Kidney stones are medically treated based on their size, number, location and the type of stones. Treatment for kidney stones has undergone rapid change in the last 30 years. Latest advancements and techniques in the way kidney stones are treated has almost eliminated open surgical procedures. Present day treatments focus mainly on minimally invasive techniques even for the tough to treat kidney stones. Newer technologies have the capacity to disintegrate larger, harder and deeper stones. Latest techniques allow greater flexibility and higher rates of faster recovery with same-day discharge and early return to office work and daily activities. Recent innovations that have improved kidney stone treatment in a variety of ways are discussed here.
Shock Wave Lithotripsy
This is the popular choice of non-invasive procedure that is effective in half of the population with kidney stones. It is the best suitable daycare procedure for small or medium-sized stones. Kidney stones are diagnosed and located with X-ray images. This procedure involves sending high-energy shock waves from the outside, aimed at the stones located in the kidney. Lithotripsy simply means to medically break down stones. The focussed shock waves shatter the stone with minimal effect on the surrounding tissues. Broken pieces of the stone are then passed out while passing urine. Fragmented stones cause very little or no discomfort with the flow of urine.
- High success rate in managing small and medium-sized stones
- Convenient outpatient procedure
- Minimal discomfort post the procedure
- No surgical incisions or invasive procedures
- Easy, fast and immediate scheduling
- Cramps or blood in the urine can occur as side effects.
- There may be bleeding around the kidney
- Infections are likely
- Shock waves may cause damage to the kidney
- Fragmented stones may block the flow of urine
Ureteroscopy is the latest advancement over cystoscopy to view the inside of the ureters and kidneys. The ureteroscope gives a more detailed image because it uses a thinner, longer and flexible device that passes along the inner lining of the ureters and kidneys. The advent of single-use ureteroscopes replacing the reusable ones that are fragile and need constant repair is a breakthrough advancement. The single-use ureteroscopes are also superior in terms of better deflection and flow with higher cost-effectiveness and improved access to kidney stone care.
Having located the stones through a ureteroscope, laser is used for breaking the stones. The fragments are extracted and remaining dust is passed with urine through an internal stent fixed from the target point of the kidney to the urinary bladder. This is a same-day, outpatient procedure done under anaesthesia. The stent needs to be removed after a period of 3 days. Ureteroscopy is preferred for stones that are harder, are not visible in the X-ray and lie low in the urinary tract.
- Higher success rates for small and medium-sized kidney stones
- Versatility and capability of treating some hard to break stones
- Stopping blood-thinning medication is not necessary as otherwise with invasive procedures
- Outpatient day care procedure
- No incisions and less invasive than open surgeries
- Scheduling of kidney stone treatment is faster
- Other techniques are better suitable for larger stones.
- Though they are small in size and flexibility is good, ureteroscopes may not be able to reach the stone.
- Stents that are often placed after ureteroscopy help maintain drainage while swelling resolves but patients may find these stents to be uncomfortable until they are removed.
- Little blood passed with urine due to the presence of the stent may worry about the patient.
Percutaneous Nephrolithotomy (PCNL)
Presently, this is the standard surgical procedure for removing large, complex stones or many stones in one kidney. The procedure requires inpatient admission with an overnight hospital stay. It is done under anaesthesia and a small puncture is made on the back through which the instruments are sent through directly into the drainage system of the kidney. Special set of equipment is used to shatter the stone. The broken stone fragments are removed either through suction or with the help of graspers. A stent may be left in place to drain the dust. A second clean up procedure may be needed for clearing complicated stones. The smaller the percutaneous nephrolithotomy device, the smaller the incision and instruments, allowing the complete procedure to be miniaturised. In comparison to the above-discussed techniques, though this may be little more invasive, is yet the safest and more effective with a high level of patient satisfaction.
Advantages of PCNL include:
- It is appropriate for very large or complex stones and for patients with several smaller stones in one kidney.
- Better scope for clearing most stones completely with a single procedure
- Safe and effective application
- Highly trained surgeons specialized in PCNL perform the procedure
- Better outcome
- Most complex stones may require follow up procedures
- A temporary drainage stent is necessary after the procedure
- Cannot be performed with patients on blood-thinning medicines
- Requires overnight stay at the hospital
- Renal trauma could be a morbid complication
Holmium Laser Technology
The use of Holmium: YAG laser for stone lithotripsy through ureteroscopy has become a safe and efficient approach. The procedure is an outpatient basis and is carried out with the patient under anaesthesia. The Holmium laser is effective for any composition of stones. A laser fibre is used to transmit Holmium energy that ablates the stone with a photothermal effect. The vapour pressure created by the laser radiation being absorbed by the residual content of water in the stone, causes the stone to break. A stent is usually placed between the kidneys and the urethra for better healing and easy passing of the stones. The device offers three different settings depending on the desired effect for shattering the stone.
- Fragmentation – the stone is broken into pieces that can be removed using tools such as grasper and basket.
- Dusting – The Moses effect uses energy to break stones into fine particles that can be passed through the urine spontaneously.
- Pop Corn effect – parameters to break the fragments further down to smaller ones are applied.
- Can be applied for all types of stones
- One of the safest tools in Urology
- High success rates with single treatment
- Complications are very rare
- Fast recovery
- Stent pain may persist until the stent is removed
- May cause mild bleeding in the urine
Retrograde Intrarenal Surgery (RIRS)
The procedure is done by a surgeon trained in RIRS. The patient may be either under spinal or general anaesthesia. A fibreoptic endoscope is used for viewing the kidney during the surgery. The scope is inserted via the urethral opening into the urinary bladder, passed through the ureter and then reaches the draining part of the kidney. The scope is moved against the direction of the flow of urine and hence the name retrograde. The stone is manipulated by viewing through the scope and is crushed with the help of an ultrasound probe or a laser probe. RIRS continues to grow with significant advancements and is emerging to be the first-line procedure for challenging stone cases in some of the best kidney stone hospitals.
- Good stone-free rate
- No incision required
- Fastest rate of recovery
- No prolonged pain after surgery
- No major complications
- One day stay at the hospital may be required
Management of kidney stones depends on selecting the most appropriate technique based on stone size, surgeon’s choice of treatment, intrarenal anatomy, stone composition and location. Furthermore, the same procedure can have a combination of techniques best suitable for the patient to achieve better results. Many new innovations for the treatment of kidney stones are expected in the coming years. However, further prevention, diet and lifestyle choices cannot be ignored in the management of kidney stones.