|
Home >> Women's Health >> Stone Disease >> Treatment
 Stone Disease - Treatment
Overview | Diagnosis | Treatment | FAQ
-
Observation – As discussed above, successful stone passage depends on the size and location. Smaller
stones are more likely to pass, and the odds of successful passage increase, as the stone gets closer to the
bladder. (approximately 80% of stones less than 5mm will pass spontaneously)
-
Medications to dissolve the stone(s) (only applicable for uric acid and cysteine stones)
-
Surgery – In the past, a major surgical operation was often required to extract stones, especially kidney
stones. Fortunately, this is no longer the case. Most stones can be removed as an outpatient in the
operating room without making a skin incision. Ureteral stones are removed by using a special
telescope to look through the urethra (tube that carries urine from the bladder to the outside), into the
bladder, and up the ureter. A special channel inside the telescope allows the passage of tiny catheters
called stone baskets - a retractable basket on the end of the catheter is used to snare and remove it
ureteral stones intact. If the stone is too big, it can be broken into smaller pieces by using a laser fiber or
other devise passed through the channel in the telescope.
-
Kidney stones are usually fragmented by an outpatient surgical procedure called lithotripsy (‘litho’is
Latin for stone and ‘tripsy’ in Greek means “a rubbing”). Lithotripsy doesn’t require any cutting. It
works like this: A special machine uses x-ray or ultrasound guidance to catch the stone in the cross
hairs. Then a devise generates shock waves that are directed from outside the body inward. The shock
waves pass through soft tissue but are absorbed by the stone. The constant barrage of shock waves
gradually fragments the stone into smaller particles that are then passed in the urine.
-
If a kidney stone is too big to be treated effectively with lithotripsy, another procedure called a
percutaneous nephrostolithotomy is used to remove the stone. A small tube is inserted through a tiny
incision in the skin (percutaneous) into the kidney under x-ray guidance. A small telescope is then
inserted through the tube into the kidney. The stone is fragmented and the pieces are removed under
direct vision (nephrostolithotomy – ‘nephrosto’ means kidney, ‘lithotomy’ means stone removal).
Treatment recommendations depend on the type, size, location, and degree of obstruction. An overview:
ESWL (Extracorporeal Shock Wave Lithotripsy):
-
ESWL is an outpatient hospital procedure that is performed in a specially equipped mobile trailer.
-
Intravenous sedation is used to control pain.
-
A dull “thumping” sensation is usually felt during the procedure. Dr. McClure first localizes the stone using
x-ray. He then treats the stone with a maximum of 4000 shocks. The power level is gradually increased to
the maximum level over the first 1000 shocks so that the skin can become acclimated to the shocks. Shocks
are normally delivered at a rate of 125 shocks per minute.
-
The shock waves are generated by electromagnetic plates contained in cushioned “shock heads” that are
positioned against the skin. The shock waves can pass through soft tissue but they can’t pass through
stones. Therefore, the stone absorbs the shock wave energy, which causes it to break into smaller pieces.
Over a period of time, ranging from days to weeks, the stone particles migrate down the ureter (tube leading
from the kidney to the bladder) into the bladder. The particles are flushed from the bladder with urination.
-
An ESWL procedure lasts approximately 45 minutes.
-
After the procedure, you will be taken to the recovery room. Once your vital signs are stable, you will be
discharged to home.
-
You will be given a prescription for pain medication and a stool softener. You will also be given a
prescription for a medicine called Flomax. Flomax relaxes smooth muscle in the ureter, thereby making it
easier for the stone fragments to pass.
-
You will be given a prescription slip for a “KUB”(stands for Kidney-Ureter-Bladder). On the day of your
follow-up appointment, take your KUB slip to Raleigh Radiology, which is located in suite 100 in our office
building. No appointment or special preparation is necessary. Arrive at Raleigh Radiology at least 30
minutes prior to your appointment time with our office. Dr. McClure or Cheri Elliott, ANP will be able to
display your films on their computer screen and discuss the findings with you during your visit.
-
If you don’t have a follow-up appointment, please call the office and make an appointment for
approximately 2 weeks after your procedure.
-
Stone fragments can vary in size from a grain of sand to larger particles. Void into a strainer every time you
urinate until instructed otherwise. Bring any stone fragments you pass with you to your follow-up
appointment.
Activity:
- You can resume normal activity the day following your procedure. Do not drink alcoholic beverages, drive,
or operate hazardous equipment while taking narcotic pain medication.
Potential complications:
1. Blood in your urine is normal after this procedure. It usually disappears within days.
2. If your ureteral stone is located near the kidney, bleeding can occur around the kidney because it is in
the ‘blast path’ used to treat the ureteral stone. For this reason, the maximum number of shocks and
power level is restricted. Bleeding around the kidney is usually minor and no further treatment is
required. On the other hand, if the bleeding is significant, a blood transfusion may be necessary.
Signs of significant bleeding include a large area of bruising in the flank area (a small area of bruising or
broken skin over the treatment area is nothing to worry about), feeling faint when bending over due
to low blood pressure, grossly bloody urine which fails to clear, or severe flank pain. Promptly
notify our office at 571-4399 if any of these signs occur. If you call after normal business hours,
follow the instructions and call our answering service and ask to speak with the on-call physician.
Blood-thinning medication and aspirin significantly increase the risk for serious bleeding
during ESWL. Therefore, these medications must be stopped at least one week prior to
surgery.
-
Urinary tract infections following ESWL are rare. Nevertheless, if you develop fever, chills or burning on
urination, call our office at 571-4399 for further instructions.
-
Persistent stone - Depending on the composition and size of the stone, it may not completely fragment.
The success rate for completely fragmenting stones is approximately 80% for stones in the kidney and 70%
for stones in the ureter. If the fragments are smaller than 5 mm they will usually pass. If the fragments are
larger than this or if they are causing symptoms, a repeat ESWL treatment or ureteroscopic procedure (see
discussion below) may be necessary.
- Obstruction – If stone fragments are too big to pass, they can obstruct the flow of urine. Urinary
obstruction can cause pain, nausea, and infection.
[Top]
Ureteroscopy, Flexible ureteroscopy with lithotripsy (using either a laser or electrohydraulic probe):
-
A ureteroscope is a specially designed instrument that is used to visualize the inside of the urinary tract.
A laser fiber, pneumatic probe device, or an electrohydraulic probe can be threaded through a special channel in
the ureteroscope and used to fragment a stone under direct vision. Ureteroscopy with lithotripsy is often used
to treat stones that haven’t responded to ESWL. In other situations, ureteroscopy may be the initial treatment
of choice. For instance, stones that are smaller than 5mm and stones that are composed of uric acid cannot be
effectively treated with ESWL. Furthermore, stones that are impacted in the ureter or located very near the
bladder are better managed with ureteroscopy.
-
Procedure: Ureteroscopy is performed in the operating room under general anesthesia. A special wire is
threaded up the ureter past the stone. If the ureter is too narrow to allow passage of the ureteroscope, a
special devise is used to carefully dilate the ureter. Next, the ureteroscope is negotiated up the ureter to level
of the stone. The stone is then fragmented with a lithotripsy device or removed in a specially designed stone
basket.
-
Ureteral stent: If it is necessary to dilate the ureter, a soft silicone stent will be threaded up the ureter to
prevent spasms. One end of the stent softly curls up in the kidney while the other end coils up in the
bladder. As long as the stent is in place, it is normal to experience pressure in the bladder area, bloody urine,
and a pressure sensation in the affected kidney every time you urinate. These sensations will resolve once
the stent is removed.
-
A ureteral stent may be part of a staged procedure if the stone can’t be reached because of swelling around
the stone or if there is a serious infection. In this situation, ureteroscopy and treatment of the stone will
generally be performed several weeks later after the swelling and/or infection has had a chance to resolve.
-
Depending upon the situation, a ureteral stent may left indwelling for days to weeks following the
procedure. If the stent will be removed within a week of so in male patients, a string that is attached to the
end of the stent will be taped to the penis. Do not pull on the string because doing so can dislodge the stent.
The onset of urinary incontinence (constant leaking of urine) it is a sign that the stent has been dislodged and
it will need to be removed. When directed to do so, the string can be removed at home by gently and
continuously pulling on the string until the stent is completely removed. The stent is about a foot long.
Although it may feel weird, removing the stent is not a painful procedure. Alternatively, our nurse can
remove the stent in the office.
-
The stent will need to be removed in the office in women, and in men whose stent will remain indwelling for
longer than a week. A special instrument called a cystoscope is gently passed through the urethra into the
bladder. A grasping forcep is then used to grasp and remove the stent.
-
In addition to the complications listed above for ESWL, possible complications following
ureteroscopic procedures include perforation of the ureter (hole in the ureter), stricture of the
ureter (scar tissue in the ureter) or other damage to the lining of the ureter. These complications
are rare and usually respond to conservative measures such as leaving a ureteral stent in place
until the area has healed. Occasionally further corrective surgery is necessary.
PCNL (PerCutaneous NephrostoLithotomy):
-
PCNL is performed in the hospital operating room under general anesthesia.
-
Prior to your PCNL procedure, a radiologist will insert a special tube, called a nephrostomy tube, into your
affected kidney. A nephrostomy tube is about the size of a cocktail straw. This procedure is performed in
the radiology department. Local anesthesia and intravenous sedation is given to minimize discomfort.
-
A foley catheter is inserted into your bladder once you’re asleep to keep your bladder from becoming over
distended during the procedure. The catheter is usually removed the day after your surgery.
-
At the time of surgery, Dr. McClure will next insert a flexible guide wire through the nephrostomy tube into
the bladder and dilate the tract with a special balloon catheter.
-
Once the tract has been adequately dilated, a smooth tapered sheath is slipped over the balloon catheter into
the kidney. The balloon catheter is then withdrawn.
-
A special instrument, called a nephroscope, is then passed through the lumen of the sheath into the kidney.
Fluid constantly runs through the nephroscope and a high intensity light at the tip of the nephroscope
allows Dr. McClure to visualize the inside of your kidney and treat your stone.
-
The stone is fragmented with a special wand that uses ultrasound and electrohydraulic energy to fragment
the stone. The fragments are then extracted using a grasping forcep or they are aspirated through the
ultrasonic devise.
-
Once all of the fragments have been removed, a new nephrostomy tube is placed.
-
A PCNL procedure normally takes several hours to perform.
-
Once the urine is no longer bloody, you will be scheduled for a special x-ray study called a nephrostogram.
This test is usually performed on the first or second day following surgery. Dye is injected into the
nephrostomy tube to make sure that there is no leakage outside the kidney and also to look for any
remaining stone fragments. If everything appears normal, the nephrostomy tube is plugged overnight. The
nephrostomy tube will be unclamped if flank pain or fever develops. If everything is okay overnight, the
tube is removed the following morning and you are discharged home.
-
If there is leakage from the kidney, the nephrostomy tube is left in place and a repeat x-ray is taken in a
week or so. Once the leakage has resolved, the tube is removed.
-
If the nephrostogram shows remaining stone fragments that are small enough to pass on their own, the
nephrostomy tube can be removed. On the other hand, if there are remaining stone fragments that are too big
to pass, it may be necessary to repeat the PCNL procedure (using the same tract) or ESWL may be
performed. In either case, the nephrostomy tube is usually not removed until after the residual stone
fragments have been treated.
-
After the nephrostomy tube has been removed, is normal to leak urine from the skin incision for a day or so.
Keep a gauze pad over the site until the drainage ceases. Apply Neosporin ointment twice daily to the
incision site until it has healed.
-
You will normally be discharged on the second or third day following surgery.
-
You will be sent home with a prescription for a pain medication and an antibiotic.
Activity:
- You can eat a normal diet, shower and move about as tolerated. It’s advisable to wait until after you’ve had
your follow-up appointment with our office before driving or returning to work. In order to prevent delayed
bleeding from the kidney, you should avoid any strenuous activity for at least several weeks following
surgery.
Potential complications:
-
Bleeding - blood in your urine is normal after this procedure. It usually resolves within a matter of days.
-
Injury to the artery or vein leading to the kidney or structures surrounding the kidney may occur during
initial placement of the nephrostomy tube or during dilation of the tract at the time of surgery. This can
usually be managed conservatively by merely placing a nephrostomy tube and inflating a balloon to stop the
bleeding. Although extremely rare, an emergency open operation may be necessary if the bleeding can’t be
stopped. If all other measures fail, an emergency nephrectomy (removal of the kidney) may be required.
-
Infection – although you will be treated with antibiotics before and after your procedure, an infection can
still occur. If you develop signs of an infection in the skin surrounding your incision or if you experience
fever, chills, or burning on urination, call our office for further instructions.
-
Obstruction - Stone fragments that are too big to pass may become stuck in the ureter and require an
additional surgical procedure.
-
Aborted procedure: If the stone can’t be visualized due to excessive bleeding, it may be necessary to abort
the procedure and insert a nephrostomy tube. In this situation, the surgery will need to be rescheduled,
typically a week or so later, which will allow time for the bleeding to stop and for the tract to mature. It will
not be necessary to reinsert another tube in radiology prior to the subsequent procedure.
-
Persistent stone - Depending on the composition and size of your stone, it may not completely fragment.
Furthermore, it may not be possible to complete the procedure if the stone migrates to or is located in a
portion of the kidney that is inaccessible. The success rate for completely fragmenting your stone is
approximately 80-85%. If the fragments are smaller than 5 mm they may pass on their own. If the
fragments are larger than this or if they are causing symptoms, another PCNL treatment or other surgical
procedure may be necessary.
[Top]
Home | Our Urology Providers in North Carolina | Cary Urology: Cary, Clinton, Dunn | Landmark Urology: Raleigh | Urology Care: Wake Forest | North Carolina Urological Associates: Cary, Raleigh | Wake Urological Associates: Raleigh | Patient Information | Men's Urology: Bladder Problems |
Erectile Dysfunction | Infections |
Infertility | Kidney Problems |
Kidney Stones | Penis Problems | Prostate Problems | Testicle Problems |
Urinary Incontinence |
Vasectomy |
Women's Urology: Bladder Problems | Kidney Problems | Kidney Stones | Pelvic Organ Prolapse | Urinary Incontinence | Urinary Tract Infection | Pediatric Urology: Hydronephrosis | Hypospadias |
Inguinal Hernia | Undescended Testicles |
Urinary Frequency | Vesicoureteral Reflux | What's New | Contact Associated Urologists of North Carolina
Disclaimer:
The pictures displayed in www.auncurology.com are images of physicians, patients and employees who have consented to have their pictures in this website.
|
