About 15% of men and 10% of women suffer from kidney stones. This medical condition is called urolithiasis. If left without treatment or observation, kidney stones can lead to severe renal impairment. In this article, we will try to systematize indications for use of different methods for the treatment of stones according to their localization (kidney or ureter) and according to the size of kidney and ureteral stones.
In recent years, enormous progress in the development of endoscopic, laser and ultrasound technology in urology led to the development and introduction into the daily practice of new, modern methods of treatment of kidney and ureteral stones. This is wonderful for the specialists but all these methods, collectively called “bloodless”, “laser”, “ultrasonic” and so confuse patients, who often are not aware and do not know what to expect or how far extends the capabilities of that method. Unfortunately, there is still no universal method for the treatment of kidney and ureteral stones (even with laser) and each of these modern methods available to modern urology, has its indications and contraindications. In each case, it is suitable one or another way of treatment, depending on the size of the stone, its location, its chemical composition, condition of the kidneys, etc. In some patients it ismore appropriate to use extracorporeal lithotripsy (usually breaking), for other it is a laser, and for third it is drug therapy. Sometimes the first step isusing one method (usually starting with the least invasive and risky manipulation), while if it fails, it may be needed to use another.
Before choosing the way of treatment one patient, the specialist urologist needs to do certain tests to determine the exact type, size and location of stones in the kidney or ureter. Only when clear size and other characteristics of the gallstones and general condition of the patient, the patient is transferred to the appropriate treatment – conservative (with drugs) or actively (crushing and removing stones).
Here we will look at the main steps and methods of treatment of the different types of stones, depending on the size and location.
For starters it is important to note that not all stones (called concretions) must at all costs be treated. Sometimes just monitoring the concretion may be enough in asymptomatic and single stones in the kidney with size about 10-15 mm. Of course, there are made periodic ultrasound or X-ray examinations, as the growth of gallstones or presence of symptoms is monitored. At present medical science has no definite answer whether each foundstone must be eliminated or some stones may be left for observation.
Decided to take proactive measures to treat kidney and ureteral stones taken at:
- Increase in concretions;
- Increased predisposal to urolithiasis;
- Obstruction of the kidney;
- Bigger than 15 mm;
- Preferences of the patient;
- Monitoring more than 2-3 years.
For concretions in the kidney, sizes up to 10 mm normally the first choice is extracorporeal lithotripsy as the least traumatic, fast and painless method.When the extracorporeal lithotripsy fails, as a second step in treating stones it may be used uretrorenoscopy and disintegration with a laser. Only if this method fails, it might be tried PNL.
At rates of kidney stone between 10 and 20 mm we are starting with extracorporeal lithotripsy. Due to the large amount of gallstones, and especially if they are multiple, you can pass the PNL in which the evacuation of the fragments is easier and more complete. Here we can again try the same withuretrorenoscopy.
When the stone is larger than 20 mm, extracorporeal lithotripsy cannot provide full disintegration. Most often it is broken into several large pieces that may block the urethra or become the basis for the formation of new stones. Placement of stent type “Double-J” is almost mandatory to ensure the smooth passage of urine. With such large stones the most appropriate method of treatment is PNL. This is a minimally invasive approach that allows to avoid open surgery, which until recently was the only available treatment for these concretions.
Open surgery remains the only alternative to anatomical abnormalities, multiple large concretions, morbid obesity, inflammation and others.
It is considered that stones to 4-5 mm in diameter, provided that there are no anomalies along the ureter, can be eliminated naturally or with ordinary analgesic therapy. In stones size 5-8 mm you can try medical expulsive therapy (MET). It weakens the muscles of the urethra directly and helps eliminate ureteral stones.
If there is a blockage in the kidney, take measures first to ensure the flow of urine – stent type “Double-J” or placing nephrostomy through the skin.
Often, in spite of drug therapy, concretion can not be eliminated even if it is of suitable size. In many cases this is due to inflammatory changes in the lining of the urethra, which swells and “bites” the stone. In such concrements in size to 10 mm and located closer to the kidney is most often begins with extracorporeal lithotripsy, as crushed fragments are pissed with the urine. If this method fails, the use of URS and whipping with a laser is required. If the same concretion is located in the portion of the ureter closer to the bladder, it is preferred to use a URS probe laser.
In concrements in the ureter with dimensions larger than 10 mm as a first-line therapy is preferred to use a laser with URS disintegration of concrements in any site. It provides both quickly and relatively safely complete destruction of the stone in the ureter, leaving in the urine only dust and small particles.
Some people may also form stones in the bladder. This occurs most commonly when there is narrowed outlet of the bladder or frequent infections.
In such stones it is most convenient to penetrate the urethra. There are methods of mechanically breaking. With their help the stones are crushed and fragments evacuate through the working channel of the instrument. A good alternative is laser breaking, which is possible for use for fragmentation ofconsiderably larger stones – 2+ inches. In some larger or multiple stone it may be needed open surgery.
As seen modern urology has a great arsenal in the battle with urolithiasis. Decision about which is the best method to treat kidney and ureteral stonesdepends on the experience of a good urologist.