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Jack D. Francis, M.D., F.A.C.S.
The treatment of stones must be individualized to the stone and the patient. During the acute painful phase the patient is treated with pain medicine and intravenous fluids. If the stone is small, less than 1/4 inch or 5 mm, there is a good chance it will pass spontaneously, and once the acute attack is over the patient may go home with a prescription for pain medicine and be followed in the urologist's office. If the stone is larger, or shows blockage on x-ray studies, or severe pain persists, or most importantly if there is fever, the patient is usually admitted to the hospital. If fever is present, antibiotics are started, and early intervention is indicated. Infection plus obstruction can lead to permanent kidney damage. Usually when infection and stones are present, or rapid, curative interventional therapy can not be done, a stent or temporary internal tube is placed from the bladder, past the stone, and into the kidney. This is done through a scope, (cystoscope), passed through the urethra into the bladder, or occasionally through a puncture, (nephrostomy), through the side and into the kidney. With a stent in place, the patient is usually comfortable, and the stone can be treated days or weeks later, as circumstances dictate. Sometimes the lithotriptor, or stone blaster, is only available one or two days a week, or the facility does not have access to one and the patient must go elsewhere for definitive treatment.
Small stones, less that 5mm or 1/4 in. will frequently pass by themselves, and so usually do not require intervention other than pain medicine, unless fever is present, symptoms are unremitting, or there is a socioeconomic reason for rapid intervention. One exception is uric acid stones which may be dissolved by making the urine less acid. This can be done with sodium bicarbonate or other medications, but should be done under the supervision of your urologist because of possible side affects. Allopurinol is a medication which blocks the formation of uric acid and therefore is used to prevent uric acid stones. Open Surgery was the main mode of treatment for most stone disease until the early 1980's. Now open operations are infrequently performed. Still there are situations where open surgery is needed. The patient with the large bladder stone which cannot be fragmented with other techniques will require operation. Patients who have Staghorn calculi that fill most or all of the drainage portion of the kidney, that can’t be cleared with the procedures outlined below may require open surgery. Staghorn stones get their name from their appearance. Rarely, a stone in the ureter may need open surgical removal. Endoscopic or Endourologic Techniques refers to the use of various modalities through telescopic instruments to treat stones. With the development of fiberoptics and miniaturization we are able to access virtually every part of the urinary tract. Bladder stones may be treated by inserting a scope through the urethra into the bladder and then fragmenting the stone with laser, ultrasound, electrohydraulic shock waves, or manual crushing techniques. Frequently, bladder stones may be so large that the best treatment is open surgery. Stones in the ureter may be accessed by the use of miniature ureteroscopes which can be passed into the ureter to visualize the stone. It can then be grasped and removed or fragmented using similar techniques. Stones in the kidney may also be treated by an endourologic instrument placed through a puncture wound in the flank. This is particularly useful where there is a large stone burden. Frequently a stent or drainage tube is left in between the kidney and the bladder for several days to allow the pieces to pass, and to prevent swelling form the instrumentation from blocking the ureter. Extracorporeal Shock- Wave Lithotripsy or ESWL, (pronounced ess-wall), commonly referred to as lithotripsy, is clearly one of the most revolutionary developments in the history of medicine. It was introduced in 1982 after its development in Germany. It has made the non-invasive treatment of many stones possible in an outpatient setting under sedation. The concept is one of focusing shock waves on the stone. The shock wave is generated by a high voltage discharge through a water medium. Situating the shock generator in a curved wave lens allows the shock waves to be concentrated on the small area where the stone is, as a magnifying lens does to sunlight. The stone is broken apart with a very high intensity shock waves, while surrounding structures suffer only minor effects. Dense structures such as stones receive the maximum disruptive forces, while adjacent soft tissues such as kidney and intestines are merely bruised. X-ray and/or ultrasound are used to image and center the stone for treatment. The original lithotriptor, the Dornier HM-3 required the patient to be immersed in a water bath and have either general or spinal anesthesia. It also required a dedicated room usually in a hospital. Advancements in technology have resulted in decreased size, cost, and inconvenience. Patients now generally have sedation and lie on a table without immersion in water. Current lithotriptors are transportable and can be put in outpatient centers with minimal space requirements. This allows multiple centers to utilize the same machine and increase efficiency. Lithotripsy can be used on virtually any part of the urinary tract with good results. Several treatments may be necessary for some stones, but that is frequently easier on the patient than other methods. The patient with a solitary stone of less than 2 cm should have a 80-90% chance of success with one procedure. This would mean complete disintegration of the stone or fragmentation into particles small enough to pass. Some stones, such as cystine or uric acid, are so hard they are difficult to treat with lithotripsy, but the majority of stones are amenable to this technology. Patients who are pregnant or who have bleeding difficulties should not be treated with ESWL. After ESWL one usually feels sore and there may be some blood in the urine. Particles of stone will usually be passed and can be saved for analysis. Occasionally there may be severe pain from particles blocking the ureter or fever which may necessitate placement of a stent in the ureter to relieve obstruction. Most of the time, however, patients do quite well with only minimal discomfort. Occasionally, your doctor will recommend placement of a stent ( an internal drainage tube from the kidney to the bladder) to help in visualizing the stone or to allow better drainage of the kidney. Clearly, noninvasive shock-wave lithotripsy is the treatment of choice when possible for the interventional treatment of stones.
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[Home] Werner - Francis Urology Associates llc - Mid Atlantic Urology Associates llc Greenbelt - Bowie - Laurel Maryland (301) 441-8900 Fax (301) 982 0453 7500 Hanover Parkway Suite 206 Greenbelt, MD 20770
Rev:03/08 |