If you have been diagnosed with a kidney or ureteral stone, there are different treatment options which you can discuss with the urologist. Together, you can decide which approach is right for you.
Factors that influence the decision include:
· Your symptoms
· Stone characteristics
· Your medical history
· The kind of treatment available in the hospital and the expertise of your doctor
· Your personal preferences and values
Not all stones require treatment. You need treatment if your stone causes discomfort and does not pass or likely to pass, naturally with urine. Urologist may also advise treatment if you have pre-existing medical conditions.
There are different treatment methods for emergency and non-emergency situations.
Treatment of emergency situations
Acute renal colic
Renal colic is an acute, painful situation caused by a stone that blocks the ureter. Go to the family doctor or the nearest emergency room as soon as possible to relieve the pain.
Pain is usually relieved with NSAIDs (non-steroidal anti-inflammatory drugs), which you can take as a tablet or a suppository. If this first step of treatment does not help, you will get stronger painkillers called opioids. Usually, they are injected directly into the vein. On a rare occasion, drugs do not work. In this case, the doctor may need to drain urine from your kidney. This is called decompression.
There are two methods of decompression:
- By placing a ureteral JJ-stent in the ureter through the urethra.
- By inserting a Percutaneous Nephrostomy Tube into your kidney directly through the skin
Both methods are equally effective
Obstructed and infected kidney
If there is renal colic together with fever, one should go to the closest urological department at once. Get blood, urine tests and imaging, to check if you have an infected, obstructed kidney. If you do, you need immediate decompression to relieve the pressure in the kidney.
After the decompression, one will get antibiotics to clear the infection. Treatment of stones in such situations to be done only after the infection is gone.
Treatment of non-emergency situations
If kidney or ureteral stone does not cause discomfort and likely to pass spontaneously (smaller in size, closer the stone to bladder……more likely to pass, bigger the stone…lessen the chance of passing), urologist can prescribe drugs to ease the process. This is called conservative treatment. Urologist will give you a time schedule for regular control visits to make sure your condition does not get worse.
If your stone continues to grow or causes frequent and severe pain, you will get active treatment.
Conservative stone treatment
Urologist can prescribe drugs if stone is smaller and causing pain or discomfort to ease its expulsion. This therapy is called as medical expulsive therapy(MET). If you have a very small stone, there is a 95% chance of passing this stone within 6 weeks.
During MET, you should visit urologist regularly - how often depends on his recommendation. The doctor needs to check if the stone keeps moving and if your kidneys continue to function well.
Active stone treatment
Kidney or ureteral stones should be treated if they cause symptoms. If you don't have symptoms, you may still get treatment in case:
· The stone continues to grow
· You are at high risk of forming another stone
· You have an infection
· Your stone is very large
· You prefer active treatment
Urologist will recommend to remove a stone in the ureter if:
· It seems too big to pass with urine
· You continue to suffer from pain while you take medication
· Your kidneys have stopped or may stop to function properly
There are three common ways to remove stones: shock-wave lithotripsy (SWL), ureterorenoscopy/Retrograde intra-renal surgery (URS/RIRS), and percutaneous nephrolithotomy (PNL). Each of these procedures has advantages and disadvantages. It is important to talk about your symptoms and test results with the urologist to find the most efficient treatment option for you.
Shock-wave lithotripsy (SWL)
SWL is done with a machine that can break stones from outside the body. To break the stone, focused shock waves (short pulses of high energy sound waves) are transmitted to the stone through the skin. The stone absorbs the energy of the shock waves and this breaks it into smaller pieces. The fragments then pass with urine
When is SWL not recommended?
There are several contraindications for SWL that either have to do with your physical condition or with the characteristics of the stone.
SWL is not recommended if:
· You are pregnant
· You have high risk of severe bleeding
· You have any uncontrolled infections
· You have uncontrolled high blood pressure
· Your physique makes it difficult to reach the stone
· You have an aneurysm
· You have an anatomical obstruction in the urinary tract, below the stone or in the bladder
· Your stone is very hard (for instance cysteine stones)
Will I be stone free directly after treatment?
No. SWL breaks stone into small pieces. These fragments will pass with urine in the days or weeks after SWL. You may need multiple sessions for larger stones
How long will it take me to get back to my normal daily activities?
In general, one can go back to regular activities right after treatment. However, make sure to get some rest on the day of the procedure. If you have received medication against the pain or to calm you down, do not drive a car or operate any other motorized vehicle within the first 24 hours after SWL.
Ureteroscopy/Retrograde intrarenalsurgery (URS/RIRS)
URS/RIRS is a type of treatment which is done with a small-calibre endoscope(Rigid/Flexible). Stones can be located, disintegrated (with laser or pneumatic), and removed in a single procedure. URS/RIRS success rates are high, and the risk of complications is low.
Based on how the operation goes, your doctor may need to place a JJ-stent in the ureter to make sure urine can flow through the urinary system. The stent will be removed when your urine flow is back to normal. This can take anywhere between several days and a few weeks.
When should I consider URS/RIRS?
If your stone is not large (generally under 2cms), URS/RIRS is an alternative to SWL. Although URS/RIRS is more invasive than SWL, it is a safe and effective treatment option for kidney and ureteral stones. Because the stone fragments are removed during the procedure, you don't have to pass them afterwards. You have a high chance of being stone-free with a single operation.
When is URS/RIRS not recommended?
In general, it can be performed in almost every patient, as long as your condition allows anesthesia and you do not have an untreated urinary tract infection. URS/RIRS can even be done without stopping medication for blood clotting. However, it is always important to discuss your individual situation with the urologist.
How long will it take me to get back to my normal daily activities?
Usually you can leave the hospital 1 day after the procedure and return to your normal daily activities. Your urine can contain some blood for a couple of days. If a JJ-stent was placed during the procedure, urologist will take it out after some time.
Percutaneous Nephrolithotomy (PNL)
PNL is a surgery to remove large stones directly from the kidney. The advantage is that even very large stones are removed in a single operation. However, compared to SWL and URS/RIRS, it is more invasive and there is a slightly higher risk of complications. The most common complications of PNL are bleeding and fever.
How is PNL performed?
PNL is carried out under general anesthesia. While you are under anesthesia, the urologist punctures the kidney with a needle through your skin. The doctor makes the puncture channel large enough to insert the nephroscope. Depending on the size of the stone, it is either removed completely or it is broken into smaller pieces first. Fragmentation of the stone is done with laser, ultrasound, or a pneumatic lithotripter (which works like a little jackhammer). At this point all stone fragments are removed. Sometimes a JJ- stent or a percutaneous nephrostomy tube is placed to make sure that urine can leave your kidney.
When should I consider PNL?
PNL should be considered when your stone is very large (bigger than 2 cms) and has not moved to the ureter. Urologist may also discuss PNL as a treatment option if:
· You have more than one stone
· Your stone is very hard
When is PNL not recommended?
PNL is a safe and effective procedure but there are some contraindications because the stone is accessed directly through the skin. If you take medication to prevent blood clotting, you should stop taking it before the procedure. However, it is always important to discuss your individual situation with the doctor. In addition, PNL is not recommended if you are pregnant or if your physique makes it difficult to access the kidney.
How long will it take me to get back to my normal daily activities?
After PNL you will stay in the hospital for two to three days. In case, you have a percutaneous nephrostomy tube, you will be discharged when it gets removed by the doctor. Your urine might be a little bloody for the first couple of days. Do not plan physical exercise the first two weeks after the procedure.
This post first appeared on Dr. Rahul Yadav Urologist In Lucknow (UP) India, please read the originial post: here
