When he was deciding which aspect of urology to specialize in, Timothy Tran, MD, Assistant Professor of Clinical Urology, asked himself, “What do I want my day to be filled with?” He didn’t need to ponder long, for the days he always enjoyed the most were the ones in which he worked with patients with stone disease.
“It is such satisfying work,” Dr. Tran said. “Kidney stones are incredibly and invariably painful. When you remove a stone, the patient goes from suffering severely right before a procedure to afterward feeling so much better and being so thrilled and grateful that they can get back to their daily lives. I knew that was the type of day I wanted to have.”
Since joining Yale Urology in January 2019, Dr. Tran has brought relief to his patients through his innovative and comprehensive approach to stone disease. He has not only streamlined the diagnostic and surgical procedures, but also redefined preventative care by using metabolic evaluations and dietary consultations to help patients avoid a painful recurrence. “Because of specialized training, we are able to offer every type of stone procedure,” he said. “That enables us to individualize each patient’s treatment plan.”
Two years ago after completing a kidney stone fellowship at Icahn School of Medicine at Mount Sinai, Dr. Tran earned certification from the American Institute of Ultrasound Medicine. That training enables him to perform ultrasounds in the clinic, instead of having to refer patients to a radiologist. That’s particularly beneficial when monitoring patients who have recurrent stone disease. “We’re providing a convenience, but not at the expense of diagnostic quality,” Dr. Tran said.
Dr. Tran’s radiology skills also enable him to streamline a procedure known as a percutaneous nephrolithotomy (PCNL), in which large stones are removed from the kidneys through a small incision made in the back. Patients usually need to first see an interventional radiologist, who plots the entry tract for the PCNL. But Dr. Tran himself performs the tract imaging in the Yale Urology surgical suite and then immediately begins the surgery. If a stone cannot be cleared through one tract, he uses imaging to create multiple access points to clear everything instead of having to schedule a second surgery. He also uses smaller instruments in order to reduce the size of the incision and subsequent bleeding. “We have a much higher stone-free rate, less time under anesthesia, and greater convenience for the patient by being able to offer PCNL,” Dr. Tran explained.
There’s a 50 percent chance that kidney stone patients will have a recurrence within five years. To prevent another stone episode, Dr. Tran prescribes a metabolic evaluation for many of his patients, especially those who’ve had a large stone, needed surgery or passed a stone but have multiple remaining stones. The evaluation consists of blood work and a 24-hour at-home urine collection. The results can identify specific risk factors for stone formation as well as the composition of the stone.
“There’s a number of different kidney stone types,” Dr. Tran said, “and for the most common types there’s maybe ten different possibilities for why they would become a stone. We don’t want to simply give people a laundry list of things to do—drink more water, eat less salt, limit nuts and chocolate, avoid spinach—without finding out the true underlying metabolic issue. That would be overwhelming. With the metabolic evaluation, we can typically identify one to three factors that really stand out and then focus on and treat those.”
The most common culprits are low fluid intake and low levels of citrate, a molecule that inhibits stone formation. Fortunately, patients can easily reduce these risk factors by boosting their daily intake of water and citrus fruits. “The metabolic evaluation gives patients direct control to help prevent another stone episode,” says Charlotte Bell, APRN, who reviews evaluations with Dr. Tran’s patients.
Some patients have more complex metabolic abnormalities. Elevated oxalate levels lead to a higher risk of forming calcium oxalate stones. Uric acid stones can form when a patient’s diet is too rich in meats. Dr. Tran refers these more complex nutritional cases to Krista Fogarty, a registered dietician at Lawrence + Memorial Hospital. She translates the metabolic evaluation into a new personalized eating plan. “Patients sometimes have other health considerations in addition to kidney stones,” Dr. Tran said. “Krista is able to help them develop a suitable dietary balance that maintains good overall health while also limiting their stone risk.”
His patients are often surprised by how a few small dietary changes can make a difference over time—improvements that are evident at their follow-up appointments in the months after surgery. “Dr. Tran appreciates nutrition as a science and how it can make a difference,” Ms. Fogarty said. “Our collaboration is excellent for making sure his patients get the best possible care.” It’s all part of a day’s work for Dr. Tran— the satisfying, rewarding days he first envisioned in his fellowship and now lives out in his daily practice at Yale Urology.