Anatomy | Causes-Risks | Symptoms | Diagnosis | Treatment

Treatment

Treating kidney stone disease depends largely on the size, position and number of stones in your system. Luckily, the majority of small stones (0.2 inch or 5 mm. in diameter) that are not causing infection, blockage or symptoms will pass if you simply drink plenty of fluids each day. Consuming two to three quarts of water increases urine production, which eventually washes kidney or other stones out of the system. Once they have passed, no other treatment is necessary. The doctor usually asks one to save the passed stone(s) for testing; a cup or tea strainer can be used for this purpose.

Also, renal colic, the sudden flank pain that occurs when small stones start down the ureter, can usually be treated with bed rest and analgesics or painkillers. Certain types of stones, such as those made or uric acid, can be broken up with medical therapy. The majority, however, are composed of calcium and are not responsive to medicine.

Surgery should be reserved as an option for cases where other approaches have failed or should not be tried. Surgery may be needed if a stone:

• Does not pass after a reasonable period of time and causes constant pain. 
• Is too large to pass on its own. 
• Blocks the flow or urine. 
• Causes ongoing urinary tract infection. 
• Damages kidney tissue or causes constant bleeding. 
• Has grown larger (as seen as follow-up X-ray studies). 

Until recently, surgery to remove a stone was very painful and required a lengthy recovery time (four to six weeks). Today, treatment for these stones is greatly improved and many options do not require major surgery.

Shock Wave Lithotripsy (SWL): This is a completely non-invasive form of treatment in which an energy source generates a shock wave that is directed at a urinary stone within the kidney or ureter. Shock waves are transmitted to the patient either through a water bath, which the patient is placed in, or using a water-filled cushion that is placed against the skin. Ultrasound or fluoroscopy is used to locate the stone and focus the shock waves. The repeated force caused by the shock waves fragments the stone into small pieces.

SWL is most often performed under heavy sedation, although general anesthesia is sometimes used. Once the treatment is completed, the small stone particles then pass down the ureter and are eventually urinated away. In certain cases, a stent may need to be placed up the ureter just prior to SWL to assist in stone fragment passage.

Certain types of stone (cystine, calcium oxalate monohydrate) are resistant to SWL and usually require another treatment. In addition, larger stones (generally greater than 2.5 centimeters) may break into large pieces that can still block the kidney. Stones located in the lower portion of the kidney also have a decreased chance of passage.

Ureteroscopy (URS): This treatment involves the use of a very small, fiber-optic instrument called a ureteroscope, which allows access to stones in the ureter or kidney. The ureteroscope allows your urologist to directly visualize the stone by progressing up the ureter via the bladder. No incisions are necessary but general anesthesia is used.

Once the stone is seen through the ureteroscope, a small, basket-like device can be used to grasp smaller stones and remove them. If a stone is too large to remove, a laser, spark-generating probe or air-driven (pneumatic) probe can be passed through a channel built into the ureteroscope and the stone can be fragmented. 

A straightforward case is complete once the stone has been shattered appropriately. However, if extensive manipulation was required to reach and/or treat the stone, your urologist may choose to place a stent within the ureter to allow the post-operative swelling to subside.
Percutaneous nephrolithotomy (PNL): PNL is the treatment of choice for large stones located within the kidney that will not be effectively treated with either SWL or URS. General anesthesia is required to perform a PNL. The main advantage of this approach compared to traditional open surgery is that only a small incision (about one centimeter) is required in the flank. The urologist then places a guide wire through the incision. The wire is inserted into the kidney under fluoroscopic guidance and directed down the ureter. A passage is then created around the wire using dilators to provide access into the kidney. 

An instrument called a nephroscope is then passed into the kidney to visualize the stone. Fragmentation can then be done using an ultrasonic probe or a laser. Because the tract allows passage of larger instruments, your urologist can suction out or grasp the stone fragments as they are produced. This results in a higher clearance of stone fragments than with SWL or URS.

Once the procedure is complete, a tube is left in the flank to drain the kidney for several days. 
Open surgery: A large incision is required in order to expose the kidney or portion of ureter that is involved with the stone. The portion of kidney overlying the stone or the ureteral wall is then surgically cut and the stone removed.

At present, open surgery is used only for very complicated cases of stone disease.

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