Read Online in English
Table of Content
Preface and Contents

Stone Disease

Treatment of Stone Disease

CHP. 19. Stone Disease 137.
Treatment of urinary stones

Factors determining the treatment of urinary stones depend on the degree of symptoms; size, position and cause of stone; and presence or absence of urinary infection and obstruction. Two major treatment options are:

A. Conservative treatment

B. Surgical treatment

A. Conservative Treatment

Most kidney stones are small (less than 5 mm in diameter) enough to pass on their own within 3 to 6 weeks of the onset of symptoms. The aim of conservative treatment is to relieve symptoms and to help stone removal without surgical operation.

Immediate treatment of kidney stones

To treat unbearable pain a patient may require intramuscular or intravenous administration of non-steroidal inflammatory drugs (NSAIDs) or opioids. For less severe pain, oral medications are often effective.

Plenty of fluid intake

In patients with severe pain, fluid intake should be moderate and not excessive because it may aggravate pain. But in pain free periods,drink plenty of fluids, taking as much as 2 to 3 liters of water in a day. Remember though that beer is NOT a therapeutic agent for a patient with kidney stones.

Patients with severe colic and associated nausea, vomiting and fever may require intravenous saline infusion to correct fluid deficit. Patient must save the passed out stone for testing. A simple way to collect stones that have passed out is to urinate through a strainer (sieve).

Plenty of fluid intake will flush out a large number of small stones in urine.
Other measures

Maintaining proper urine pH is essential especially for patients with uric acid stone. Drugs like calcium channel blockers and alpha-blockers inhibit spasms of the ureter and dilate the ureters sufficiently to allow the passage of the ureteral stone. This is particularly helpful when the stone is located in the ureter close to the urinary bladder. Treat associated problems such as nausea, vomiting and urinary tract infection. Follow all general and special preventive measures (dietary advice, medication etc) discussed.

B. Surgical Treatment

Different surgical treatments are available for kidney stones that cannot be treated with conservative measures. Most frequently used surgical methods are extra-corporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotripsy (PCNL), ureteroscopy and in rare cases open surgery. These techniques are complimentary to each other. These procedures are performed by the urologist who decides which method is the best for a particular patient.

Which patient, with urinary stone, needs surgical treatment?

Most patients with small stones can be effectively treated conservatively. But surgery may be needed to remove kidney stones when the stones:

CHP. 19. Stone Disease 139.
  • Cause recurrent or severe pain and do not pass out after a reasonable period of time.
  • Are too large to pass on their own. Stones > 6 mm may need surgical intervention.
  • Cause significant obstruction, blocking the flow of urine and damaging the kidney.
  • Cause recurrent urinary tract infection or bleeding.

Prompt surgery may be required in patients with kidney failure due to stone obstructing the only functioning kidney or both the kidneys simultaneously.

Stone recurs in more than 50% cases. Instructions for prevention are emphatically advised.
1. ESWL - Extra-Corporeal Shockwave Lithotripsy

ESWL or extra-corporeal shock wave lithotripsy is the latest, effective and most frequently used treatment for kidney stones. Lithotripsy is ideal for kidney stones less than 1.5 cm in size or upper ureteric stones. In lithotripsy highly concentrated shock waves or ultrasonic waves produced by a lithotriptor machine break up the stones. The stones break down into small particles and are easily passed out through the urinary tract in the urine. After lithotripsy, the patient is advised to drink fluids liberally to flush out stone fragments. When blockage of the ureter is anticipated after lithotripsy of a big stone, a “stent” (special soft plastic tube) is placed in the ureter to avoid blockage.

Lithotripsy is generally safe. Probable complications of lithotripsy are blood in urine, urinary tract infection, incomplete stone removal (may require more sessions), incomplete stone fragmentation (which can lead to urinary tract obstruction), damage to kidney and an elevation in blood pressure.

Advantages of lithotripsy are that it is a safe method that does not require hospitalization, anesthesia and incision or cut. Pain is minimum in this method and it is suitable for patients of all age groups.

Lithotripsy is less effective for large stones and in obese patients. Lithotripsy is not advisable during pregnancy and in patients with severe infection, uncontrolled hypertension, distal obstruction in the urinary tract and bleeding disorders.

After lithotripsy, regular follow up, periodical checkup and strict adherence to preventive measures against recurrence of stone disease, is mandatory.

Lithotripsy is an effective and most frequently used non-operative treatment for kidney stones.
2. Percutaneous Nephrolithotomy (PCNL)

Percutaneous nephrolithotomy, or PCNL, is an effective method for removing medium-sized or large (bigger than 1.5 cm) kidney or ureteral stones. PCNL is the most frequently used option when other treatment modalities such as ureteroscopy or lithotripsy have failed.

In this procedure, under general anesthesia, the urologist makes a tiny incision in the back and creates a small tract from the skin to the kidney under image intensifier or sonographic control. For the insertion of instruments the tract is dilated. Using an instrument called a nephroscope, the urologist locates and removes the stone (nephrolithotomy). When the stone is big it is broken up using high frequency sound waves and then the stone fragments are removed (nephrolithotripsy).

By and large PCNL is safe, but there are some risks and complications that can arise as with any surgical treatment. Probable complications of PCNL are bleeding, infection, injury to other abdominal organs such as the colon, urinary leak and hydrothorax.

The main advantage of PCNL is that only a small incision (about one centimeter) is required. For all types of stones, PCNL is the most effective modality to make the patient totally stone-free in a single sitting. With PCNL hospital stay is shorter and recovery and healing is faster.

PCNL is the most effective method for removal of medium or large-sized kidney stones.
3. Ureteroscopy (URS)

Ureteroscopy is a highly successful modality for treating stones located in the mid and lower ureter. Under anaesthesia, a thin lighted flexible tube (ureteroscope) equipped with a camera is inserted via the urethra into the bladder and up the ureter.

The stone is seen through the ureteroscope and, depending on the size of the stone and the diameter of the ureter, the stone may be fragmented and/or removed. If the ureteric stone is small, it is grasped by the grasper and removed. If a stone is too large to remove in one piece, it can be broken into tiny fragments using pneumatic lithotripsy. These tiny stone pieces pass out on their own in urine. Patients normally go home the same day and can resume normal activity in two to three days.

The advantages of URS are that even hard stones can be broken by this method, and that it does not require incisions. It is safe for pregnant women, obese persons, as well as those with bleeding disorders. URS is generally safe, but, as with any procedure, risks exist. Possible complications of URS are blood in the urine, urinary tract infection, perforation of the ureter, and formation of scar tissue that narrows the diameter of the ureter (ureteral stricture).

Mid and lower ureteric stones can be successfully removed by ureteroscopy without surgery.
4. Open Surgery

Open surgery is the most invasive and painful treatment modality for stone disease requiring five to seven days of hospitalization. With the availability of new technologies, the need for open surgery has been reduced drastically. At present, open surgery is used only in extremely rare situations for very complicated cases with very large stone burden.

142. Save Your Kidneys

Major benefit of open surgery is complete removal of multiple, very big or staghorn stones in a single sitting. Open surgery is an efficient and cost-effective treatment modality especially for developing countries where resources are limited.

When should a patient with kidney stone consult a doctor?

A patient with kidney stone should immediately consult a doctor in case of:

  • Severe pain in the abdomen not relieved with medication.
  • Severe nausea or vomiting which prevents intake of fluid and medication.
  • Fever, chills and burning urination with pain in abdomen.
  • Blood in urine.
  • No urine output.
Reserve open surgery for very few patients with very large kidney stones or when other modalities have failed.