New Treatment Options for Kidney Stones
by James E Lingeman, M.D. and Glenn M. Preminger, M.D.
James E. Lingeman, M.D. is a clinical professor in the Department of Urology at the Indiana University School of Medicine and the Director of the Methodist Hospital at The Institute of Kidney Stone Diseases. Dr. Lingeman is a member of the A.F.U.D. Kidney Health Council.
Glenn M. Preminger, M.D. is a Professor of Urologic Surgery, Director of the Comprehensive Kidney Stone Center and Director, Urology Residency program at the Duke University Medical Center. Dr. Preminger is a member of the A. F.U.D. Kidney Health Council.
Kidney stones are formed by various crystals that gather in your kidneys or urinary tract. These materials build up over a period of time and ultimately interfere with urination. Stones can be anywhere from gravel or pebble-sized to several inches in diameter. Kidney infections can create much larger or "staghorn" kidney stones.
Ureteroscopy
Advances in miniaturized telescopes and laser technology now allow passage of a small endoscope into the urinary tract to identify and remove stones both in the ureter (kidney tube) and the kidney. The major advantage of ureteroscopy is having the ability to directly visualize the fragmentation of your stone and to insure that all of the fragments are removed during the procedure. There is no need to wait for all of the fragments to pass as with shock wave lithotripsy treatment.
Most ureteroscopy procedures can be performed as a day surgery under either a general or regional anesthetic. Once you are anesthetized, your physician will look into your bladder and, through a catheter, will inject a small amount of dye into your kidney tube and kidney to outline the exact location of the stone. A very small, flexible guide wire will be advanced into the kidney to act as a road map for passage of the telescope. Either a rigid or flexible fiberoptic telescope will be advanced through the bladder, up the ureter, and, in some cases, into the kidney using x-ray guidance and direct visualization. These specialized telescopes are half the size of your pinky, yet allow excellent visualization of the inside of your urinary tract.
Once the stone is located, either a small laser fiber or a small ultrasound, or jack hammer device, will be used to fragment the stone into multiple small pieces. Depending upon the size and number of the stones, small graspers or baskets can also be used to remove the fragments from the ureter or kidney.
At the completion of the procedure, your physician will assess the degree of swelling and trauma caused by the kidney stone. If the swelling or trauma to the urinary tract is significant, your physician may elect to insert a ureteral stent, which will remain in place for a few days following the procedure. A stent will prevent obstruction and reduce the risk of significant discomfort following the ureteroscopy procedure. The stent will be removed by your physician through a simple procedure in the office.
The ureteroscopy operation will usually last one to two hours, depending upon the type and extent of the problem being treated. Your doctor will speak with your family following the completion of the procedure. In most cases, you will be given pain medication, medication to reduce the amount of discomfort following the procedure, and antibiotics. Heavy lifting, straining, or exercising should be avoided for a few days following the procedure. Return to normal physical activity is usually possible within two to three days following the ureteroscopy operation. If severe pain or high fever (more than 101 degrees) is experienced, your physician should be contacted immediately.
A small amount of bleeding is normal following the ureteroscopy operation. Even mild trauma to the ureter or kidney, either from the small telescopes or the ureteral stent, will cause intermittent blood to be seen in the urine. The risk of serious bleeding is very low, as the need for transfusion after ureteroscopy is less than one in 1000 patients.
Kidney stones and endoscopic procedures within the urinary tract may be associated with urinary infection. For this reason, antibiotics may be prescribed before and/or after your ureteroscopy procedure. These antibiotics are used to minimize the risk of severe infection, but it is possible that the urinary infection could be aggravated temporarily by the ureteroscopic procedure.
During the ureteroscopy operation, the ureter or the hollow portion of the kidney may be injured. This injury may be due to the kidney stone itself or due to the small instruments or fragmentation devices that are used to break up and remove the kidney stones. However, 99 percent of these injuries are minor and can be easily treated with placement of a ureteral stent. Occasionally, significant trauma to the ureter may be caused by the kidney stone or the ureteroscopy operation, leading to open surgery. Fortunately, the risks of serious complications are extremely low and much less than older surgical methods for kidney stone removal.
You will be given an appointment to return to see your physician following the ureteroscopic procedure. Depending on what was done during the original procedure, you may need to have the ureteral stent removed in your physician's office. In addition, your physician may request that you have followup x-rays to make sure that your urinary tract has returned to normal.
