Common treatments for urinary stones include lithotripsy, lithotripsy, intracavitary lithotripsy (cystoscopy, ureteroscopy, nephrolithotripsy), extracorporeal shock wave lithotripsy (ESWL), laparoscopic lithotripsy, and open surgery. All of these treatment options are available for clinical use; however, for a specific patient, the treatment option with relatively less damage and lower complication rate should be chosen according to the specific location of the stone.
In the last 20 years, endoluminal urology and ESWL have evolved rapidly and have been able to treat most stones. Some stone treatment centers have largely eliminated open surgery for stones alone. Currently, open surgery is only indicated for special cases, such as patients with stones that require simultaneous anatomical reconstruction. Laparoscopic stone extraction has some advantages in terms of reducing the degree of surgical damage, but it is also only indicated for patients who require open surgery.
ESWL has the advantage of being less invasive, with fewer complications and no need for anesthesia, and is the standard method for treating kidney stones less than 20 mm in diameter or with a surface area of less than 300 mm2. For larger stones, ESWL can successfully break the stones but requires repeated treatments and is prone to the formation of stone fragments or “stone streets” after treatment.
Percutaneous nephrolithoscopy (PNL) is a faster and more effective way to fragment and retrieve stones, so it is usually chosen for larger kidney stones and upper ureteral stones if the technology and equipment are available. There has been a debate as to which is the better method of treating ureteral stones with ESWL or ureteroscopic stone extraction.
The choice of the most appropriate treatment method depends on the experience of the urologist, the equipment available and the treatment environment.
Lithotripsy by percutaneous puncture can remove residual fragments of stones and reduce the risk of stone recurrence. Cystine stones can be treated with lithotripsy as an adjunct. As for uric acid stones, oral lithotripsy is effective and oral drug lithotripsy is the treatment of choice. Lithotripsy followed by lithotripsy can increase the rate of lithotripsy and is indicated for patients with larger uric acid stones. However, it should be noted that lithotripsy is more effective for pure stones, but less effective for mixed stones.
I. Extracorporeal shock wave lithotripsy
Indications
1.Kidney stones
Single stone less than 20 mm;
Stones 20-30 mm, double J tube can be left in place before lithotripsy;
Cast or multiple stones, usually choose comprehensive treatment, PNL treatment first, then ESWL for residual stones;
For patients with inferior calyx stones, horseshoe kidney, ectopic kidney and transplanted kidney stones, the patients can be treated with postural stone removal after lithotripsy or other methods;
Difficult stones (cystine, calcium oxalate monohydrate stones) should be treated by other methods if the stones do not change or change very little after 2-3 trials of lithotripsy;
Isolated kidney stones larger than 15 mm, preoperative placement of double J-tube.
2, Ureteral stones should be selected for ESWL first. If combined infection and serious renal impairment need emergency treatment, other methods can be considered for treatment first.
3.ESWL is generally not used for vesicoureteral stones, and special cases need to be treated by urologists according to specific conditions.
II. Ureteroscopic lithotripsy
Indications
1.Conservative treatment of middle and lower ureteral stones is not effective.
2.Ureteral stones in the upper segment ESWL is ineffective or stay for a longer period of time, and there may be ureteral edema stone impaction. Try to remove the stone by in situ lithotripsy, flush the stone back to the renal pelvis with perfusion solution if necessary, leave the ureteral stent tube and then perform ESWL or PCN.
Ureteroscopy for kidney stones is mainly based on ureteroscopy. Ureteroscopy with holmium laser can treat kidney stones (less than 20 mm) and renal calyx diverticulum stones.
Percutaneous nephrolithotomy
Indications
1. All kidney stones that cannot be discharged are indications for PNL. Due to the widespread use of extracorporeal shock wave lithotripsy, PNL is now mainly used for stones for which ESWL is not suitable or has poor efficacy;
2. For cast stones or multiple stones, PNL can be performed first, and then ESWL can be performed for residual stones;
3. For residual stones after open surgery, a nephrostomy tube can be left in place during surgery and postoperative lithotripsy can be performed through the fistula;
4, isolated kidney, hoof-shaped kidney and transplanted kidney stones, experienced operators can perform PNL;
5, symptomatic diverticular calculi, stromal calculi and cystine calculi;
6. Ureteral stones above the level of the 4th lumbar vertebra, with long obstruction combined with hydronephrosis, and unsuccessful ESWL and ureteroscopy, PNL can be considered;
7. Kidney stone combined with pelvic ureteral junction stenosis, lithotripsy and pelvic junction dissection can be performed simultaneously.
IV. Open surgery
Indications
1. Difficulties in the application of ESWL, ureteroscopic lithotripsy and PNL, such as lack of appropriate instruments, economic reasons.
2. Failure of ESWL, PNL and ureteroscopic lithotripsy, or complications of the above treatment modalities that require open surgery.
3.Diseases that also require open surgery, such as anatomical abnormalities of the intrarenal collecting system, funnel stenosis, obstruction or stenosis of the ureteropelvic junction, renal prolapse with poor rotation, etc.
4.Concomitant other surgical procedures; non-functional lower pole of the kidney or renal atrophy, requiring partial or total renal excision; transplanted kidney stones or ectopic kidney stones.
5. Huge bladder stones, huge kidney stones in children.
V. Lithotripsy
Lithotripsy is the chemical dissolution of stones or stone fragments to achieve complete stone removal, and is an effective adjunctive treatment, often used as an adjunctive treatment after extracorporeal shock wave lithotripsy, percutaneous nephrolithotripsy, ureteroscopy lithotripsy and open surgery to remove stones, stones that are broken into small pieces have a better lithotripping effect than large stones due to the increased surface area of stones.
Currently, stones that can be chemically dissolved include uric acid stones, cystine stones and infected stones, while for calcium oxalate stones and calcium phosphate stones, drug lithotripsy is still in the exploratory stage.
Commonly used lithotripsy methods include oral drug lithotripsy, intravenous infusion lithotripsy and local drug infusion lithotripsy.