Minimally Invasive Surgical Treatment of Kidney Stones
Options for Treatment of Kidney Stones
The choices for surgical management in general remain the same for all types of stone disease. Recommended options depends on stone size, stone location in the kidney or the ureter, and on any symptoms and signs, particularly of obstruction.
At New York Urology Specialists, we utilize advanced methods such as low-rate ESWL lithotripsy, advanced endourological techniques, stone size, location and Hounsfield units to optimize the treatment for kidney and ureteral stones.
Kidney stones can be managed by lithotripsy (ESWL), flexible uretro-renoscopy (URS) and laser removal, or percutaneous nephrolithotomy (PCNL).
Lithotripsy for kidney stones is a procedure that is performed with mild-to-moderate sedation or general anesthesia. The patient is fully asleep and does not feel pain or remember anything.
A special machine that can break kidney and ureteral stones from outside the body is used. Lithotripsy is recommended for stones <20 mm (0.75 inches) in size. To break kidney and ureteral stones, focused shock waves (short pulses of high energy sound waves) are transmitted to the stone through the skin. The stone absorbs energy of the shock waves and fragments into smaller pieces. Stone fragments then pass with urine.
Who Should Not Have Lithotripsy
Contraindications to lithotripsy are pregnancy; women of childbearing age can have lithotripsy of kidney stones and upper ureteral stones but not lower ureteral stones. Patients cannot take blood thinners such as aspirin, warfarin and clopidogrel for a week before and up to 2 weeks after the procedure.
Complications of lithotripsy are rare but can occur. ESWL is suitable for over 90% of patients with kidney stones less than 1-2 cm.
Ureteroscopy (URS) with Laser Lithotripsy
Renal stones that do not respond to lithotripsy (ESWL), that are very hard or located in areas where ESWL does not work well can be treated by flexible ureteroscopy. Many men and women who have contraindication to ESWL or for whom ESWL is unlikely to work (such as morbid obesity) may do well with ureteroscopy. Ureteroscopy is also effective for larger stones.
Ureteroscopy is a procedure typically performed under general anesthesia (patient is asleep) or spinal anesthesia (patient is numb from chest down).
An endoscope (small camera) is inserted through the urethra (pee-hole) without making an incision. The stone is then located, broken to pieces with Holmium laser and fragments can be pulled out using a special “basket”. There are two types of ureteroscopes: flexible ureteroscope is used for kidney and upper ureteral stones. Semirigid ureteroscope is used for lower ureteral stones.
During the procedure, holmium laser is used to break up the stones in the kidney, ureter or bladder through a small endoscopic camera. A small scope (ureteroscope) is passed through the urethra into the bladder, and from there up into the ureter to reach stones in the ureter and the kidneys.
Once the stones are located, they are targeted with a laser that breaks the stone into smaller pieces, which are then extracted, or into tiny pieces of dust that wash out from the kidney with normal urine flow. Most commonly Holmium laser is used to break up kidney stones as well as ureteral stones. Bladder stones can also be broken with holmium laser.
PNL (PCNL): Percutaneous Nephrolithotomy
Percutaneous Nephrolithotomy (PCNL or PNL) is most suitable for removal of larger kidney stones (≥1-2 cm or >1 inch) or stones that are difficult to reach and break using ESWL lithotripsy or ureteroscopy. It is a surgical procedure that is performed under general or spinal anesthesia.
During PCL, a needle is passed into the kidney via a 1 cm incision in the back. A guide wire is passed through the needle into the kidney. The needle is then withdrawn with the guide wire still inside the kidney. A nephroscope (a camera with a light source for viewing the inside of the kidney) is then passed inside the kidney; kidney stones are identified, broken and removed. This procedure can take anywhere from 1-4 hours depending on the size of the stones and complexity.
Follow Up After Surgical Treatment of Kidney Stones
Once a patient is rendered stone free, a full evaluation to elucidate reasons for stone formation is undertaken. The results of further testing allows our urologists to make specific recommendations to prevent recurrent kidney stone formation.
Dr. Alex Shteynshlyuger is a board-certified urologist. He treats men and women with kidney and ureteral stones. He is among the most experienced specialists when it comes to treatment of large kidney stones and ureteral stones. Dr. Shteynshlyuger has performed hundreds of ureteroscopy and lithotripsy procedures for large kidney stones, in addition to ESWL procedures. He is among a select number of urologists in the United States who performs PCNL for large kidney stones.
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