Kidney stone treatment

Treating Kidney Stones

Our kidney stone specialists work with you to create a plan to manage and treat your stones. Whether or not you need surgery, patient education is an important part of our program.

Should my stone be removed?
Most stones do not require surgery. A variety of factors are considered when deciding if surgery is the best option. Decision making depends on where your stone is located:

How should my stone be removed?
At the HealthEast Kidney Stone Institute, we offer a complete range of treatment options. If you need surgery, we carefully explain your options - including advantages, disadvantages and success rates. Our specialists will guide you to choose the best treatment for your condition.

Our goal is to provide treatment that is successful in a single procedure, with the least possible discomfort. This helps you get back to your regular activities as quickly as possible.

The Kidney Stone Institute offers these treatments:

Shock wave lithotripsy (ESWL) - High-intensity sound waves are directed at the stone. The goal is to break the stone into tiny fragments (about the size of grains of sand) so they can flush out of the body with the urine.
Ureteroscopy - A small telescope is passed through the urethra and bladder and up the ureter until the stone can be seen. Small stones may be removed in one piece. Larger stones are broken using a laser and fragments are then removed.
Percutaneous nephrolithotomy (PCNL) - A small incision (about the size of a fingertip) is made in the side. A narrow tunnel is then created directly into the kidney. A special telescope is used to break the stones and remove the fragments from the kidney.

Success Rates
Success rates vary by treatment and no treatment for stones works 100% of the time.

Every patient wants to know, and absolutely should know, before their procedure what the chance of success for their particular situation should be. Any time a stone is broken, fragments and dust are generated and there is the possibility that some will be left behind.

Should my kidney stone be removed?

Kidney stones fall into two basic categories:

Those that are currently causing symptoms (such as infection or pain). These stones require treatment.
Those that have the potential to cause symptoms in the future. Although there's usually no need to treat a stone that's not causing symptoms, we understand that many people do not want the potential for disruption in their lives. Approximately 50% of kidney stones that currently aren't causing problems will cause symptoms sometime in the next five years.

What is "watchful waiting"?
Watchful waiting means that you currently don't need treatment to remove kidney stones, but your doctor continues to watch the stones to see if they are growing or changing. At the HealthEast Kidney Stone Institute, periodic x-rays or CT scans are performed to determine if stones are increasing in size and number. Patients can undergo stone removal if their condition or priorities change.

Reasons to leave a kidney stone untreated

Your stone isn't currently causing symptoms
Your stone is small (those stones less than 5 mm in size are often capable of passing on their own if they fall into the ureter).
You prefer to avoid treatment

Reasons to treat a kidney stone

Stone is causing pain or other symptoms
Chronic or recurrent urinary tract infections
Kidney stones may harbor infections that the body is unable to clear, even with antibiotics. At that point, the only way to clear these infections is by removing the stone.
Larger stones
Stones greater than 5 mm are unlikely to pass on their own and usually require treatment if they fall into the ureter. This creates an unwanted emergency.
Staghorn stones
Staghorn stones are large and usually infection related. Because they can grow to huge sizes and fill the kidney, they can pose kidney and health risks if left untreated. The American Urological Association recommends that these stones be treated whenever they are discovered.
Occupational requirements
For example, FAA regulations require that airline pilots be grounded until the stone is cleared. Even when not required by their occupations, many people do not have schedules that allow unanticipated time away from their work.
Women of childbearing age
During pregnancy an obstructing stone is often more difficult to diagnose and treat and can pose risks to mother and unborn child. We recommend that any woman planning pregnancy who has known stones undergo elective stone clearance prior to conception.
Travel to medically underserved areas
People who frequently travel to areas where medical care is unavailable or unreliable should consider treatment to avoid an incident in less than optimal conditions.
Patient preference
Many patients simply want their stones removed. We are particularly sensitive to those patients who have taken steps to reduce their risk of stone recurrence but have one or more stones remaining in their kidneys. Many patients opt to schedule treatment when it's convenient for them and select therapies that are most likely to clear the stone in a single treatment.

Should my ureteral stone be removed?

A ureteral stone is a stone that is in the ureter (the narrow duct that drains urine from the kidney to the bladder).

Once a stone enters the ureter, one of two things will happen:

The stone will pass. The chances that a stone will pass can be predicted from previous experience.
The stone will need to be removed. If it looks unlikely that the stone will pass, we offer treatment as soon as possible.

Ureteral stones and size:

Large stones generally cause symptoms as soon as they enter the ureter.
Some larger stones are big enough to have irregular shapes, so they may not completely obstruct the ureter and cause severe symptoms.
Smaller stones often make their way further down the ureter before they are noticed.
Small smooth stones often are associated with more severe pain as they are more likely to completely obstruct the ureter.

Stone symptoms occur when a stone gets stuck. Stones are commonly discovered at these three locations:

The start of the ureter.
Two-thirds of the way down the ureter.
Near the bladder.

A single stone may cause symptoms at any or all of these locations. Unfortunately, the severity of pain and number of attacks vary from person to person and aren't good indicators if a stone will pass on its own.

Reasons to leave a ureteral stone untreated

Smaller stones are more likely to pass
Stone location - the farther a stone progresses, the better its chances of passing.
Previous successful stone passage - patients who have successfully passed stones in the past will often do so again.
Patient who wish to avoid surgical intervention will often tolerate episodes of discomfort

These factors support pursuing a trial of passage.

What is "trial of passage"?
When a ureteral stone has a reasonable chance of passing by itself, we support the patient through this process. Depending on the size, location and symptoms, follow-up CT scans are performed every one to two weeks. Patients are closely monitored for signs of trouble.

What if I pass the stone?
If the stone passes, it is important to save it and bring it into the clinic. An analysis of the stone's composition may provide important information to help you prevent future stones.

When treatment is required
Treatment is always available if the stone fails to progress down the ureter or begins to cause more severe symptoms. Emergent surgical stone removal is available on a prompt basis when necessary. In general, we allow about one month for a stone to pass if symptoms are tolerable.

Reasons to treat a ureteral stone

Fever
Larger stones are less likely to pass
Stone location - the farther a stone needs to move, the less likely it is to do so.
Previous stones that didn't pass - patients who have had trouble in the past, often will again.
Duration of symptoms - treatment is recommended if a stone hasn't progressed within one month.
Patient preference - many patients want the stone removed as quickly as possible.

These factors support early treatment.

Shock wave lithotripsy (ESWL)

-------------------------------------------------------------------

Research in the News:
Researchers at Mayo Clinic reported an increased rate of diabetes and high blood pressure in patients who have been treated by shock wave lithotripsy (ESWL) for stone disease.
Click here to view the New York Times article.

In a separate study, researchers in Indiana found that ESWL can damage kidneys. The more ESWL treatment they had, the more kidney damage they experienced.

What this means for stone sufferers: Even prior to the study, Dr. Andrew Portis, Medical Director of the HealthEast Kidney Stone Institute, largely stopped using ESWL because the treatment was not effective enough in clearing stones. If you are planning to have ESWL, it is important to ensure that the procedure is likely to be successful in a single treatment. If you have had ESWL in the past, talk to your primary doctor about annual screenings for high blood pressure and diabetes.

To give you the best results possible: The Kidney Stone Institute offers innovative non-ESWL techniques that have high success rates. These include ureteroscopy and percutaneous nephrolithotomy . We work with each patient to aggressively treat and prevent stone disease.

------------------------------------------------------------------------------

About ESWL
Shock wave lithotripsy, or ESWL, is an outpatient procedure usually performed under general anesthesia. ESWL generally takes about an hour.

ESWL procedure
First, the kidney stone is located by x-rays. Then, the doctor directs high-intensity sound waves at the stone. The goal is to break the stone into tiny fragments (about the size of grains of sand) which may then flush out of the body with the urine. After three months, many ESWL patients are free from stones; however, some may require additional treatments.

During ESWL, it is possible that some stones may not break or may break into large pieces that are difficult to pass. There is a limit to the number of shock waves that can be safely administered in a single treatment session.

If you need a stent
A ureteral stent may be inserted at the time of treatment if your doctor is concerned that stone fragments will block the ureter. Stents are most commonly used for patients with ureteral stones, large stones (usually greater than 15 mm), particularly dense stones or a history of urinary tract infections. Stents are usually removed in the urologist's office, after post-treatment x-rays indicate that there is no longer a risk of obstructing fragments.

Advantage of ESWL
The major advantage of ESWL is that it doesn't require incisions (like surgery) and recovery is very fast.

ESWL may be a good option for:

Stones that can be seen on an x-ray (are radio-opaque)
Kidney stones less than 20 mm
Ureteral stones less than 10 mm

ESWL may NOT be a good option for:

Stones that are difficult to see on an x-ray
Stones in the bottom part of the kidney (lower pole stones)
Mid ureteral stones - Treating stones in the region of the ureter overlying the bony pelvis is not recommended because bone blocks shockwaves and makes it difficult to find the stone.
Distal ureteral stones - These stones are often better treated by ureteroscopy
Chronic infection - The only way to stop chronic infection associated with kidney stones is to completely remove the stones. ESWL tends to leave small fragments behind.
Obstruction distal to stone - if the ureter is blocked by scarring or some other proces, the stone fragments are unlikely to pass.
Patients on "blood thinners" - ESWL treatment carries a risk of bleeding from the kidney.
Obesity - Stones can be difficult to see in heavier patients. Most ESWL units cannot support a patient heavier than 350 pounds.
Patients who require complete stone clearance - It may take up to three months for all fragments to clear after ESWL and that time period may be unacceptable for some patients.

What is the success rate of ESWL?
As with any medical procedure, your doctor can't guarantee success. To give our patients the best chance at getting rid of stones, we select patients who are most likely to succeed before recommending ESWL.

Much of the research evaluating the effectiveness of ESWL was completed before CT scans were commonly used for stone disease. Therefore, it is difficult to compare older research with current research.

Older research
Using plain x-rays, patients with fragments less than 4 mm in size were generally considered to have had a successful treatment. Using this criteria, "successful treatment" occurs for 70 - 80% of ureteral stones and 60 - 80% of kidney stones.

Current research
A more recent study used CT scans to look for fragments in patients with lower pole stones less than 1 cm who had undergone ESWL treatment. Researchers found that less than 30% of patients had completely successful treatment.

How will I feel after ESWL?
Most patients experience discomfort for a day or two after ESWL. Generally, the discomfort is at its worst the evening after surgery and then gradually lessens. It is normal to see small amounts of blood in the urine for up to a month after surgery. As with any procedure requiring general anesthesia, many patients also find that they are more tired for up to a month after the procedure.

While most patients who undergo ESWL don't have complications, it's important to report any of the following to your doctor:

Increasing pain - May be sign of an obstruction caused by kidney stones or kidney injury
Heavy bleeding or blood clots - May be a sign of kidney injury
Fever - May indicate a serious kidney infection
Feeling unwell - It is normal to feel tired but it is not normal to feel sick

What follow-up is required after ESWL?
If you have a stent, your urologist will want to see you one week after the procedure. An x-ray will be taken to see if the stone has cleared. If so, the stent can be removed. If the stone fragments haven't cleared, x-rays may be repeated every one to two weeks.

If you don't have a stent, an x-ray will be performed one month after the procedure to see if the stone fragments have cleared.

In either case, if large stone fragments remain, further treatment with ESWL or ureteroscopy may be recommended.

Ureteroscopy

Ureteroscopy is a procedure that removes stones and stone fragments. It doesn't require an incision and is usually performed under general anesthesia.

Ureteroscopy procedure
The doctor passes a small telescope (called a ureterscope) through the urethra and bladder and up the ureter until the stone can be seen. Small stones are often removed in one piece. Larger stones are broken using a laser and pieces of the stone are removed. A stent (small tube) may be left in the ureter for several days after treatment to make sure that the kidney drains well.

Ureteroscopy may be a good option for:

Stones in any location in the ureter or kidney
Stones that may or may not be seen on an x-ray
Stones smaller than 1.5 cm, anywhere in the urinary tract
In very carefully selected situations, patients with who cannot be safely treated by ESWL or PCNL may be treated by ureteroscopy.
- People who are on blood thinners for heart or blood clotting disorders may be treated without stopping their medication.
- Pregnant women may be safely treated during pregnancy.

Ureteroscopy may NOT be a good option for those with:

Large stones - Destruction of stones greater than 15 mm may generate too many fragments to completely clear.
History of bladder or ureteral reconstruction - Patients who have had their bladders removed for cancer or who have had major bladder or ureteral reconstruction may be poor candidates for ureteroscopy.

Chronic urinary tract infection - The only way to stop chronic infection associated with kidney stones is to completely remove the stones. To minimize the chances of leaving fragments behind, percutaneous surgery may be a better option for patients with larger stones (about 10 mm).

What is the treatment success rate?
Success rates are generally high because the stone or stone fragments are removed. It is very unusual for patients to require any further treatment after ureteroscopic stone treatment. 95% of patients who undergo ureteroscopy require only a single treatment.

What should I expect after treatment?
After ureteroscopy, most patients experience irritation of the bladder and urethra. You may have to urge to urinate frequently and feel some burning when urinating. Many of these symptoms are due to irritation from the stent. You may also experience blood in your urine, as well as some discomfort from the stent.

Call your doctor if you experience:

Increasing pain - May be sign of ureteral injury or blockage
Heavy bleeding or blood clots - May be a sign of ureteral injury
Fever - May indicate a kidney infection
Feeling unwell - It is OK to feel tired but it is not OK to feel sick

What follow-up is required after ureteroscopy?
Ureteral stents are generally removed a week after the procedure, during a doctor's visit. A CT scan is usually performed one month after the procedure if a laser was used to break up the stone. The scan checks on the kidneys and makes sure that all stone fragments have been cleared.

Percutaneous nephrolithotomy (PCNL)

Percutaneous nephrolithotomy, or PCNL, is performed under general anesthesia. During the procedure, your doctor makes a small incision in your side about the size of a fingertip. A narrow tunnel is then created directly into the kidney. A special telescope (called a nephroscope) is used to examine the inside of the kidney. Stones are broken by high speed vibration or a laser. This procedure usually requires a one to three day hospital stay and most patients resume normal activity within two weeks.

Watch a PCNL procedure
Click here to view our web cast. Watch St. Joseph's doctors perform PCNL surgery.

Traditional Percutaneous Nephrolithotomy
Traditional PCNL involves a series of steps performed over several days.

On the first day, a tract is established into the kidney and the doctor tries to remove all stones.
A nephrostomy tube (a soft plastic tube that is inserted though the back and into the kidney) is left in to help the kidney drain.
The day after surgery, a CT scan is performed to look for any remaining stones.
If stones remain, a "second look" procedure may be performed on day two or three through the existing tract or, if necessary, new access tracts are created.
When all stones are cleared, x-ray contrast media is injected into the nephrostomy tube to ensure that the kidney is draining well. If it is, the nephrostomy tube is removed. If the kidney is not draining well, the nephrostomy tube may be left in for a few more days or an internal ureteral stent may be placed temporarily until the kidney and ureter recover from surgery.

"Tubeless" Percutaneous Nephrolithotomy
During a "tubeless" procedure, stones are removed in the same way as traditional PCNL. The difference comes at the end of the procedure. If the urologist is confident that all stones are cleared, a ureteral stent is inserted in place of a nephrostomy tube.

If all stones cannot be cleared during the initial procedure or if there is significant bleeding during the procedure, patients must undergo traditional PCNL.

Advantages of the tubeless procedure

Most patients leave the hospital after overnight observation.
Many require half the pain medication.
At the HealthEast Kidney Stone Institute, 90% of patients with large, complex stones are able to have the tubeless procedure.

What are the best stones to be treated by PCNL?
PCNL is usually reserved for the largest and most complex stones.

Kidney stones treated with PCNL are usually larger than 1.5 cm or cannot be effectively treated with ESWL or ureteroscopy.
On occasion, smaller stones may be treated by PCNL if there is a history of serious infection or if the kidney is malformed.
If a nephrostomy tube has already been inserted for emergency drainage, it may be a simple to complete PCNL treatment

PCNL is used to treat stones:

In any location
That may or may not be seen on an x-ray
Of any size

Who is not a candidate for PCNL?
PCNL is the only way to effectively treat large and complex stones, short of open kidney surgery. There are very few patients with these difficult stones who should not be treated with PCNL. In rare cases where the patient is too fragile or the stone has already destroyed the kidney, the doctor may decide not to treat the stones, but instead to remove the kidney.

PCNL may NOT be a good option for those with the following. Ureteroscopy may be a better option.

Stone less than 10 mm
Morbid obesity (patients who weigh more than 450 pounds)
Patients on blood thinners

What is the treatment success rate?
It is somewhat difficult to generalize about the success rate after PCNL because it is so often used for the most complex stones and patients. In our experience, about 90% of patients with complex stones can be succesfully treated with a single procedure. We strictly adhere to the philosophy that large and complicated stones must be completely removed to minimize the recurrence of similar stones.

What should I expect after treatment?

Blood in the urine, as long as a stent or nephrostomy tube is in place
For patients with a stent

You may need to urinate frequently
There may be discomfort in the back as you begin to void
There may be discomfort in the bladder when voiding is near complete.

For patients with a nephrostomy tube

It may be uncomfortable to sleep on the side of the tube
There may be urine leakage around the tube
After removal of the tube urine may leak out for 1-2 days

The incision in the back may be uncomfortable but should not be painful
It is normal to feel tired for up to one month

What follow-up is required after PCNL?
If your doctor suspects that stone fragments remain after PCNL, a CT scan will be performed the day after surgery to plan further treatment.

If your doctor thinks all stones have been cleared, a CT scan will be performed one month after surgery to confirm that stone fragments have been cleared and to check on the kidneys.

What should I watch out for after surgery?

Blood clots in urine - May be a sign of kidney bleeding
Abdominal pain - May be a sign of urinary leakage
Shortness of breath - May be a sign of fluid in the chest
Fever - May be sign of kidney infection
Persistent leakage from nephrostomy site - May be a sign of an obstructed ureter

Emergency drainage procedures

It may not be safe to remove stones in certain situations, such as:

An active kidney infection, where treatment could cause illness
When patients have other untreated medical problems

In these circumstances, pain can be relieved by placing a stent (internal tube between kidney and bladder) or nephrostomy tube (tube inserted into the kidney through the back).

While these procedures can be performed quickly and can relieve pain, they do not do anything to treat the stone. In emergency situations, the procedures create time and allow treatment to be performed safely.

Stents

Stents are soft plastic tubes that help the kidney drain urine to the bladder. They may be inserted either before treatment because of blockage by stones or after treatment until swelling goes down.

Stents may be inserted:

Before treatment - when stones are causing a blockage
After treatment - until swelling goes down or stone fragments pass.

What should I expect?

A stent may cause some discomfort, including:

The need to urinate suddenly (urgency)
The need to urinate often (frequency)
Pain during urination (dysuria)
Dull backache, which may get worse during urination
Blood stained urine (like fruit punch) and occasional clots, which may increase with physical activity

What can I do to feel better?

Take painkillers as prescribed and required
Bladder relaxing drugs, such as Detrol or Ditropan, may be helpful in some circumstances
Take a warm bath
Understand that the stent is necessary and is only temporary

What should I NOT expect?

Fever
Increasing back pain
Large amounts of blood in the urine
Leakage of urine (incontinence)

How does the stent get removed?

Stents are usually removed in a brief procedure in the urologist's office.

It is your responsibility to make sure your stent is removed. Stents that remain in too long can become encrusted. If this happens, you may require a surgical procedure to remove the stent and encrustations. Except in very select circumstances, stents should never be in the body for longer than 3 months.

What should I expect after stent removal?

Brief increase in back pain about an hour after stent removal as the kidney fills before it starts to drain
Bladder symptoms disappear within 24-48 hours
Blood in urine disappears within 2-4 days

Nephrostomy Tubes

A nephrostomy tube is a soft plastic tube that is inserted though the back and into the kidney. It ensures that the kidney is draining urine well. Nephrostomy tubes are commonly used for complex kidney stones. They may be inserted either before treatment because of blockage by stones or after treatment until swelling goes down or until stone removal is completed by further surgery.

What should I expect?

A nephrostomy tube may be associated with

Dull backache, which may get worse during urination
Blood stained urine (like fruit punch) and occasional clots, which may increase with physical activity
Irritation at the insertion site
Leakage of small amounts of urine around tube