MANAGEMENT OPTIONS FOR KIDNEY / URETERIC STONES

1. Do all kidney stones need treatment?

No. Not all stones need immediate treatment.

In general:

• Small stones that sit in the kidney, do not block the flow of urine and cause no symptoms can sometimes be safely monitored with regular scans.

• Stones that are large, growing, causing repeated pain, reducing kidney function, causing repeated infections or blocking urine flow usually need active treatment.

The decision to treat or monitor depends on stone size, location, number of stones, your symptoms, your kidney function and any other medical problems. This decision should be made together with your urologist.

2. Treatment options for kidney stones

a) Medical treatment (watchful waiting and helping the stone to pass)

Many stones up to about 5 mm in size may pass on their own.

During this time:

• Strong painkillers and antispasmodic medicines are used to control pain.

• You are encouraged to drink plenty of fluids, unless your doctor advises otherwise.

• In some cases, medicines that relax the ureter (for example, tamsulosin) may be prescribed to help the stone pass.

This is sometimes called “medical expulsive therapy”.

Not every stone is safe to “wait and see”. In some situations, waiting can harm the kidney. The decision to wait must be made by your doctor and you should be monitored during this period.

b) ESWL (Extracorporeal Shock Wave Lithotripsy)

ESWL uses shock waves from outside the body to break the stone into smaller pieces.

• You lie on a special table and the machine sends shock waves through the skin and tissues, focusing them on the stone.

• The stone is broken into smaller fragments.

• These fragments then pass out naturally in the urine over days or sometimes weeks.

Often, a mild sedative or pain relief is given during the procedure.

Possible downsides:

• The stone may not break into very fine pieces, and some fragments can still be large enough to cause pain.

• Passing fragments can be painful.

• Urine infections can occur.

• Occasionally, many small fragments collect in the ureter, causing a blockage (“steinstrasse” or stone street), and extra treatment may be needed.

c) Ureteroscopy (endoscopic treatment of ureteric stones)

The ureter is the narrow tube that carries urine from the kidney to the bladder. Stones that become stuck in the ureter and do not pass may be treated with ureteroscopy.

• A thin telescope (rigid or flexible ureteroscope) is passed through the urethra, into the bladder and then up into the ureter.

• The stone is seen directly on the camera.

• A laser (most commonly Holmium laser) or a pneumatic device is used to break the stone.

• The pieces may be removed with tiny baskets or left to pass if they have been reduced to fine fragments.

Generally:

• There is no cut on the skin; it is a keyhole procedure through the natural urinary passage.

• Most patients go home the same day or the following day.

Often a temporary soft plastic tube called a ureteric stent (Double-J stent) is left in place:

• This keeps urine flowing freely

• Reduces swelling

• Helps stone fragments to pass

The stent is usually removed after a few days or weeks with a short day-case procedure.

d) Flexible ureterorenoscopy / RIRS (endoscopic kidney stone surgery)

In this modern “keyhole from below” technique:

• A very thin, flexible telescope is passed through the urethra and bladder, up the ureter, into the kidney itself.

• The tip of the scope can bend in different directions, allowing access to almost all parts of the kidney.

• The stone is seen directly.

• A laser is used to break the stone into dust or small fragments.

• Some pieces are removed; the rest pass in the urine over time.

Advantages:

• No cut in the skin.

• Usually a short hospital stay and quick recovery.

• Very effective for many small and medium-sized kidney stones.

It does require specialist equipment and an experienced team. As with all procedures, there are potential risks such as infection, bleeding, or scarring in the ureter, which your surgeon will explain.

e) Percutaneous nephrolithotomy (PCNL, keyhole surgery through the back)

For large or complex kidney stones, especially stones:

• Larger than about 2 cm

• Filling a large part of the kidney (so-called “staghorn” stones)

it may be better to remove them through a small cut in the back.

In PCNL:

• A small incision is made in the skin of the back, near the kidney.

• A tract is created into the kidney and widened to allow a telescope and instruments to pass.

• The stone is broken up and the pieces are removed directly.

Compared with old-style open surgery, PCNL uses a much smaller cut and recovery is faster, but:

• There is a risk of bleeding, so blood must be available if needed.

• A hospital stay of 2–4 days is common.

f) Open surgery

Traditional open surgery for kidney stones is now rarely needed, thanks to modern endoscopic and keyhole techniques.

It may still be considered if:

• The stone is extremely large (for example, larger than 4 cm), and other methods are unlikely to clear it in one session

• The anatomy makes keyhole access very difficult or impossible

• There are severe internal scars from previous operations

Even in these situations, open surgery is used only in selected cases.

3. What should I do while waiting to pass a stone?

If your urologist has recommended watching and waiting:

• Drink small amounts of water regularly throughout the day, unless you have been told to restrict fluids. Your urine should be pale yellow or almost clear.

• Take your prescribed painkillers and any other medicines as directed.

• Try to catch the stone: urinate through a tea strainer or special stone filter when possible. This allows the stone to be analysed later.

• Seek urgent help if you develop severe pain, fever, shaking, feel very unwell, cannot pass urine or if your symptoms suddenly worsen.