Kidney Stones Treatment options
The last thirty years has seen a revolution in the surgical management of urinary stone disease with the gradual disappearance of open stone surgery and the emergence of increasingly efficacious minimally invasive techniques. This is probably best illustrated by the extraordinary success of extracorporeal shockwave lithotripsy, which is now considered first line management for the majority of renal and ureteric calculi.
Pain relief is the first priority and there has been a trend toward the use of non-steroidal anti-inflammatory agents (NSAID) as first line agents perhaps because of the worry concerning the opiate seeking patient. Evidence suggests opiates and NSAID’s are equally effective at relieving the pain of ureteric colic and are often used in combination. There is concern that opiates may lead to an increase in ureteric tone but, conversely, NSAID may interfere with the kidney’s ability to autoregulate its response to obstruction leading to a reduction in renal blood flow. NSAIDs are contra-indicated in patients with pre-existing renal impairment and care should be taken in those with asthma and pre-existing gastro-intestinal disorders. The role of other agents such as desmopressin and acupuncture is uncertain.
Not all patients require hospital admission. However, it is mandatory in some circumstances, namely: signs or symptoms of superadded infection requiring emergency treatment to relieve obstruction; unremitting, uncontrolled pain; renal failure relating to an obstructing stone in a single functioning renal unit or bilateral calculi and probably in those patients with stones of sufficient size that they are unlikely to pass (i.e. ›5mm).
Most calculi will pass spontaneously (90%); the golden rule is that stones ‹5mm will pass naturally. There is now quite strong evidence that previously normal kidneys can resist clinically significant damage from obstruction for up to 4 weeks, so it is reasonable to leave stones of ‹5mm for four weeks prior to considering intervention. The indications for treatment of ureteric stones are therefore:
1) Uncontrollable pain
2) Renal impairment with single functioning renal units or bilateral calculi
3) Stones larger than 5mm diameter
4) Stones that have been in-situ for up to 4 weeks
5) Recurrent urinary tract infections