Dr Tanuj Paul Bhatia
Senior Consultant, Department of Urology
Sarvodaya Hospital and Research Centre

From Open Surgery to Scar-less and Blood-less Laser Treatment: Changing Trends in Kidney Stone and Prostate Surgery

The urinary system starts with paired urine forming organs (kidneys) followed by bag like urinary collecting systems (pelvis). Pelvis continues as thin tubes and run on either side of spine as ureters. Ureters open into urinary bladder where urine is stored. Finally, urine is emptied via another tube called urethra. Near the bladder neck, urethra runs through a walnut like gland called prostate. As age increases, prostate increases in size and causes blockage in passage of urine. Stones are usually formed in kidneys due to lack of hydration and deposition of salts. These may grow silently in the kidney until they block the kidney and cause severe pain. Most stones formed in the kidney are small and pass out spontaneously or with help of some medicines. It is only stones which are larger (more than 7 mm are less likely to pass), or those that have caused a further complication like fever, infection, or renal failure; that require surgical removal.

Kidney stone surgery is as old as history medicine. Legendary Indian surgeon Sushruta (600 BC) was one of the first surgeons to treat urinary stones. Stones were removed by instruments and techniques that may seem barbaric now, but paved way for development of open followed by percutaneous and now scar less stone surgeries. In the modern era, kidney stones were removed by procedures like mephrolithotomy or pyelolithotomy which involved a long cut in the flank. It was rather ironic though necessary to remove a 1 to 4 cm stone with a 15- 20 cm cut on the body. Due to hard work and research by erstwhile urologists the era of endoscopic stone surgeries dawned. Rigid tube like endoscopes were used to access the kidney through a 1 cm hole in the back and thus into the kidney (percutaneous nephrolithotomy, PCNL). With time miniaturization of endoscopes occurred and stones could be accessed by smaller cuts/holes in the body, thus called mini-PCNL, micro-PCNL, super mini-PCNL etc.

Another scar-less technique called extracorporeal shock wave lithotripsy (ESWL) was popular in past as a day care procedure. This technique was good for soft, small favourably placed calculi in the urinary collecting system. But in case of hard stones, large stones and multiple stones, this would usually require multiple sittings and thus loss of time, loss of pay and a poorer clearance rate. Even before miniaturization of percutaneous access endoscopes, scientists had discovered flexible ureteroscope, first use reported as early as 1964. This made access possible to the kidney through the outlet of urinary tract (urethra). However, there was no technology to break the stones through these flexible ureteroscopes. This was made possible with advancements in field of medical lasers, especially Holmium Laser. The thin and flexible laser delivery fibres have made possible treatment in the most distal and earlier inaccessible parts of Kidney (Calyces) via flexible ureteroscopes. This technique, referred to as retrograde intrarenal surgery (RIRS), has replaced the earlier techniques of extracorporeal lithotripsy (ESWL) and is now preferred by most patients over the more invasive techniques like PCNL.

The main advantages of RIRS are that it is a no- cut scar-less surgery, poses lesser risk of severe complications like bleeding, enable an early recovery, early discharge (24 hours) and faster return to work. The limitations of RIRS are that it cannot be used as primary modality for very large stones like Staghorn Stones. However, it serves as a very useful adjunct in treatment of these stones as well, as many patients require 2 stage surgery for such stones and RIRS can be done the salvage procedure after the first percutaneous procedure. RIRS has also enabled no-cut access to kidneys which are not in normal position inside the body like ectopic kidneys, horseshoe kidneys, malrotated kidneys, post-transplant kidneys etc. It is evolving as the procedure of choice for such kidneys. In the western world ureterorenoscopy or RIRS is now the most commonly performed treatment of kidney stones followed by ESWL and then PCNL. In India, however percutaneous procedures still form the bulk of kidney stone treatment and only few centres are providing the facility of RIRS on regular basis. This is because of the costly instrumentation and advanced skill and training required RIRS. However, RIRS is becoming more and more popular as more urologists are learning the technique and more patients are demanding for same.

Similarly, there have been major advancements in treatment of another common urological disorder, benign enlargement of prostate (BEP/BPH). As age advances, Prostate causes blockage in urinary tract leading to symptoms like poor flow of urine, intermittent stream, frequent toilet breaks, urgency, etc. We now have very effective drugs and most patients with prostatic enlargement are now managed with medicines instead of surgery. Only those patients who do not respond well to medicines require surgery.  Prostate surgery in the past was about taking out the prostate through a cut in lower abdomen. However, this was taken over by transurtheral no-cut surgery decades ago (TURP-transurethral resection of prostate). Even though it was a no-cut surgery, some problems remained, like severe bleeding and inability to manage very large prostate glands.

With introduction of lasers in urological treatment, this deficiency of severe bleeding and inability to manage very large prostate is well taken care of. With Holmium laser enucleation of prostate, there is minimum bleeding, larger glands can be easily removed in one sitting, catheters can be removed faster and patient can be discharged early with faster return to work. At Sarvodaya Hospital and Research Centre Faridabad, we are well equipped with Lumenis P100 Holmium laser machine and we perform hundreds of RIRS, PCNL, and HOLEP procedures in a year. Lumenis P100 Holmium laser has turned out to be the most versatile laser as it can be used not just for treatment of stones and prostate, but also for various other urological disorders like stricture urethra, ureteroceles, bladder tumors, etc. At our Institute of Laser Urological Surgery we train surgeons in the newer techniques of advanced endourology including RIRS and laser prostate surgery (HoLEP) on simulators.

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