Greater Boston Urology Blog

Surgical Options for Kidney Stones: Determining What's Best for You

Kidney stones are no fun. Just ask anyone who's ever had one. And if by some chance you haven't had one yet, consider yourself lucky, not exempt. Because 1 in 10 people will experience a kidney stone in their lifetime.

Luckily, there are steps you can take to prevent kidney stones. But if you find yourself dealing with one (or more) of these painful little buggers and you can't pass it successfully on your own when you pee, you might need surgery. And that's what this article is all about.

We've asked Dr. Mark V. Silva from our Plymouth Care Center to join us on the blog and provide an overview of the various types of kidney stone surgery. To say he's passionate about treating kidney stones would be an understatement. (Don't believe us? Consider his handle on Twitter: @st0necrusher)

As with all content on our blog, the information provided in this article is meant to be educational in nature, not medical advice. Always consult a physician regarding your specific health needs, especially if you've had a previous experience with kidney stones.

First, a quick refresher: What is a kidney stone? And why are they so problematic?

DR. SILVA: A kidney stone is not a complicated thing. It is a collection of salts and minerals that come together, harden and can grow over time. Kidney stones can cause a variety of issues. Common issues include pain, recurrent urinary tract infections, and blood in the urine. The most worrisome issue is kidney dysfunction.

Do all stones cause pain? Must they be removed if they're not causing pain?

DR. SILVA: It is a common belief that the kidney stone is causing the pain when that is not exactly true. The pain of kidney stones is when the stone causes a blockage of the urine. When this happens, the kidney gets backed up and stretches, causing the famous kidney stone pain. If a stone is not causing pain and it is a size that is passable (smaller than 4-5mm), then yes—a stone can be observed, but this does require a discussion between patient and MD to review all the pros/cons.

At what point would a patient and their urologist consider surgical options for kidney stones?

DR. SILVA: Kidney stones often pass on their own without surgery. However, surgery is needed in certain situations to break them up and take them out. Examples include if the stone is too large to pass, has lodged itself in the drainage tube between the kidney and the bladder (ureter), or is causing a blockage of one or both kidneys, which can result in UTIs or excessive pain.

What are the surgical options for kidney stones?

DR. SILVA: There are four surgical options for kidney stones, each with its advantages/disadvantages. The least invasive is shockwave lithotripsy, which uses targeted sound waves from the outside to break up the stone. The next more invasive is ureteroscopy with laser lithotripsy—here we use a small camera and a laser to break up and extract all the stone from the natural tubes. More invasive is called percutaneous nephrolithotomy (PCNL). With PCNL, we make a temporary tract from the back down to the kidney and use a telescope with larger tools to break up and extract the stone. The most invasive method is robotic/open surgery, which is only reserved in rare situations.

OK, let's discuss the various surgical options for kidney stones—how each procedure works and what patients can expect.

DR. SILVA: All stone surgeries have the common risks of surgery, including bleeding, infection, and injury to any of the urologic or adjacent organs.

Shock wave lithotripsy (SWL)
  • Best used in stones in the kidney that are 2cm and less; can also be used on stones in the ureter (drainage tube from kidney to bladder)

  • During this procedure, the patient undergoes general anesthesia, and “shocks” are sent from a targeted ultrasound machine to the stone.

  • Pros: Non-invasive and no ureteral stent needed

  • Cons: Does not work well on harder stones or when the stone is farther away from the skin. The remaining stone particles or dust needs to be passed from below. Stone-free rate (the effectiveness of the surgery) decreases as the stone gets larger or in the lower part of the kidney. Lowest risk of injury to organs.

  • I would use this for all stones in the ureter and for stones less than 1.5cm in the kidney.

  • During this procedure, the patient undergoes general anesthesia, and a small camera is placed into the body through the urethra and up to the stone. A laser is then used through the scope, and the stone is broken up. The remaining fragments are then removed and sometimes a ureteral stent is left to act as an internal band-aid which is removed in the office 3-5 days later.

  • Pros: Higher success rate than SWL for ureteral stones; highly effective for stones in the kidney up to 1.5cm.

  • Cons: Invasive procedure with the possibility of needing a ureteral stent for a few days. Loses effectiveness as stones get larger. Low risk of injury to genitourinary (GU) or adjacent organs.

Percutaneous nephrolithotomy
  • Used commonly for larger stones > 1.5-2 cm or stones that are difficult to get to from other means.

  • During this procedure, the patient undergoes general anesthesia, and a small incision is made into the back (from the size of a pea to maximum the size of a nickel). A temporary tube is put into the kidney, and a telescope with tools are used to break up and remove the stones. A ureteral stent is then usually placed at the end of the surgery. In my practice, I DO NOT leave tubes in the back unless there are extenuating circumstances.
  • Pros: Highest success rate for clearing larger, harder, or more-difficult-to-get-to stones.
  • Cons: Most invasive of the three commonly done stone surgeries. Low/moderate risk of injury to GU/adjacent organs. Sometimes requires an overnight stay at the hospital.

Open or robotic surgery
  • Rarely used and saved for only the largest of stones, when PCNL is not available or if the kidney does not look like it is working and possibly needs to be removed with the stone itself.

Are there any newer surgical options for kidney stones in the works that you're particularly excited about?

DR.  SILVA: The management of stones and the technology in surgical options is always advancing and is very exciting. The scopes are always getting smaller and easier to use, the lasers are becoming more efficient, and the approaches we use for PCNL are always evolving.

The goal is to always improve patient care and success. In that sense, things that I am excited for include in-office ultrasound to move and possibly treat kidney stones (burst-wave lithotripsy) and the improving landscape of lasers to be able to treat larger stones faster and more efficiently. I stay actively involved in the industry and work with endourologists from around the country to stay up to date with the most advanced and effective ways to treat stones.

Any final thoughts that you want to convey about surgical options for kidney stones—or kidney stones in general?

 DR. SILVA: Yes! Surgery is not the end of a kidney stone. Thirty percent (30%) of people who have a kidney stone will have another symptomatic episode within 10 years. I love treating kidney stones, and not just because the surgery to remove them is so elegant and rewarding, but because like other medical conditions, there are changes we can implement to help prevent kidney stones from coming back.

 After surgery to remove the kidney stones, I offer a metabolic evaluation to see if there were any underlying reasons why a person formed the kidney stone. If the tests reveal a possible culprit, then we can work together to alleviate the risk factor and hopefully prevent future stones.

Interested in making an appointment with Dr. Silva?

Dr. Silva is accepting new patients in our Plymouth Care Center. Click here to make an appointment with him or one of our other world-class physicians.

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