B26. Non-medical treatment of urolithiasis: Therapeutic modalities, indications, and contraindications

Kidney stone disease, also called nephrolithiasis or urolithiasis, refers to the presence of symptomatic kidney stones in the urinary tract. When stones are present in the ureter it may be called ureterolithiasis, while stones in the bladder are usually simply called bladder stones or bladder calculi. It's a relatively common condition, with a lifetime prevalence of 10 - 20 percent.

Many have asymptomatic kidney stones (which is not considered kidney stone disease), but in some cases stones can cause urinary obstruction (obstructive uropathy) and resulting damage to the kidney, as well as episodes of severe pain called renal colic. The vast majority of kidney stones pass without intervention within a few days or weeks, but there are options for treatment, including using radiowaves to crush them (ESWL) and removing them surgically.

Extracorporeal shockwave lithotripsy (ESWL)

• First choice to remove stones in most cases
• Procedure
  • The stone is located by x-ray or US
  • Uses shockwaves to fragment the stones into fragments which can pass spontaneously
  • May have to be repeated
• Indications
  • Kidney stone < 20 mm
  • Ureter stone < 10 mm
  • Uric acid stones
• Contraindications
  • Non-urological
    • Untreated hypertension
    • Pregnancy
    • Uncorrected bleeding disorder
    • Aortic aneurysm
  • Urological
    • Kidney dysfunction
    • Untreated UTI
    • Obstruction distal to stone
• Complications
  • Generally very safe
  • Perirenal or intrarenal haematoma
  • Haematuria

Percutaneous nephrolithotomy (PCNL)

• Percutaneous access into the renal pelvis -> stones fragmented by shockwaves or laser -> fragments are removed by forceps
• Indications
  • Stones unsuitable for ESWL
  • ESWL treatment failure
• Contraindications
  • Uncorrected bleeding disorder
  • Untreated UTI
• Complications
  • Injuries of adjacent organs
  • Haematoma
  • AV fistula

Ureterorenoscopy (URS)

• Indications
  • Ureteric stones
  • Ureteral strictures
• Complications rare

Open surgery

• For complex stones (staghorn calculi), or if other methods have failed