A kidney stone is a small, hard deposit that forms from minerals and salts in the urine. It can sit quietly in the kidney or drop into the ureter (which is a muscular tube connecting kidney to the bladder) and cause pain, blockage, or infection. Treatment is not one-size-fits-all. It depends on
1) size (a grain of sand vs. a marble),
2) location (kidney, upper/mid/lower ureter, bladder),
3) symptoms/complications (pain only vs. fever, kidney injury),
4) stone type (uric acid, calcium, struvite, cystine), and
5) patient factors (pregnancy, bleeding risks, single kidney, body habitus, prior surgery, job demands).
Below are the main treatment options. However, treatment decision should always be made after discussion with your urologist.
Stones in Kidney / upper ureter - RIRS, PCNL, ESWL, Dissolution therapy
Stones in Ureter - URS, Medical Expulsion Therapy
Stones in Bladder - cystolithotripsy, PCCL
q) Medical Expulsion Therapy (MET) with an Alpha-Blocker
An alpha-blocker is a medication which relaxes the ureteric muscle to help in stone passage.
Indications
Stones less than 5mm in the lower ureter with mild pain and no features of infection / impairment of renal function
MET can be tried for a maximum of 2 weeks. A repeat ultrasound scan is required to ensure stone passage.
q) Ureteroscopy (URS) with Laser Lithotripsy
A Ureteroscope is passed through the urethra and bladder into the ureter (and kidney if needed). A laser fibre is passed through the ureteroscope and is used to fragment the stone. The small fragments are either removed with grasper or will pass out along with urine. A temporary stent may be placed to aid the passage of fragments and to ensure unobstructed drainage of urine.
Indications
Ureteric stones of most sizes and locations (especially mid/distal ureter)
Patient is usually discharged the next day.
Considerations: You may feel urinary urgency while a stent is in place; for which alpha blockers are given. The symptoms mellow down in 3-4 days. Stent maybe kept for 2 weeks to few months depending upon the impaction of stone and injury to ureter.
q) Urgent Drainage- DJ Stenting / PCN (Percutaneous Nephrostomy)
In a patient who is unfit for definitive surgery, When a stone blocks urine drainage and causes infection or impaired renal function, the priority is to drain, not to break the stone right away. A stent bridges the obstruction from inside; a nephrostomy drains the kidney outside directly with a small tube.
Indications:
Fever or suspected infection with an obstructed system (urological emergency)
Rising creatinine, single kidney, transplant kidney, or uncontrolled pain/vomiting
Pregnancy with obstruction and pain not responsding to conservative management
Notes: Once you’re stable, definitive stone treatment is scheduled.
q) Retrograde Intrarenal Surgery (RIRS/ Flexible Ureteroscopy)
A flexible scope reaches the kidney; the laser fragments and dusts the stones within the kidney.
Indications:
Kidney stones up to ~2 cm, including lower-pole stones.
Patients who want an incision less intervention.
Those with bleeding risks that preclude ESWL or PCNL
Considerations: May require a staged approach for multiple large stones; often paired with a short-term stent.
q) Percutaneous Nephrolithotomy (PCNL)
Through a small keyhole incision in the flank, a tract is created directly into the kidney; the stone is fragmented and pieces removed.
Indications:
Large stones (commonly >2 cm), staghorn stones, or very hard stones
Stones not suitable for or failing ESWL/URS/RIRS
The need for high stone-free rates in one session
Considerations: Usually 2-3 days in hospital post surgery. A nephrostomy tube may be placed temporarily which is usually removed prior to discharge. A DJ stent is usually placed and removed after a month.
q) EXTRACORPOREAL Shock Wave Lithotripsy (SWL/ESWL)
Shock waves from outside the body are focused on the stone to break it into smaller fragments that can be passed along with urine. This was a very commonly used procedure previously but has gone out of vogue once RIRS came into the picture.
q) Medical Dissolution Therapy.
Unlike calcium stones, uric acid stones can sometimes be dissolved by making urine less acidic (alkalinization) with potassium magnesium citrate, sodium bicarbonate or similar agents..
Indications:
Radiolucent stones (not visible) on X-ray
Low density on CT KUB (HU <800)
Small stones
Stones not causing obstruction / infection / pain and not requiring emergency treatment.
q) Cystolithotripsy:
A small camera is introduced into the urinary bladder and the stone is fragmented with laser or lithoclast and the fragments are retrieved.
q) Percutaneous cystolithotripsy (PCCL):
Under vision, a small incision is made in the lower abdomen and a tract is made into the urinary bladder. A scope is introduced through the tract and the stone is broken and fragments retrieved. This is useful for large bladder stones.
Special Situations
Pregnancy: Prefer conservative management; if intervention is required URS or long term DJ stent is preferred. ESWL is contraindicated
Single kidney/transplant kidney: Urgent drainage if kidney is obstructed.
Occupational needs (pilots, merchant navy, oil rig workers, remote workers): Even “silent” kidney stones may be treated to avoid sudden colic in critical settings, where access to healthcare may be difficult.
