Just a brief information given here about kshara and shastra chikitsa which are explained in classics along with current surgical procedures for Ashmari management.

1. KSHARA AND SHASTRA KARMA IN THE
MANAGEMENT OF MUTRASHMARI
1

2. CHIKITSA
 1. Aushadhi - Chikitsa
 2. Basti - Chikitsa
 3. Kshara - Chikitsa
 4. Shastra - Chikitsa
2

3. KSHARAS ADVISED BY SUSHRUTA FOR
DIFFERENT ASHMARIS
Vataja ashmari Pittaja ashmari Kaphaja ashmari
Vasuka(shwetha
arka)
Patha Devadaaru
Gokshura Patala Maricha
Gunja Yava Chitraka
Pashanabheda Kusha guggilu
Kulattha kasha agnimantha
Varuna kadali Apamarga
3

4. PROBABLE MODE OF ACTION OF KSHARA :
 Properties of Kshara are:-Katu, Tikta, lavana rasa, Ushna Virya and
Kapha Vata Shamaka.
 As in the disease Ashmari, main involved Dosha is Kapha, the drug
pacifies the aggravated Kapha by its above mentioned properties.
 Kshara property of the drug having Shodhana, Lekhana, Bhedana,
Pachana and Tridoshagna properties, it reduces pain and probably
disintegrate the stone and thus helps to dislodge the Ashmari from its
own site. Finally Vata Shamaka property of the drug normalizes the
function of Apana Vayu and helps in expulsion of the stones.
 It also acts as a scrapper for the stone which acts mainly on Kapha
Dosha, it is 100% soluble in water, so it actively precipitate to
counteract the pathogenesis of stone formation and it neutralize
acidic media of urine as it behave as alkaline substance.
 obstruction to urinary outflow leads to stasis and here kshara acts
with its property of bhedana, lekhana and pachana karma dissolves
the stone
4

5. MECHANISM OF KSHARA ACCORDING TO
MODERN
 Crystalloid, colloid imbalance :-
 The urinary crystalloids are – calicum
Ammonium
Oxalate
Phosphate
Urates and uric acid
 Colloids:- Mucin and chondroitin sulphuric acid
The presence of colloids in urine allows the crystalloids to be kept in solutions by
the process of adsorption. If the proportion between them changes eg-
crystalloids increases colloids decreases or if the colloids loss their dissolving
property, the crystalloids get precipitated and stone formation occurs.
Kshara is highly alkaline if stone formation taken place due to above said etiology it
dissolves the acidic stones by its alkaline nature.
If stone formation occurs either by urinary infection, decalcification and increase in
the concentration of calcium, or hyperparathyroidism, increased vit D,
decreasesd vit A, Kshara wont help in these circumstances.
5

6. If no relief with above medications then
surgical extraction of calculus should be
performed.
 sloka
6

7. SURGICAL EXTRACTION
 Purvakarma-
 consent from the king,
 First, the patient should be given Snehana and swedana
 Light diet
 sacrificial offerings (while the patients should) chant
auspicious hymns
 collecting all things mentioned in Agropaharaniya chapter, he
should be reassured. (Su. Chi. 7/30 )
7

8. PRADHANA KARMA
 This technique is Perineal Vesicolithotomy
 Position is lithotomy postion, head resting in lap of attendant
 Sneha is applied on the nabhi and pressure massaging done on
left lateral region till ashmari decends into Basti.
 Lubricated middle and index finger is inserted into anal canal
of the patient.
 Calculus is then pushed with those fingers in upward direction
towards in between guda and external genital. Ashmari can be
felt as nodule
8

9. 9Lithotomy position as explained by Sushrutha during
ashmari shastra chikitsa

10.  While performing this procedure if patient becomes
unconscious or goes into shock, in such condition
procedure should be hold and extraction shouldn’t be
done.
 Site of incision- vamaParshwa (left lateral) 1
yava(grain) distance from the sevani(perineal raphe).
Incision should be adequate to remove stone
 While extracting the calculus, it should be brought out
without crushing it. Otherwise it can cause recurrence.
 Instrument used is अग्रवक्र आहारण यन्त्र (curved
forcep)
10

11.  In case of female – uterus should be protected, incision
should not be too deep otherwise it causes vrana through
which urine oozes out.
 Avoid damaging important structures like mutravaha,
shukravaha, mutrapraseka, sevani, yoni, guda, basti.
11

12.  If damage to-
1. Mutravaha srotas and Basti-death due to
extavasation of urine
2. Shukravaha srotas-death or infertility
3. Mushkasrot- dhwajabhanga (erectile dysfunction)
4. Mutraprasek- vesical fistula urine discharge
5. Sevni and yoni- severe pain
6. Guda and basti- death
12

13. PASCHATH KARMA
 Patient should be kept in hot water tub, this prevents collection
of blood in bladder.
 If blood gets collected in bladder then Uttarabasti of
kshirvruksha kwatha should be administered, it removes the
collected blood out of bladder (bladder wash)
 For mutramargavishodhana – rice mixed with jaggery should
be given.
 After removing from tub, apply honey+ghrita on the incision
wound
13

14.  For diuresis - trunapanchamoola,gokshura etc drugs in the form
of yavagu is given 2-3 times a day.
 For rakta-mutra shodhan and vrana kledanartha- jaggery mixed
milk along with cooked rice is given in small quantity for 10
days.
 After 10 days- sour fruit like dadima and jangala mamsa rasa is
given.
 Carefully snehana and swedana is performed.
 Clean wound with kshiravruksha decoction.
 Apply lepa of rodhra, madhuka, manjishtha, prapaundarika
kalka
14

15.  If urine doesn’t come through its normal route and comes
out from incision site (vrana), then it should be thermally
cauterized ( agnikarma).
 After urine comes out via normal route, uttarbasti,
anuvasan and niruha basti are given prepared from
kakolyadi gana or Kshiravrukshadi gana.
15

16. PATHYA:-
 Avoid coitus, horse-elephant-camel ride, climbing
mountain, riding chariots, swimming, heavy to digest
food for 1 year after healing of the wound.
16

17. MODERN SURGICAL MANAGEMENT
17

18. INDICATIONS
 Pain, infection and obstruction.
 Infection with Urinary tract obstruction is dangerous
because of significant risk of urosepsis and death.
 Urethral stones/ Renal stone ˃ 10mm
 Impacted stones
 Even after the conservative treatment for 4- 6 weeks
stones are not passed out.
18

19. CONTRAINDICATION
 Active and untreated UTI
 Uncorrected bleeding conditions
 Pregnancy
19

20. MANAGEMENT
Non-operative mechanical methods :-
 a) ESWL
 b) Ultrasonic Lithotripsy
 c) Electro hydraulic lithotripsy (EHL)
 d) Percutaneous nephrolithotomy (PCNL)
 e) Ureteric catheterisation and DJ stenting
 f) Dormia Basket
 g) Push Band
 h) Litholapaxy
 i) Laser lithotripsy
 j) Uretero-renoscopy (URS)
20

21. OPERATIVE METHODS :-
 The following operations can be performed for these
conditions :-
 i. Pyelolithotomy
 ii. Subcapsular nephrolithotomy
 iii. Nephrolithotomy
 iv. Pyelo - nephrolithotomy
 v Partial nephrectomy
 vi Anatropic nephrolithotomy
 vii Coagulum pyelolithotomy
 viii Bench renal surgery and autotransplantation
 ix. Nephrostomy
 x. Nephrectomy.
21

22. ULTRASONIC LITHOTRIPSY :
 Efficient ultrasonic lithotripsy requires a proper balance
between the flow of irrigation and the suction applied to
the ultrasound probe. During ultrasonic lithotripsy the
stone should be trapped between the probe and the
urothelium. The application of gentle pressure to the
stone will enhance fragmentation.
22

23. ELECTROHYDRAULIC LITHOTRIPSY (EHL)
 Some stone are difficult to break with ultrasound but will
yield to EHL. The advantaged EHL is that the probes are
flexible and small, allowing them to be utilized with the
flexible nephroscope.
23

24. EXTRA CORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL)
 The most common system for the generation of shock
waves for lithotripsy involves the discharge of an
electrical spark under water.
 Here the patient is positioned by computer controlled
table movement, so that the stone comes in the exact
focus of the shock wave generator after which the shock
waves are initiated.
 Sharply and accurately focused shock waves break the
stone into sand and pieces, which is passed out via ureter
and it may sometime result in ureteric colic.
 Breakage of stone depends upon the consistency of the
stone and its site. Oxalate and phosphate stones break
well than cystine stones. Stone lying in renal pelvis
clears early that the calyceal stone.
24

25. 25

26. Ureteric stone
suitable for
ESWL
26

27.  Contraindications of ESWL :-
 1. Bleeding disorders
 2. Patients with pacemaker
 3. Obesity, where it is difficult to localize the stone
 4. Ureteric stricture
 5. Pregnancy
 6. Large stone burden
 7. Pelvi-ureteric junction obstruction
27

28. PERCUTANEOUS NEPHROLITHOTOMY
 This is the most recent remedy for the kidney stones. Stones are
removed with the help of Nephroscope, without exploring the
kidney.
 Indications :-
 i. Stone situated in calyces
 ii. Stone situated in renal pelvis
 A stone less than 0.5 cm. in diameter, arrested at any part of ureter
often passes after ureteric catheterisation.
 It is used in lower third of ureter and is always used under
flouroscopy to avoid injury to ureter.
 If stone is in middle and upper ureter it can be pushed or flushed
back into renal pelvis to avoid hydronephrosis or pyonephrosis.
 Mostly it is used in bladder stones. Crushing the stone with a
lithotrite is highly satisfactory. 28

29. Percutaneous Nephroscope and Lithoclast
29

30. OPEN SURGICAL PROCEDURES
Nephrectomy Nephrolithotomy Cystolithotomy
30

31. 31

32. CONTRAINDICATION FOR OPERATION: IN ADVANCE,
 bilateral calculus in the presence of other diseases with
hopeless outlooks: ƒ
 Primary anaemia ƒ
 Leukemia ƒ
 Haemophilia ƒ
 Certain forms of central nervous disease ƒ
 Advanced renal or other neoplasia ƒ
 Advanced pulmonary tuberculosis ƒ
 Severe cardiac diseases ƒ
 Acute obstruction ƒ
 Acute renal infection
32

33.  Pyelolithotomy :
 Indications : When stone is in the extra renal pelvis.
 Technique : For removal of the stone an incision is made
on to the stone in the long axis of the renal pelvis and
stone is removed with suitable forceps. It may even be
applied to dislodge stone from one of the calyces through
the pelvis.
33

34.  Subcapsular Nephrolithotomy :
 Indications : When stone is situated in the intra-renal
pelvis.
 Techniques : An incision is placed parallel to the hilum
of the kidney, 1 cm lateral to the margin of the hilum.
Capsule is opened up and retracted medially. Now the
intrarenal portion of the pelvis is exposed. An incision
placed over it and stone is extracted out. Pelvis and
capsule are sutured again with interrupted stitches of
chronic catgut.
34

35.  iii) Nephrolithotomy :
 Indications : When stone is very tightly embedded in the
neck of the calyx.
 Technique : Removal of the stone through renal
parenchyma is practiced when the pelvis is mostly intra-
renal or when the kidney can not be mobilized
sufficiently to expose the pelvis.
35

36.  ) Pyelo-nephrolithotomy
 Indication : When stones are in the pelvis as in the calyx.
 Technique: Removal of the stone through both the pelvis
of the kidney and through renal parenchyma. This may
be required when a stone is impacted in the calyx, that it
cannot be removal through the pyelotomy incision. So a
second incision through the renal parenchyma becomes
necessary.
36

37.  Partial Nephrectomy :
 Indication: Multiple stone at one place of the kidney with
much damage to the pole.
 Technique: A partial removal of the kidney helps to
extract out the stone.
37

38.  Nephrostomy
 Indication: Bilateral renal calculi with acute renal failure
or pyonephrosis.
 Techniques: Simple drainage of kidney with removal of
calculi should be the operation of choice in grossly
infected cases and when the patient is to ill. It is also
indicated in calculus anuria. This also can be done by the
percutaneous route and is called PCN.
38

39.  Nephrectomy :
 Indication: Grossly damaged kidney with pyonephrosis
and when the other kidney is normal.
 Technique : Removal of the whole kidney is indicated in
case of hydro-nephrosis and grossly infected kidney
containing stones provided of course the opposite kidney
is healthy.
39

40. COMPLICATIONS:
 ƒHaemorrhage ƒ
 Urinary fistula ƒ
 Damage to pelvic organ ƒ
 Ureteric stenosis
40

41. POST-OPERATIVE TREATMENT
 ƒHigh intake of fluids nearly 2500 to 3000 cc per day.
 ƒLiquid diet,
 nutrition ƒ
 Further investigation ƒ
 Regular follow up
41

42. 42