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.