Having a kidney stone stuck in the ureter might be the most painful experience a human can go through. The pain, cramping, and sadness are all compounded further by the nausea that comes with the pain. For those who have experienced this before, these are all recognizable symptoms. For those who are going through this right now, it is very important that you see a medical professional who is able to provide a treatment that is able to help you with this issue as soon as possible.
The most modern and minimally invasive technique that ensures the safe and efficient relief of ureteric stones and small and medium sized kidney stones is the Laser URSL treatment. The work begins with a small camera that is inserted through the urethra and advanced to the location of the kidney and ureter and the stone that is in the way. The camera is used to get a the stone ready to be pulverized and then the stone is then dusted to powder by the Holmium laser which can be removed through the normal urine stream. This is a no cut, no scar, no stitch procedure. This involves very little recovery and often times patients can return home later that day.
URSL stands for Ureteroscopic Stone Laser Lithotripsy. Let us break this down simply:
The ureteroscope is a slim optical tool designed to fit within a diameter of 4-8mm. Ureteroscopes come equipped with a light and a camera to capture images and videos. Additionally, a working channel is included to accommodate the passing of a retrieval basket. Ureteroscopes are designed to be introduced through the urethral opening and then guided to the bladder using a camera and light.
When the ureteroscope is in the bladder, the ureteroscope is then moved to the ureteral orifice. The ureteral orifice is a small opening in the wall of the bladder that is the entry point of the ureter. The ureteroscope is moved upward through the ureter to the kidney. This is done with a live camera view and saline is used to clear the camera lens of debris.
The ureter is a a natural tube that is typically 3-4mm in diameter. This typically does not present a problem for the ureteroscope. For new ureteroscopic patients, the ureteral orifice is typically a narrow opening. This, combined with a narrow ureter, may require a ureteral access sheath or a DJ stent for 2-4 weeks before the ureter to allow passive dilation to accommodate the ureteroscope. The treatment for the stone begins once the ureteroscope reaches the stone.
Once the ureteroscope has reached the stone, a Holmium:YAG laser fiber that is actually about as thick as a human hair (200-365 microns) is placed through the working channel of the ureteroscope until either the laser fiber is either touching the stone, or is as close as possible to the stone. Once that occurs, the laser is activated.
The Holmium appears to be the best laser for stone fragmentation as it works to split stones that have varying stone compositions including calcium weight stones or calcium oxalate monohydrate, calcium stones, calcium phosphate stones, cystine substance, uric acid, and Struvite. The way that the laser operates is through the transformation of laser energy to a rapid paradoxical thermal burst against the stone which creates a thermal and mechanical disruption of the stone.
The way that Dr. Vikas Singh operates, is the dusting technique as it works to laser the stone against to create the smallest particles of the stone dust that are almost 0.1 µm rather than fragmentation of the stone to be large particles of stones. The advantages of the dusting method along with fragmentation are as follows: stone dust appears to naturally pass along in the urine which works to prevent the stones from passing along in the urine from blocking the urethra, large stone particles along with a stone blocking the urethra no longer need to be removed, and the rate at which a particulate appears to be removed is actually appearing within imaging is greater in that the stone dust is removed from below the imaging or imaging appears to be greater.
For larger or harder stones, an efficiency-maximizing hybrid method can be employed which involves dusting the stones at the edge and basketing the central core. Fragments larger than 4mm are often captured with a nitinol basket to minimize the risk of steinstrasse. Steinstrasse refers to a chain of smaller stone fragments that can become lodged within the ureter, increasing the likelihood of post-operative pain.
There are two types of ureteroscopes used in clinical practice, and understanding the difference helps patients understand what to expect:
This telescope is thin, firm, and bendable, but not deflectable. It gives aid in the lower/mid-ureter and, in some instances, the upper ureter. It is less costly, easy to set up, and very useful for the most typical ureteric stone locations: the distal and mid-ureter. However, its rigidity restricts its use on the upper ureter or kidney in patients with twisted anatomy. Most stones that are present in the mid and lower-ureters are dealt with the use of a semi-rigid ureteroscope.
A completely flexible telescope with a tip that actively deflects by 270 degrees. It can traverse the entire ureter, including the upper ureter, and can be further advanced into the kidney to access stones in any calyx. It is beneficial for conditions involving upper ureteric stones (due to the complex anatomy), kidney stones (RIRS – Retrograde Intrarenal Surgery), and for patients in whom the semi-rigid scope is unable to reach the stone safely. The flexible ureteroscope is more sophisticated and offers a steep learning curve which Dr. Vikas Singh has successfully met by use of single-use flexible ureteroscope. This scope eliminates the cross-infection risk of reusable scopes and provides the best curve for every patient.
URSL is the top choice for stones stuck anywhere in the ureter (the tube connecting the kidneys to the bladder) – the ureteropelvic junction (where the ureter connects to the kidney), the mid-ureter, and ureterovesicular junction (the junction just before the bladder). Ureteric stones are also the most painful because the ureter is a narrow tube and is made of smooth muscle. This causes the ureter to spasm when trying to push the stone through, and causes extreme pain to the patient. This is the type of pain that most patients would describe as something that causes them to go to the emergency department.
URSL should be considered for ureteric stones that have not passed on their own within 4 to 6 weeks, cause continued pain, fever, or infection. Even stones that fully block the ureter are a good candidate for URSL. The success rates in the most reviewed studies for stones that were left embedded in the ureter, and then operated on with URSL, had stone-free rates of over 90 to 95%. URS is considered one of the most successful surgical options in the field of urology for removing ureteric stones.
RIRS (Flexible Ureteroscopy) is the main technique for managing kidney stones greater than 1 cm. However, URSL (Ureterorenoscopy) with a semi-rigid scope for kidney stones in the renal pelvis / Upper Ureter (Upper Urinary Tract Pelvis) is successful for the stones which are 1 cm to 1.5 cm in dimension. For stones that lie in this size and anatomical category, URSL (Ureterorenoscopy) is an efficient technique as favourable anatomical conditions for the stones are available, and also achieve comparable stone-free rates as RIRS (Flexible Ureteroscopy) which is a stone-free technique and has a fairly straightforward stone-free instrument.
ESWL or shockwave treatment, is best used for kidney and upper ureteric stones, but does have its drawbacks. For stones that are hard (CT density above 1,000 Hounsfield units), stones located in the lower renal pole, stones that are above 1.5 cm, and stones located in obese patients, the ESWL process will not work. Rather, patients that have had one or two unsuccessful treatments with ESWL one or two times and have not attained a stone-free status, must be suggested to undergo URSL or RIRS. These treatments are not restricted by stone’s hardness and attain higher stone-free status than ESWL.
URSL, like RIRS, causes no external scarring on the body. The ureteroscope traverses the urinary track through the urethra. There are no incisions or punctures to the skin. For patients who are distressed about post-surgical skin incisions and the healing process or who are concerned about complications from the incision or puncturing, URSL is a surgical technique that helps to remove urinary calculi and causes no external scarring when compared to open- or laparoscopy-based surgical techniques. There is no external effect to be seen, and nothing to be healed after URSL, while the stone has been treated.
Renal colic is commonly described as one of the most painful experiences a person can have. It us caused by a stone that gets stuck in the ureter and causes a sudden pain that occurs in the back or in the flank that comes in waves and us severe enough to cause cramping. The pain can last for minutes or even hours, and between the pain experiences one can expect to feel discomfort, but have a small chance of the pain disappearing. It is often hard to find one comfortable position to be in, and lying still is even worse. This is pain caused by a muscular injury. The sharp but horrible pain caused by the stone us a ureteric stone, and any colicky flank or back pain as described above is a good reason to seek urgent urological assistance. Urgent urological situations require the assistance of a professional in the light of possible severe pain caused by a stone.
As a stone moves through the ureter and toward the bladder the pain changes and moves down through the flank and into the lower abdomen and groin. For men, the pain can also radiate to the testicle or even to the tip of the penis. This pain ultimately is a result of the same nerve supplies and the relationship between the ureters and those structures. This pain migration is useful to a urologist, as he or she will have an idea of the stone’s location in the ureters. If a patient has pain in these nociceptive territories and the testicle is found to be fine, then the case is of a lower ureteric stone.
Blood in the urine, which causes red, pink, or brown urine, occurs with most cases of ureteric stones. When ureteric stones move within the ureter, they cause harm to the inner lining of the ureter, which bleeds. Blood caused by the stones can be seen with the naked eye or by performing a urine dipstick or microscopic examination. Blood in the urine should be evaluated by a medical doctor. In the most cases where stones cause blood in the urine, stones in the kidney or ureters are the causes, however, it should be noted blood in the urine can result from more complicated and serious factors outside of the urinary system.
The intense pain from renal colic nausea and vomiting causes stomach symptoms. There is a type of pain so bad and so visceral that it causes a vomit reflex. There are far too many ER patients w/ renal stone diseases that vomit and are unable/not willing to take a pill. These types of patients require insertion of IV lines for hydration and pain relief.
An infect of the urine destructs the balance of the body and the loss of equilibrium causes the blood to become uncontrolled and kills the body. Urosepsis is a likely state for a person too. Fever, along with the symtoms of a renal calculous is a cause for an emergency department and not a clinic. This is too complex and requires and URSL and a full treatment.
Ureteric stones located in the lower ureter can induce bladder hyperactivity and irritation and symptoms which can mimic a urinary tract infection (UTI) including a burning sensation during micturation, increased frequency of urination, the feeling of having an incomplete voiding of the bladder, and in some cases the urgent need to micturate even when the bladder is not full. Patients with lower ureteric stones may be mistakenly diagnosed and treated for a UTI. An ultrasound or KUB X-ray or, even better, a CT KUB can quickly establish a diagnosis and localization of the stone.
Here is a comparison of Laser URSL against the main alternative stone treatment options:
Factor | Laser URSL | ESWL (Shockwave) | Open/Laparoscopic Ureterolithotomy |
External Incision | None – through urethra | None – external shockwaves | Yes – 3–5cm laparoscopic or larger open |
Anaesthesia | General or spinal | Local or sedation | General |
Stone Size | Any size in ureter; up to 1.5cm kidney | Best for <1.5cm; kidney preferred | Any size but rarely needed today |
Stone Hardness | All compositions including hard stones | Limited – fails on very hard stones | All compositions |
Stone-Free Rate (Ureter) | 90–98% in 1 session | 60–85% (may need repeat) | 95%+ but invasive |
Hospital Stay | Same day or 1 day | Day procedure | 2–5 days |
Recovery | 3–7 days | 1–3 days | 1–3 weeks |
Blood Loss | None (no incision) | None | Moderate |
Lower Pole Stones | Accessible with flexible URS | Poor results | Accessible but invasive |
Obstructed/Infected Ureter | Yes – treats urgently | Not suitable acutely | Not suitable acutely |
URSL is completely incisionless and is performed through the urethra, the natural pathway through which urine is released from the body. So, no cuts, no stitches, and no scars. After this procedure, your body will have remained untouched, and will have no visible signs from the procedure-related visits to the doctors. If it were to have resolved the issue related to the kidney stone which could have caused enduring and excruciating pain, this procedure which takes around thirty to sixty minutes is truly incredible. This is the case with modern laser ureteroscopy.
A major clinical advantage of URSL is the treatment of stones irrespective of their position in the ureter. As such, the ureter stones can be at the proximal, mid, or distal sections of the ureter. No matter their location, the stones can be treated with the ureteroscope. Compared to URSL, ESWL is less effective for stones that are in the mid and distal sections of the ureter. This is because the stones are shielded by the bones of the pelvis and the hips, thereby preventing the extracorporeal shockwaves from fully reaching the stones. Regardless of their location, URSL is the gold standard for treatment of all ureteric stones.
URSL at Kokilaben Hospital in Indore is processed as a short-stay surgical procedure. On most occasions, patients are hospitalized on the day of the surgical procedure and discharged either on the same day as the procedure or on the morning of the immediate following day. A stay of 8 to 24 hours. This is the standard practice at our hospital for same day discharge for cases of uncomplicated lower ureter stones procedure. The patient’s hospital stay is greatly reduced and therefore, the patient’s work or family commitments are minimally disrupted. There is a great reduction in the overall treatment costs.
URSL does not entail any cutting of the skin or the underlying tissue. Hence, there is no recovery pain related to any type of wound. In addition, since there is no incision, pain is manageable. After the anaesthesia is no longer effective, patients might experience a urinary burning or stinging pain, which subsides in about 2 to 5 days. This is much more bearable than pain after open surgery or laparoscopic surgery. In the days the patients experience pain, they might need pain relief, which is usually in the form of oral medication like paracetamol and ibuprofen. Generally, most patients get back to a desk job after 2 to 4 days and return to a more rigorous daily routine after about 1 to 2 weeks.
Laser URSL is a very safe procedure in experienced hands. The following side effects and complications should be understood before the procedure:
During & Immediately After Surgery: URSL can be done under general or spinal anesthesia. Usually the operation lasts between 30 and 60 minutes, and the placement of a DJ stent is the norm. A urinary catheter is used for 12 to 24 hours. You will wake up in the recovery room with some mild discomfort in the lower urinary tract, which can be easily controlled with pain relief. After 2-3 hours you can walk, eat, and drink.
The urinary catheter, if applicable, is taken out that same evening or the next. A discharge is organized, with accompanying instructions, after it is established that you can urinate and pain is managed. Most patients leave with a disposable urine bag which becomes unnecessary after the catheter removal.
With a DJ stent, a mild burning sensation while urinating is common. Urine frequency and urgency typically occur as a normal symptom of the DJ stent, however, note that they can subside as the medication starts to work. The presence of blood in your urine is expected for the first 7 days. Please be sure to finish the entire antibiotic regimen and anti-inflammatory medication. Most patients are able to resume desk work within 2 to 3 days. Heavy lifting, strenuous exercise, and sexual intercourse are prohibited until the DJ stent is removed.
Typically, the DJ stent is removed at an outpatient appointment 1 to 4 weeks after the URSL. The removal is done in a few minutes using cystoscopy. Stents are removed using strings in many cases. There is a drastic improvement in the painful attempts of urination removal. The effects of the removal are almost immediate. The effects of frequent and urgent attempts at urination typically disappear in a day. There are no restrictions on the activities after removal.
There is no retained obstruction or hydronephrosis if a CT KUB or Ultrasound demonstrates stone free ureters and kidneys. Infection is ruled out on a urine test. Stone prevention strategies will be explained by Dr. Vikas Singh at this visit. Dietary recommendations, targets for fluid intake, and guidelines for metabolic risk factors will be discussed based on fluid balance or urine tests.
Ureteroscopic stone treatment includes stones in the ureters and those in accessible parts of the kidneys. This area of treatment is covered by the term ureteroscopic stone laser lithotripsy (USRL). Retrograde intrarenal surgery (RIRS) is an even narrower subclass of USRL in which a flexible ureteroscope is used to treat stones in the renal calyces and the renal pelvis. Thus, stones in the ureters and in the accessible parts of the kidneys can be treated by USLR; stones in the deep parts of the kidneys can be treated by RIRS. In many centers, ureteric stone treatment is referred to as “URSL” and intrarenal (or inside kidney) stone treatment is referred to as “RIRS”.
Most URSL procedures for single ureteric stones take 30 to 60 minutes. Larger stones, stones in tight or tortuous upper ureter, complex cases which require semi with flexible scopes take 60 to 90 minutes. At the pre-procedure consultation, Dr. Vikas Singh will convey the expected duration based on your CT scan.
URSL is done using either general or spinal anaesthesia which means you won’t feel a thing. Spinal anaesthesia means you will be awake but from the waist down you’ll be completely numb to any pain. General anaesthesia means you’re completely unconscious for the whole procedure. Once the anaesthesia wears off, you may feel some stinging and discomfort in the lower abdomen. This will be completely manageable using standard oral pain relievers.
Kidney stones in pregnancy can be very problematic. When pregnancy calls for stone intervention, URSL is considered the safest approach. It avoids the negatives of radiation (CT imaging is minimized, ultrasound is used), the downsides of the prone position (as used in PCNL), and can be performed easily using spinal anaesthesia. Dr. Vikas Singh is the representative in charge of dealing with the urological stone crisis in pregnancy. He will collaborate with the pregnant woman’s obstetrician in the pregnant patient’s URSL.
Not always. DJ stents after URSL can placement can depend on a number of factors: procedural complexity, ureteral trauma, perforation, residual stone debris, and infection. For relatively simple cases without significant ureteral trauma, and accompanied by complete stone dusting, Dr. Vikas Singh may choose to forgo the stent and save the patient the 1 to 4 weeks of stent related symptoms. This is decided at the procedural conclusion and is directly communicated to the patient at the time of discharge.
Yes, URSL is a great option stone procedure for older patients and for patients with a lot of serious comorbidities. The procedure is brief (half an hour to an hour), bloodless, woundless, and causes little to no physiological disruption. If spinal anaesthesia is offered and chosen, a patient avoids the risks of undergoing general anaesthesia. Most of the elder patients with conditions like hypertension, diabetes, or heart disease, are good surgical candidates. Dr. Vikas Singh assesses the patients’ histories and, if needed, collaborates with the respective specialities.
Please bring your CT KUB scan (CD and written report) – this is the most important investigation. Also bring the ultrasound KUB report, urine culture and sensitivity report, blood tests (including kidney function and complete blood count, coagulation), and a complete list of all your medications. If you have had any prior urological procedures or prior treatment of kidney stones (ESWL, prior URSL), the operative notes or the above mentioned reports would be very useful.
Yes, URSL can be done multiple times if new kidney or ureteric stones appear. There are no long-term changes to the urinary tract caused by URSL that restrict future procedures. Each procedure offers a solution for a particular stone at a particular time. The most effective way to lower the reoccurrence of stones is to find and treat the metabolic cause, which is what Dr. Vikas Singh does through 24-hour urine collections and blood tests at his follow up.
Yes, almost always. Modern Laser URSL procedures have similar or better stone-free outcomes compared to open ureterolithotomy, but with no incision, significantly shorter hospital stay (1 day compared to 4 – 7 days), less pain, and quicker recovery. Open ureterolithotomy for ureter stones is practically obsolete in modern urology. Operative Ureterolithotripsy (URSL) has become the standard procedure in such cases. Open or laparoscopic stone surgery is preferable to URSL only in exceptional cases where the ureter is severely scarred and URSL is not possible due to the scope’s diameter, where additional complex ureteral surgery is concomitant, or involving complex/ atypical stone surgery.
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