatment of ureteral stones, combining effectiveness with patient-centred benefits that enhance the overall treatment experience.

While URSL is generally safe and effective, like any medical procedure, it carries certain risks and potential complications. Understanding these risks is important for making informed decisions about your treatment. Below are the main risks associated with URSL.

• Bleeding: During URSL, manipulation of instruments within the ureter and kidney can occasionally lead to bleeding. This is typically minor and resolves on its own, but in rare cases, it may require additional interventions to control.
• Infection: Infection is another potential risk associated with URSL. Any time instruments are introduced into the urinary tract, there's a small risk of introducing bacteria. Symptoms of infection may include fever, chills, increased pain, or changes in urine colour or odour. Prompt treatment with antibiotics is crucial if an infection occurs.
• Ureteral Injury: The insertion and movement of instruments within the narrow ureter can inadvertently cause injury to the ureteral wall. While urologists take precautions and use imaging techniques to guide their actions, there is still a risk of ureteral injury, which may require further treatment.
• Urinary Tract Obstruction: After URSL, small stone fragments or swelling may temporarily obstruct the ureter, causing symptoms such as pain or difficulty urinating. In some cases, a temporary ureteral stent may be placed to maintain urine flow while the obstruction resolves.
• Residual Stone Fragments: Despite successful stone fragmentation and removal during URSL, tiny residual stone fragments may remain in the urinary tract. These fragments can potentially grow larger over time or serve as sites for recurrent stone formation. Follow-up imaging studies may be recommended to ensure complete stone clearance.
• Allergic Reactions: Allergic reactions to medications used during URSL, such as anaesthesia or contrast dye, are rare but possible. It's important to inform your healthcare provider of any known allergies beforehand to minimise this risk.
• General Anesthesia Risks: If URSL is performed under general anaesthesia, there are inherent risks associated with anaesthesia administration, such as respiratory issues or adverse reactions. Anesthesiologists carefully evaluate each patient's medical history and overall health to tailor anaesthesia and minimise associated risks.

What types of stones can be treated with Ureteroscopic Lithotripsy? 

Ureteroscopic Lithotripsy (URSL) is effective for treating various types of kidney stones, including calcium oxalate stones, uric acid stones, struvite stones, and cystine stones. The procedure is particularly suitable for stones that are located in the ureter, which is the tube connecting the kidney to the bladder.

Is Ureteroscopic Lithotripsy painful? 

Ureteroscopic Lithotripsy is typically performed under anaesthesia, either general or regional, to ensure the patient's comfort and minimise pain during the procedure. Afterward, some patients may experience mild discomfort or soreness, which can usually be managed with pain medication prescribed by the doctor.

How long does Ureteroscopic Lithotripsy take? 

The duration of Ureteroscopic Lithotripsy can vary depending on factors such as the size and number of stones being treated. On average, the procedure typically takes between 30 minutes to 1 hour to complete.

Will I need a stent after Ureteroscopic Lithotripsy? 

In some cases, a temporary ureteral stent may be placed during or after Ureteroscopic Lithotripsy. The stent helps to promote healing of the ureter, maintain urine flow, and reduce the risk of complications such as swelling or blockage. Your urologist will decide if a stent is necessary based on the specific circumstances of your procedure.

What are the alternatives to Ureteroscopic Lithotripsy? 

Alternatives to Ureteroscopic Lithotripsy include Extracorporeal Shock Wave Lithotripsy (ESWL), which uses shock waves to break up kidney stones from outside the body, and percutaneous nephrolithotomy (PCNL), a minimally invasive surgery to remove larger or more complex stones through a small incision in the back.

What should I do if I experience severe pain after Ureteroscopic Lithotripsy? 

If you experience severe pain after Ureteroscopic Lithotripsy, it's important to contact your healthcare provider immediately. Severe pain could indicate complications such as infection, excessive bleeding, or blockage, which require prompt medical attention.

Will I have visible scars after Ureteroscopic Lithotripsy? 

Ureteroscopic Lithotripsy is performed using very small instruments inserted through the natural openings of the body (urethra and bladder), so visible scars are usually minimal or absent. Any small incisions made for stent placement, if necessary, are typically tiny and heal well over time.

Can stones recur after Ureteroscopic Lithotripsy? 

There is a possibility of kidney stones recurring after Ureteroscopic Lithotripsy, especially if underlying conditions that contribute to stone formation are not addressed. Your healthcare provider may recommend dietary and lifestyle changes, as well as medications, to reduce the risk of stone recurrence.

What dietary changes might be recommended after Ureteroscopic Lithotripsy? 

Dietary recommendations after Ureteroscopic Lithotripsy may include increasing fluid intake to promote urine production and reduce stone formation, avoiding excessive intake of foods high in oxalate (such as spinach, chocolate, and nuts), moderating salt intake, and maintaining a balanced diet rich in fruits and vegetables.

Are there any long-term side effects of Ureteroscopic Lithotripsy? 

While Ureteroscopic Lithotripsy is generally safe, potential long-term effects may include a small risk of ureteral stricture (narrowing of the ureter), recurrent urinary tract infections (UTIs), or persistent discomfort related to the presence of a stent. These risks are minimised with proper post-operative care and follow-up.

What are the signs of infection after Ureteroscopic Lithotripsy? 

Signs of infection after Ureteroscopic Lithotripsy may include fever, chills, persistent or worsening pain, foul-smelling urine, or blood in the urine. If you experience any of these symptoms, it's crucial to seek medical attention promptly for evaluation and treatment.

Reviewed By Dr. Juned Shaikh - Consultant- Urology, Kidney Transplant on 22 July 2024.