Kidney Stones

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Surgery

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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

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This procedure can be used to remove or break up (fragment) stones located in the ureter. A special telescopic instrument resembling a long, thin telescope (ureteroscope) is inserted through the urethra and passed through the bladder and up the ureter 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 up the stone with a laser or similar device. The fragments are then passed by the patient. Ureteroscopy is performed under general or regional anesthesia on an outpatient basis.

Lithotripsy
This procedure is most effective for stones in the kidney or upper ureter. Lithrotripsy uses an instrument, machine, or probe to break the stone into tiny particles that can pass naturally. This procedure is not appropriate for patients with very large stones or certain other medical conditions.

Ultrasonic lithotripsy uses high frequency sound waves delivered through an electronic probe inserted into the ureter to break up the kidney stone. The fragments are passed by the patient or removed surgically.

Electrohydraulic lithotripsy (EHL) uses a flexible probe to break up small stones with shock waves generated by electricity. The probe is positioned close to the stone through a flexible ureteroscope. Fragments can be passed by the patient or extracted. EHL requires general anesthesia and can be used to break stones anywhere in the urinary system.

Extracorporeal shock wave lithotripsy (ESWL) uses highly focused impulses projected and focused 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 generally be used for struvite stones, stones over 1 inch in diameter, or in pregnant women.

Patients undergoing lithotripsy are given a sedative and general or regional anesthesia, and the procedure takes over an hour. More than one treatment may be required.

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Percutaneous Nephrostolithotomy (PCN)
This surgical procedure is performed under local anesthesia and intravenous sedation. 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 inside of the kidney. The surgeon then threads various catheters over the guidewire into the kidney and manipulates surgical instruments through the catheters to fragment and remove the kidney stones. This procedure achieves a better stone-free outcome in the treatment of medium and large stones than shock wave lithrotripsy. The procedure usually requires hospitalization, and most patients resume normal activity within 2 weeks.

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Ureteroscopic Stone Removal
This procedure is performed under general anesthesia to treat stones located in the middle and lower 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 fragments, 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.

Prevention

Prevention of renal stone disease depends on the type of stone produced, underlying urinary chemical risk factors, and the patient's willingness to undergo a long-term prevention plan. The patient will be asked to make lifestyle modifications such as increased fluid intake and changes in diet.

Orange juice and lemonade with real lemon juice are good sources of citrate and may be recommended as an alternative to water. Limiting meat, salt, and foods high in oxalate (e.g., green leafy vegetables, chocolate, nuts) in the diet may also be recommended. Medication may be prescribed and treatment for an underlying condition that causes renal stone disease may be necessary.

24-Hour Urine Test

Effective preventative measures are based on the patient's chemical risk factors, which can often be uncovered with a 24-hour urine test and a blood test.

1. The patient strains their urine to collect stones for chemical analysis.
2. The physician performs a blood test to evaluate the serum calcium, uric acid, phosphate, electrolytes, and bicarbonate content.
3. Urine is collected during a 24-hour period and analyzed for calcium, citrate, uric acid, magnesium, phosphate, sodium, oxalate, pH (acid level), and total volume.

The physician evaluates the data and recommends dietary modifications, supplements, and medications to minimize the risk for developing kidney stones. The 24-hour urine test may be repeated several months after treatment has begun to determine the success of the therapy and any adjustments that should be made. Long-term strict compliance and periodic retesting will substantially reduce the risk for future stone formation.

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