The main treatment objectives of urinary stones: to relieve obstruction, protect and save the function of the affected kidney, relieve symptoms and prevent recurrence.
The treatment of urinary stones mainly includes conservative treatment and surgical interventions, the former includes anti-inflammatory, antispasmodic and analgesic, herbal lithotripsy and jumping activities, the latter includes extracorporeal shock wave lithotripsy, endoscopic lithotripsy and lithotripsy, laparoscopic surgery and open surgery to remove stones.
I. Indications for conservative treatment.
Ureteral stones with obvious pain and hematuria, normal parenchyma on ultrasound, only mild hydronephrosis or no hydronephrosis, and stones less than 0.5 cm in diameter. For such patients, conservative treatment is highly effective.
Because the stone discharge depends on the following points.
1, whether the kidney function on the affected side is normal and whether it can urinate normally: if the ultrasound indicates that the affected kidney parenchyma is normal, the affected kidney is only mildly hydronephrosis or no hydronephrosis, it means that the obstruction is not serious, the obstruction time is short, the affected kidney function is lightly damaged, urination is normal, and it has the ability to discharge stones.
2. Ureteral internal diameter: the diameter of the stone is less than 0.5 cm, i.e. the stone is not larger than the ureteral internal diameter, and it is possible to discharge by itself.
3.Whether the stone is wrapped and adhered: if there is obvious pain and hematuria, it means the stone may be moving and not wrapped and adhered.
II. Indications for extracorporeal shock wave lithotripsy.
This is an excellent surgical intervention for the treatment of urinary stones, but extracorporeal lithotripsy is not suitable for all patients with urinary stones, and it has strict indications.
The success of extracorporeal shock wave lithotripsy requires the following.
1. An accurate positioning system.
2. Sufficient shock wave energy.
3. The stones are not too hard (cystine and calcium oxalate stones are hard and not easy to crush).
4.The stone is not too big, so that the stone is not formed to aggravate or cause new obstruction during stone removal.
5.The patient’s own ability of stone removal.
6.The doctor’s rich experience and technology, etc.
The ability of stone removal depends on the following factors.
1.The kidney on the affected side has a better urine production function, which can create a certain pressure in the pelvis ureter to induce stone discharge.
2. The urinary tract is open and free of obstruction (no strictures, distortions, polyps, deformities, etc.).
3. The stone is not adhered, encapsulated, etc.
Therefore, patients who choose extracorporeal shock wave treatment should have the following indications.
1, the affected kidney has good urinary function (basically normal function of the affected kidney, no hydronephrosis or moderate or less hydronephrosis).
2. The urinary tract is open and free of obstruction other than stones (no strictures, distortions, polyps, deformities, etc.).
3, The stone is not adhered or encapsulated.
4. The stone is not too large (less than 2 cm in diameter).
The following types of stones are not suitable for extracorporeal shock wave lithotripsy.
1.Urethral stones: special sites, the best impact point on the body surface cannot be selected.
2, bladder stones: stones are mostly large and rolling in the bladder, which are difficult to break, and even if they are broken, they are very likely to cause urethral stone steps, leading to acute urinary retention instead.
3. Huge kidney stones: it takes too long to break the stones, and the formation of ureteral stone steps after lithotripsy causes serious obstruction and aggravates the damage to the affected kidney. Long time extracorporeal lithotripsy can affect the function of the affected kidney.
4. Symptomatic stones in the calyces, especially in the lower calyces: these patients have malformations of the calyces and pelvis, which is the reason for the presence of stones in the calyces. Even if the stone is crushed, it cannot be expelled.
5.Patients with acute and chronic post-renal insufficiency: the most important thing is to release the post-renal obstruction to save the kidney function, and extracorporeal lithotripsy does not ensure the success of lithotripsy and release the obstruction. If extracorporeal lithotripsy is forced, the best treatment time may be delayed.
6. Patients with moderate or above hydronephrosis: such patients have longer obstruction time, most of them have ureteral stenosis, stone encapsulation or adhesion, twisted ureteral deformity, etc., which seriously affect the success rate of extracorporeal shock wave lithotripsy, and because of the impaired function of the affected kidney and reduced urinary capacity, even if the stone is broken, it is difficult to discharge by itself.
III. Indications for endoscopic lithotripsy for stone extraction.
Endoscopic lithotripsy is indicated for urinary stones that have failed conservative treatment and extracorporeal shock wave lithotripsy, or are not suitable for conservative treatment and extracorporeal shock wave lithotripsy, and have symptoms and signs that cause obstruction and affect the function of the affected kidney.
Specifically, these include.
1. Urethral stones and lower ureteral stones for which conservative treatment has failed.
2. Upper and middle ureteral stones that have failed conservative treatment and extracorporeal shock wave lithotripsy.
3.Ureteral stones and renal stones with moderate hydronephrosis or above.
4, Symptomatic renal calcium stones.
5.Giant renal stones causing certain obstruction.
6.Bladder stones that cannot be discharged.
7, Urinary stones that have led to post-renal renal insufficiency.
8.Urological stones with other obstructions such as ureteral stenosis.
The special advantage of endoscopy is that it is not only a treatment means but also an examination means. Compared with extracorporeal shock wave, it can not only deal with the stones causing obstruction at one time, but also clarify whether there are other obstructions such as strictures and polyps, and can release these obstructions at the same time.
4. Indications for laparoscopic ureterotomy for stone extraction:
It is indicated for patients with organic ureteral strictures.
V. Indications for surgical management of urinary stones:.
Surgical intervention should be considered only when extracorporeal shock wave lithotripsy or lumpectomy lithotripsy is really inappropriate for a patient or when lumpectomy has failed, or when there are unexpected circumstances.