1) What is the main cause of getting kidney stones?
The main cause of developing kidney stones is “IDIOPATHIC”. The Condition of having Kidney stones is also referred as nephrolithiasis or urolithiasis. The medical terminology for kidney stone is ‘RENAL CALCULUS’. These stones are made up of salts and minerals from our body. Some of the known factors which led to the formation of kidney stones are less water drinking i.e., dehydration, heat exposure, obesity, diabetes, cardiovascular diseases and CKD (chronic kidney disease). Usually, men are more prone for urinary stone disease than women. Also, study has proved that there is higher prevalence of stone disease in hot, arid or dry climates.

2) How do you know if I have kidney stones?
The typical presentation of kidney stones is called as renal colic or ureteric colic. Renal colic means symptom complex arising due to urinary stone in kidney like one sided back pain associated with nausea or vomiting and sometimes haematuria i.e., blood in urine. This symptomatology is so diagnostic of kidney stone that it is called as “triad of renal stone”.

Similarly, there is a term called Ureteric colic, which means the symptom complex arising due to stone in ureteric region. Ureter is the thin or narrow lumen tube which connects kidney to urinary bladder. When the stone gets stuck in the ureter and causes obstruction to the flow of urine, it leads to ureteric colic. Ureteric colic is constellation of one sided back or flank region pain radiating to front side along the site of ureter and coming to groin/ testis/ tip of penis or vagina/ mid-thigh region alongwith nausea and vomiting.

The most common, simplest and radiation free way to know whether one has kidney stone or not is ULTRASOUND or SONOGRAPHY (also known as USG-KUB). Usually, USG is the first and most commonly done investigation for urinary stones or kidney stones. There are few stones smaller stones which can be missed on sonography but the after effects is clearly visible on USG.

CT-SCAN (plain) is the standard recommended investigation of choice for diagnosing urinary stones. It gives lot of information about the stone like size, site, number, density. Also, it will show the status of kidney, ureter, bladder. Even 1mm stone cannot be missed on CT-SCAN, but the drawback is radiation exposure. Hence only when the urologist feels that there is a need for CT scan, it should be done. Otherwise, USG-KUB/ sonography itself provide lot of information.

3) How do you clear out kidney stones?
Treatment of kidney stones depend upon the size of stone, location of the stone, condition of the patient, comorbidities in the patient, after effects of the stone or you can say complication caused due to the stone.
Broadly tiny and smaller stones like less than 5mm stone usually passed out on its own or with the help of medical therapy in whom it is not passing on its own.

Hydration is the chief and most important treatment for urinary stones. Drinking water is the remedy for kidney stones. Adequate fluid intake (2.5-3.5 litres) has been recommended daily to clear out the smaller stones. This also helps in avoiding the formation of the stone into the kidney.
Calcium supplements has been recommended to lower the formation of oxalate stones as it reduces the level of oxalate in urine.

Avoid non-dairy animal protein to reduce uric acid stone formation.
Alkalisation of urine too helps in decreasing formation of urinary stones.
Increase fruits and vegetables in meal to avoid urinary stones.

4) Is a kidney stone serious?
When there is a stone in kidney, it does not obstruct the flow of urine, hence it doesn’t cause any symptoms. This leads to the kidney stone remain undetected. When the kidney stone start obstructing the flow of urine, the symptoms will appear in the form of pain or blood in urine and this usually makes patient to visit urologist or doctor.

Then the set of investigations identify the presence of renal stone. Early diagnosis with early treatment doesn’t lead to serious condition. But sometimes pain is not so severe enough or pain remains absent even in presence of large kidney stone/ staghorn calculus or if mild back pain is ignored, then it leads to some serious complications which may require ICU admission, sepsis, or kidney failure/ renal failure.

To avoid such serious condition, health check-up is advisable with USG/sonography or ultrasound as one of the investigations.

5) What are 5 symptoms of having kidney stones
The typical presentation of kidney stones is called as renal colic or ureteric colic. Renal colic means symptom complex arising due to urinary stone in kidney like one sided back pain associated with nausea or vomiting and sometimes hematuria i.e., blood in urine. This symptomatology is so diagnostic of kidney stone that it is called as “triad of renal stone”.

Similarly, there is a term called Ureteric colic, which means the symptom complex arising due to stone in ureteric region. Ureter is the thin or narrow lumen tube which connects kidney to urinary bladder. When the stone gets stuck in the ureter and causes obstruction to the flow of urine, it leads to ureteric colic. Ureteric colic is constellation of one sided back or flank region pain radiating to front side along the site of ureter and coming to groin/ testis/ tip of penis or vagina/ mid-thigh region alongwith nausea and vomiting.

In case of complication like infection, fornicial rupture; there will be fever with chills, burning during urination, weakness, loss of appetite, etc.

6) What foods causes kidney stones? Or What Drinks causes kidney stones?
The main cause of renal /kidney stones is IDIOPATHIC. But there are few factors which are responsible for the formation of kidney stones and diet constitutes one of the important factors.
► Consumption of sugar-sweetened soda and punch are associated with increased risk of stone formation.
► Intake of Non-dairy animal proteins like meat, fish, poultry, eggs also increase risk of renal stone formation.
► Restriction in calcium rich diet increases kidney stone formation
► Increased consumption of salt results in increased formation of urinary stones
► Oxalate rich diet also increases stone formation, like black tea, cocoa, spinach, mustard greens, pokeweed, Swiss chard, beets, rhubarb, okra, chocolate, nuts, wheat germ, soy crackers, pepper.

7) How can I avoid getting kidney stones?
The factors which lead to increase formation of urinary stones needs to be avoided and it forms the mainstay to avoid getting kidney stones.
Factors which decrease the urinary stone formation are:
· High fluid intake: it has been proved that to avoid urinary stone formation or to wash out urinary stone from the body, the minimum amount of urine produced per day is 2.5 litres. To achieve this urine output, one healthy adult needs to drink atleast 3.5 litres of water per day. So, intake of more fluids lead to decrease stone formation.
· Grape fruit juices is more effective in preventing stone formation followed by lemon and orange juices due to high content of citrus.
· Other juices which may help in decreasing urinary stone formation are lime, cranberry, black currant and even tomato.
· Beverages like coffee, tea, beer and wine prevent stone formation to some extent.
· Diets high in potassium and lower in animal protein may prevent kidney stone formation
· Diets high in fruits and vegetables have been associated with a reduced risk of stone formation.
· Calcium supplementation with meal is the recommended dietary habit associated with a reduced risk of urinary stone formation
· Alkalizer like potassium citrate

8) What is the fastest way to dissolve a kidney stone?
There is no way to dissolve a kidney stone or urinary stones. Small stones in kidney need to be flushed out from the body. There are natural remedies which can help in flushing out the urinary stones or the other method is medical or surgical. The fastest way to get rid of the stone is “SURGERY” but it is needed only in large stones like greater than 5 mm stones. Nowadays urinary stone removal has been achieved without making any cut into the body and as a day care procedure and patient can go to office directly from the urology hospital / centre.

9) How long do kidney stone surgery take?
There are multiple surgeries for kidney stone. Which surgery is best for the kidney stone depends upon the location of the stone, size of the stone, kidney status and comorbidity of the stone. The major factor which decides the type of surgery is patients’ choice. Broadly, there are three procedures done for kidney stone. They are:

ESWL: it stands for extra-corporeal shock wave lithotripsy. This procedure is done for small kidney stones in selected patients. This is OPD based procedure and it takes 30-60 min. Multiple sittings can be required for the same stone.

PCNL: it stands for Per-Cutaneous Nephro-Lithotomy. In this surgery a small hole is made into the kidney, stone was fragmented with laser/ pneumatic lithoclast and removed in pieces. This surgery usually takes 1hr to 2 hrs depending upon the size of the stone and hardness of the stone. There are varieties of PCNL done nowadays.

RIRS: it stands for Retrograde Intra-Renal Surgery. This is the most advanced form of kidney stone surgery. In this, kidney stone was fragmented into powder form also called as dusting. In this surgery, there is absolutely no cut on the body. Stone is broken down from the natural hole or orifices given by God. This surgery takes 1hr to 2hrs as well depending upon the hardness and size of the stone. In few cases, multiple sittings are required.

10) Is kidney stone removal a major surgery?
Kidney stone surgery varies from mild to major surgery depending upon the size of the stone, complication due to the stone, age of the patient, comorbidities of the patient and status of the patient. Usually, PCNL and RIRS surgery are major surgeries in aged patients and in patients with multiple comorbidities and when stone size is greater than 2cm.

11) Is kidney stone surgery removal painful?
Kidney stone surgeries are least painful of most of the surgeries. In fact, if we consider the pain due to stone as 100%, post-surgery the pain will be between 10-25%, it means the pain decreases after the surgery. One of the indications for the surgery is intractable pain. During the surgery, the patient remains in anaesthesia so there won’t be a pain during surgery.

12) What is the best procedure to remove kidney stones?
There are various surgeries/ procedures for removal of kidney stones depending the location of the stone, size of the stone, comorbidities of the patient, age, complication due to stone and kidney position and anatomical orientation. So best procedure differs from patient to patient. Urologist can guide the patient which surgery will be best suitable for him/her after thorough investigation and clinical examination.

But if we consider the scenario, where PCNL and RIRS both are possible options so most likely patient tend to choose RIRS as it doesn’t involve any cut into the body. But its best to discuss with the urologist regarding the pros and cons in that patient for that particular stone.
13) What is RIRS surgery? or What is the meaning of RIRS?
RIRS stands for Retrograde Intra-Renal Surgery. This is the most advanced and modern form of kidney stone surgery. This surgery involves the use of the most modern technique of stone breaking/ fragmentation and it is LASER. Around a decade ago, the best approach to reach kidney stone was making a hole into the kidney and reach it to fragment it as there was no flexible instrument available. But with the introduction of flexible scope or we can say flexible viewing optical instrument, RIRS came into existence. Urine is formed into kidney and then was excreted out of the body after passing through various channels/tunnels/pipe/holes. As this natural passage already exists in body, with the invent of flexible scope, it was possible to reach inside the kidney through these naturally existed passages without making any hole or cut into the body. In this, kidney stone was fragmented into powder form by using LASER (like holmium or thulium). In this surgery, there is absolutely no cut on the body. Stone is broken down from the natural hole or orifices given by God. This surgery takes 1hr to 2hrs depending upon the hardness and size of the stone. In few cases, multiple sittings are required. (PLZ click on the link to see RIRS surgery).

14) What is PCNL and RIRS?
PCNL: PCNL stands for Per-Cutaneous Nephro-Lithotomy. In this surgery a small hole is made into the kidney to reach the kidney stone, stone was fragmented with laser/ pneumatic lithoclast and removed in pieces. This surgery usually takes 1hr to 2 hrs depending upon the size of the stone and hardness of the stone. There are varieties of PCNL done nowadays viz. Prone PCNL or Supine PCNL depending upon position of patient. PCNL depending upon the size of hole viz., standard PCNL, MINI-PCNL, ultra mini PCNL, , micro-PCNL.

The major complication of PCNL is Bleeding/haemorrhage. Other less common complications are infection, sepsis, urinary leak, perinephric collection, AV malformation, pseudoaneurysm, etc.
RIRS: RIRS stands for Retrograde Intra-Renal Surgery. This is the most advanced and modern form of kidney stone surgery. This surgery involves the use of the most modern technique of stone breaking/ fragmentation and it is

LASER : Around a decade ago, the best approach to reach kidney stone was making a hole into the kidney and reach it to fragment it as there was no flexible instrument available. But with the introduction of flexible scope or we can say flexible viewing optical instrument, RIRS came into existence. Urine is formed into kidney and then was excreted out of the body after passing through various channels/tunnels/pipe/holes. As this natural passage already exists in body, with the invent of flexible scope, it was possible to reach inside the kidney through these naturally existed passages without making any hole or cut into the body. In this, kidney stone was fragmented into powder form by using LASER (like holmium or thulium). In this surgery, there is absolutely no cut on the body. Stone is broken down from the natural hole or orifices given by God. This surgery takes 1hr to 2hrs depending upon the hardness and size of the stone. In few cases, multiple sittings are required. As such RIRS is a very safe procedure. The most common complication of RIRS is Infection and it accounts from 2% to 16%. (PLZ click on the link to see RIRS surgery).

15) How many days rest after RIRS?
RIRS is a very safe and most minimal invasive surgery for kidney stone removal. Nowadays it is being performed as day care surgery as there is no cut involved. Usually, no rest is required after RIRS surgery. Only exercises were advised to be avoided till stent is there into the ureter.

16) Does RIRS damage kidney?
RIRS surgery is done for kidney stone removal. It involves the use of most advanced fragmentation technique for stone breakage i.e., LASER fragmentation. Also, there is continuous water irrigation taking place during the RIRS surgery into the kidney. As there is no hole created, it acts as closed environment system inside the kidney and this led to minimal kidney damage. In expert hands, this damage gets minimised to large extent or we can say it gets nullified. Out of the three procedures for kidney stone removal, RIRS causes least damage to kidney.

17) Is stent necessary after RIRS?
During the initial days of the introduction of RIRS, the flexible scopes were thicker or broader in diameter. The normal ureter usually has narrow lumen as compared to the diameter of flexible scopes, so during those days RIRS was 2-step procedure – 1st step being to put DJ stent in the ureter on the side of the surgery and this ureter used to get dilated in 5 days to 10 days. So, after 5-10 days 2nd step of surgery used to be done i.e., RIRS and then again DJ stent used to be put.
Nowadays due to available of smaller flexible scopes, this 1st step of DJ stenting is now no longer required in majority of the patients. Post-RIRS surgery, whether DJ stent is required or not is decided by the urologist depending upon the character of the stone, consistency of the stone, size of the stone and condition of the patient and ureter.

18) Why stent is placed after RIRS?
There are multiple reasons for stent placement in ureter after RIRS surgery. RIRS is done for the kidney stone removal. In this surgery, stone was fragmented into very minute pieces or made into powder form with the help of LASER. This stone powder/ fragments comes out from the narrow lumen ureter after the surgery slowly over few days. DJ stent was placed into ureter in order to prevent ureteric obstruction due to this stone powder or fragments. DJ stent is actually a thin lumen tube. Also, DJ stent leads to the dilatation of the ureter over few days which expediate the process of powder removal. Thirdly stone causes injury to the ureter where the stone was stuck, DJ stent helps in early healing of the area by preventing obstruction and good drainage of urine. Fourth, usually after RIRS there is mild injury happens to the mucosa of the kidney due to stone movement or infection or due to LASER which leads to mild bleeding from the injured surface. This blood changes its state from liquid to solid and forms clot in few seconds and this clot will block the ureter which has very narrow lumen and will lead to ureteric obstruction which will cause very severe pain also called as clot colic. So, in order to prevent clot colic, DJ stent was put after RIRS.

19) Which is better PCNL or RIRS?
There are various surgeries/ procedures for removal of kidney stones depending the location of the stone, size of the stone, comorbidities of the patient, age, complication due to stone and kidney position and anatomical orientation. So best procedure differs from patient to patient. Urologist can guide the patient which surgery will be best suitable for him/her after thorough investigation and clinical examination.

But if we consider the scenario, where PCNL and RIRS both are possible options so most likely patient tend to choose RIRS as it doesn’t involve any cut into the body, early discharge from the hospital, early resumption of normal activity. But its best to discuss with the urologist regarding the pros and cons in that patient for that particular stone.

20) What are the complications of RIRS?
RIRS is a very safe and most minimal invasive surgery for kidney stone removal. Nowadays it is being performed as day care surgery as there is no cut involved. Usually, no rest is required after RIRS surgery. Only exercises were advised to be avoided till stent is there into the ureter. Still there are few complications of RIRS which is seen in few patients. They are pain, fever, infection, minimal transient bleeding leading to hematuria (blood in urine), urine extravasation, urinoma, forniceal rupture, etc. Ureteric avulsion, sepsis, bleeding requiring transfusion are the rare complications after RIRS.

21) Is stent removal painful?
DJ stent is removed in the similar fashion as it is put. Stent removal if not done under anaesthesia is mildly painful. At MITR Hospital, DJ stent was removed under anaesthesia only and by using flexible scope which doesn’t cause any pain to the patient.