What are my options for treatment?

Conservative Management (Spontaneous Passage)

Urinary stones can damage the kidney and urinary tract. Therefore elimination of stones is necessary. Fortunately, almost 70% to 80% of all kidney stones pass spontaneously. Sometimes drinking plenty of water assists in the passage of the stone by itself. A patient may stay home and take pain medication as needed; the doctor will ask to save the passed stone for analysis. Over 90% of stones less than 4 mm in size will pass spontaneously. Thus patients with smaller stones are usually recommended to try and pass their stone with the aid of hydration and pain medication as needed. Those who do not pass their stone can usually be treated without open surgery most of the time.

Surgical Intervention

Extracorporeal Shockwave Lithotripsy (ESWL)

If the stone ends up causing too much pain, becomes too large to pass spontaneously, blocks urine flow, causes tissue damage, or results in some type of urinary tract infection, a form of surgical intervention may be needed. Several treatment modalities are available to the patient. A non-invasive process known as lithotripsy (short for extracorporeal shockwave lithotripsy or ESWL ) breaks up stones into smaller sand-like fragments that may pass on their own. This technique has been in the United States since 1984 and is the most frequently used procedure to combat kidney stones. It does not require an incision. The principle for stone destruction among all types of lithotripters is the same. Shock waves are generated outside the body and focused on the target stone. There are different kinds of lithotripters. Some devices allow the patient to be placed in a water bath to allow the propagation of the shock waves; others use a soft cushion or membrane on which the patient rests for shock wave transmission. Prior to the procedure, patients undergo a physical examination, and their history is reviewed. Because this process can produce pain, most patients are given some type of anesthesia. Your doctor will help you decide whether you need only a sedative, regional, or general anesthesia.

Most patients receive regional or general anesthesia. Lithotripsy uses x-rays or ultrasound to allow the physician to locate the stone for focusing the lithotripter. The procedure usually lasts 45 minutes to an hour. With the shock waves traveling through body tissue, side effects such as mild skin bruising in the back or abdomen may occur but usually heal in a matter of days. Blood in the urine can be another common side effect. Doctors usually advise patients to avoid taking aspirin, ibuprofen (Advil, Motrin, etc ), or other drugs that affect blood clotting prior to treatment to avoid complications. ESWL is usually done on an outpatient basis, and recovery time is usually only one to two days. Patients need to know that ESWL does not remove their stone. When effective, stones are fragmented to be small enough to pass out of the kidney. Because the residual fragments can cause discomfort while they pass, the doctor may insert a stent, a narrow tube placed through the bladder and into the ureter, to assist passage. Repeat ESWL can be a possibility if initial treatment is not successful. Your doctor will evaluate your x-rays to determine if ESWL is appropriate for your stone.

Percutaneous Nephrolthotomy (PCNL)

Another treatment option is called a percutaneous nephrolithotomy (PCNL ). This surgery is recommended if the stone is too large or located in a place in the urinary tract that may not allow for effective ESWL results. Patients have a tube called a nephrostomy tube inserted through a small incision in the flank and into the kidney to help drainage. The surgeon can use the small incision in the back to insert a fiberoptic telescope called a nephroscope. This allows the urologist to view the stone inside the kidney. Smaller stones can be grasped and removed. Larger stones may need to be broken up by an electrohydraulic or ultrasonic energy probe. The patient will need to stay in the hospital for several days with the nephrostomy tube in the back during healing. Once the nephrostomy tube is removed, the incision and kidney will heal in several days, and the patient can return to normal work and exercise usually within one week. One advantage PCNL has over ESWL is that the stones are broken and removed in most cases at the time of the surgical procedure.

Ureteroscopy

A third type of procedure, called ureteroscopy, allows for treatment of stones in the mid and lower parts of the ureter. A small telescope, called a ureteroscope is inserted through the urethra (without an incision) into the bladder and ureter. The stone can then be removed via a cage-Iike instrument (stone basket) or shattered with an ultrasonic probe or laser. This procedure allows for the option of pushing the stone back into a region where ESWL is better suited. A stent may be left in the ureter to allow for healing.

With these treatment options available today, open surgery, where the kidney is opened for stone removal, is almost always unnecessary and used in less than one percent of stone cases.