Dr. Kardi Suteja, SpU

When you hear the doctor say, “You need kidney surgery!” usually most patients feel afraid. Some even choose to refuse surgery despite being informed of potentially fatal outcomes. Open surgeries accompanied with a wide incision will certainly instil fear in patients. Not to mention the wound’s  lengthy healing process. However, since the last two decades, treatment for the kidney stones and urinary tract has since advanced rapidly. There has been a revolution in the management of kidney stones and urinary tract after the ESWL (extracorporeal shock wave lithotripsy). And currently undergoing open surgery out of the country is the last choice taken if non-invasive measures cannot be taken.

Should all stones be operated ?

The symptoms of kidney stones and urinary tract disease are low back pain that radiates to the front abdomen or groin, accompanied by reddish urine, sandy urine and pain at the end of urination. Sometimes it only aches at the waist, and often patients even experience no symptoms (silent stone).

Therapy that can be done depends on the type of stone, the size of the stone, and the location of the stone, and its kidney function. Alternative therapies range from conservative (with drugs), non-invasive therapy, minimally invasive therapy, to the most invasive last resort (open surgery). For kidney stones and urinary tract disease caused by metabolic processes in the body, for example uric acid stones, there is still room to only give a stone decay drug. However, if the stone is large and has caused urinary tract obstruction, action is needed to quickly remove the obstruction that can damage and reduce kidney function.

Not all kidney stones and urinary tract diseases must be operated on. With sizes and locations that make the kidney stones difficult to reach from the surface of the kidney, surgery must be avoided. Because the procedure will be more damaging to the kidneys. Nowadays, minimally invasive methods (kidney-like endoscopy) are used to treat kidney stones and urinary tract diseases (non-invasive). These are actions taken from outside the body, i.e. there is not any kind of device used that enter the patient’s body.

Extracorporeal shock wave lithotripsy (ESWL) is a non-invasive method that breaks stones from outside the body by the use of shock waves. Kidney stones and urinary tract stones can be broken into fine pieces, so that stone fragments can flow out together with the urine.

Kidney Stone Handling Revolution

The first time the concept of using a shock wave (shock wave) to break stones was recorded in 1950 in Russia. Through observations made by an aircraft company in Germany, it turns out that shock waves originating from small fragments that cross the atmosphere can destroy objects that are very hard.

During its development, there were 2 types of energy sources found to generate shock waves, namely : point sources and extended sources. Point sources include spark gap generators, lasers and micro explosives. Extended sources are produced by electromagnetic, piezoelectric generators and the last electroconductive generator has been developed.

Experiments to solve human kidney stones in vitro (stones that have been removed from the body) using shock waves were first performed in 1972 in Munich, West Germany. Then it was conducted in vivo animal experiments (stones in the animal’s body) to prove the ability of shock wave energy in breaking stones. After the ESWL action was successful in animals, the ESWL action in humans began. With the implementation of ESWL in humans, there is a revolution in the handling of stones in the kidneys and urinary tract.

Christian Chaussy was the first person recorded to carry out an ESWL procedure clinically in humans on February 7, 1980. His attention was still limited to stone free rate (the patient’s success rate is free of stones after the procedure). ESWL actions at that time still required anaesthesia. Patients still felt uncomfortable because the first generation ESWL required patients to soak in water during the procedure.

Today the ESWL tool has been developed to its third generation. There are two main concerns for handling stones in the kidneys and urinary tract, namely stone free rate and patient comfort during the ESWL procedure. While the third generation ESWL devices with electroconductive systems operate successfully with stone sizes up to 4 cm, patients need not be sedated because they would not be disturbed by pain. Patients do not need to be immersed in water until they are freezing cold, like required by the first generation ESWL.

In Indonesia the history of ESWL began in 1987 at the Jakarta Pertamina Hospital. Only about seven years ago the government joined a collaboration with France to spread ESWL tools in several teaching hospitals in Indonesia. Starting from Ujung Pandang, then Medan, Jakarta, Bandung, Semarang and Surabaya.

Around 2003 there were 17 ESWL devices in Indonesia. Conditions vary, there are ESWL devices from the first generation made in Korea, China, Turkey, America, Germany to the third generation made in France. Nine of them are in state and private hospitals in Jakarta. In Bali, the first ESWL started from the private sector at Karsuneka Urology Clinic Denpasar.

The therapeutic concept is polyclinic just like the concept from ‘his hometown’ in America, Germany or France. Painless, no operation and just ambulatory care. Patients do not need special preparation, the procedure takes about one to two hours. No need to be sedated. Patients do not need to be admitted in hospital. Post procedure, patients can go straight home and are permitted to work the following day.

Safe ESWL therapy

Like taking medicine in cases of other illnesses, if you want to recover, you certainly cannot take medicine at once. There is a maximum dose per day that must be followed for many days. Likewise, there is a maximum shock wave dose that must not be violated to avoid possible tissue damage during ESWL.

For one ESWL action session a stone size limit is determined at each stone location. In general, stones in the kidney can be treated with ESWL if the maximum size is 2 cm. This also depends on the type of ESWL tool used. If the patient insists on ESWL, even though the size of the stone exceeds the stone burden, the ESWL action must be done more than once with a minimum period

of a week.

The key to the success and safety of ESWL therapy lies in the ability of its own ESWL tool and of course the skills of its doctors who have been specially educated and trained for ESWL measures. The doctor must be a sniper so that he is not mistaken. If the standards are followed, the ESWL procedure for patients will be far safer and farther from complications than surgery.

In this era of globalization, more and more diseases are known. More and more therapy is offered. If the doctor does not provide education to the patient properly, the patient might look for alternative treatments that are sometimes misleading. If the patient is not actively seeking information, they might get sub-optimal treatment. Because good patients are critical patients and they are always looking for as much information as possible to get the most appropriate treatment options. Safe, efficient, and comfortable therapy.

Dr. Kardi Sutej, SpU. is a specialist in urological surgery at Karsuneka Clinic Denpasar and several private hospitals in Bali.