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Kidney Stone Treatment

Treatment
Treatment depends on the size and type of stone, the underlying cause, the presence of urinary infection, and whether the condition recurs. Stones 4 mm and smaller (less than 1/4 inch in diameter) pass without intervention in 90% of cases; those 5 – 7 mm do so in 50% of cases; and those larger than 7 mm rarely pass without intervention. Patients are advised to avoid becoming sedentary, because physical activity, especially walking, can help move a stone.

If possible, the kidney stone is allowed to pass naturally and is collected for analysis. The patient is instructed to strain their urine to obtain the stone(s) for analysis. It is important to analyze the chemical composition of kidney stones to determine how to prevent recurrent stone formation. The urine may be strained using an aquarium net or another device. Each voiding should be strained until the physician instructs the patient otherwise.

Dietary changes may be required and fluid intake should be increased. Patients with stones must increase their urinary output. Generally, 2000 cc of urine per day (slightly more than 1/2 gallon) is recommended and patients should drink enough water to produce this amount of urine daily. In some cases (e.g., some cystine stone formers), even higher levels of fluid intake are required.

Dietary calcium usually should not be severely restricted. Reducing calcium intake often causes problems with other minerals (e.g., oxalate) and may result in a higher risk for calcium stone disease.

Hypercalciuria
Thiazides, water pills (diuretics), are sometimes prescribed to reduce high levels of urinary calcium (hypercalciuria) and to increase urinary volume. Patients with hypercalciuria who do not respond to thiazide therapy may be prescribed orthophosphates to reduce calcium absorption and may be given dietary calcium restrictions. Patients should not reduce their calcium intake unless their physicians advise them to do so.

Hyperuricosuria
Patients with elevated uric acid levels (hyperuricosuria) are advised to drink 3 liters of water a day and reduce excessive dietary protein. Potassium citrate (medication that maintains the antacid level in urine) or allopurinol (medication that stops the production of uric acid) may also be prescribed.

Hyperoxaluria
Hyperoxaluria (high levels of urinary oxalate) may be mild, enteric, or primary. Mild hyperoxaluria is usually caused by an excess of dietary oxalate (found in tea, chocolate, cola, nuts, and green leafy vegetables). Prevention consists of daily doses of pyridoxine (vitamin B-6), which reduces oxalate excretion, increased fluids, phosphate therapy, and sometimes, calcium citrate supplementation.

A low-oxalate, low-fat diet, increased fluid intake, and calcium supplementation is prescribed for enteric hyperoxaluria. This rare condition is often severe and is usually caused by an intestinal disorder (e.g., Crohn’s disease, colitis). Calcium citrate, magnesium, iron, and cholestyramine may be given to reduce oxalate levels.

Primary hyperoxaluria is rare, severe, and caused by an inherited liver disorder. Primary hyperoxaluria requires aggressive treatment to prevent severe renal stone disease and kidney failure. High doses of vitamin B-6, orthophosphates, magnesium supplements, and increased fluid intake (to produce 2 liters of urine/day) are prescribed. Rarely, kidney and liver transplants are necessary.

Hypocitraturia
Hypocitraturia (low level of urinary citrate) usually requires a prescribed supplement, such as potassium citrate. The dosage depends on the level of urinary citrate, which is determined by the 24-hour urine test. Patients with renal tubular acidosis usually respond well to treatment with potassium citrate supplements. Citrus fruits and lemon juice also can be used as supplements.

Cystinuria
Treatment for high cystine levels in the urine (cystinura) includes increasing fluid intake and raising the pH of the urine (usually with bicarbonate). Penicillamine (Cuprimine®) and tiopronine (Thiola®) may also be prescribed.

Medication
Over-the-counter pain relievers (e.g., aspirin, Tylenol®, Advil®) usually are not effective for severe pain caused by kidney stones. Oral analgesics such as acetaminophen/codeine (Tylenol with Codeine&174), propoxyphene HCL (Darvon®), and oxycodone/acetaminophen (Percocet®) may be prescribed to minimize moderate pain associated with stones.

Injectable medications such as morphine sulfate (Duramorph PF®), meperidine HCL (Demerol®), and tramadol HCL (Ultram®) may be administered intravenously (IV) or intramuscularly (by injection) for severe pain. There is a risk for dependency with oral narcotic analgesics. Side effects of these medications include the following:

  • Constipation
  • Drowsiness
  • Nausea
  • Slowed breathing (respiration)
  • Vomiting

Surgery
If a kidney stone does not move through the ureter within 30 days, surgery is considered. Urologists use several procedures to break up, remove, or bypass kidney stones.

Ureteroscopy
This procedure can be used to remove or break up (fragment) stones. A fiberoptic instrument resembling a long, thin telescope (ureteroscope) is inserted through the urethra and passed through the bladder to the stone. Once the stone is located, the urologist either removes it with a small basket inserted through the ureteroscope (called basket extraction) or breaks the stone with a laser or similar device. The fragments are then passed by the patient. Ureteroscopy is performed under general anesthesia or spinal.

Extracorporeal shock wave lithotripsy (ESWL) uses highly focused impulses projected from outside the body to pulverize kidney stones anywhere in the urinary system. The stone usually is reduced to sand-like granules that can be passed in the patient’s urine. Large stones may require several ESWL treatments. The procedure should not be used for struvite stones, or in pregnant women.

Patients undergoing lithotripsy are given a sedative and general or local anesthesia.

Percutaneous Nephrostolithotomy (PCN)
This surgical procedure is performed under general anesthesia. Percutaneous (i.e., through the skin) removal of kidney stones (lithotomy) is accomplished through the most direct route to stones through the kidney. A needle and guidewire are used to access the stones. The surgeon then threads various catheters over the guidewire and into the kidney and manipulates surgical instruments through the catheters to fragment and remove kidney stones. This procedure achieves a better stone-free outcome in the treatment of medium and large stones than shock wave lithrotripsy. This procedure usually requires hospitalization, and most patients resume normal activity within 2 weeks.

Ureteroscopic Stone Removal
This procedure is performed under general anesthesia to treat stones located in the ureter. A small, fiberoptic instrument (ureteroscope) is passed through the urethra and bladder and into the ureter. Small stones are removed and large stones are fragmented using a laser or similar device. A small tube (or stent) may be left in the ureter for a few days after treatment to promote healing and prevent blockage from swelling or spasm.

Open Surgery
This procedure requires general anesthesia. An incision is made in the patient’s back and the stone is extracted through an incision in the ureter or kidney. Most patients require prolonged hospitalization and recovery takes several weeks. This procedure is now rarely used for kidney stones.