• Conservative Treatment
• Surgical Treatment
• Minimally Invasive Surgical Treatment

Surgical intervention may be warranted for stones that are resistant to conservative therapy, large stones, obstructing stones, or for patients with anatomic abnormalities of their urinary tract that may prevent the passage of even small stones. Several types of surgical therapies will be described here. Further discussion of many of these techniques can be found in the section on Minimally Invasive Surgery.

Extracorporeal Shock Wave Lithotripsy (ESWL)

• General - ESWL is a noninvasive method of breaking kidney stones using high energy shock waves. The shock waves are generated outside of the body by a lithotripter machine and travel through the body and are focussed directly onto the stone by X-ray guidance. The stone is fragmented into smaller pieces, which then can pass spontaneously.

• Indications - ESWL can be used for any type of stone, however, in general ESWL works best for softer stones such as uric acid stones and are less successful with hard stones like calcium oxalate monohydrate or cystine stones. ESWL is commonly used for stones located in the kidney and for stones less than 1 to 2 centimeters. Multiple ESWL treatments may be required for larger or multiple stones.

• Procedure ESWL can be performed with either intravenous sedation or general anesthesia. Because ESWL is a noninvasive procedure, an incision is not required. During ESWL the patient typically lies flat on the lithotripter table, however, older models require the patient to be partially submerged in a water bath. A small flexible plastic internal tube (called a ureteral stent) is sometimes passed into the ureter from the bladder using a cystoscope to promote passage of stone fragments and to prevent obstruction from the stones. An ESWL procedure typically takes 1-2 hours to perform.

• Contraindications - Contraindications to ESWL include bleeding tendencies, pregnancy, uncontrolled hypertension, active urinary tract infection, morbid obesity, and certain anatomic abnormalities of the urinary tract.

• Postoperative - Overnight stay in the hospital is generally not required. A small amount of bleeding in the urine is expected after this procedure. Postoperative pain is usually described as a "bruise"-like sensation in the flank.

Ureteropyeloscopy And Laser Lithotripsy

• General/Indications - For stones that get caught in the ureter during passage to the bladder, urinary obstruction due to impaction of the stone can occur. This is often due to stones larger than 5 mm in size. If these stone fragments do not pass spontaneously after conservative therapy (i.e. hydration and pain medication) then ureteropyeloscopy and laser lithotripsy may be required.

• Procedure - Ureteropyeloscopy is usually performed under general anesthesia. Ureteropyeloscopy is performed by introducing a small telescope (called a ureteroscope) through the urethra, into the bladder, and up the ureter. With direct visualization of the stone within the ureter, a laser fiber can be used to fragment the stone into smaller pieces. A ureteral stent is often required with this procedure. Ureteropyeloscopy with laser lithotripsy can require anywhere between 1-3 hours depending on the size and location of the stone within the urinary tract.

• Contraindications - Contraindications to ureteropyeloscopy include bleeding tendencies, active urinary infections, or patients deemed unsuitable for general anesthesia.

• Postoperative - A small amount of bleeding in the urine is expected after this procedure. Postoperative complaints include the urge to urinate from irritation of the bladder and urethra from passage of the ureteroscope. Overnight stay in the hospital is typically not required.

Percutaneous Nephrostolithotomy (PCNL)

• General/Indications - For kidney stones larger than 2 centimeters in size or for hard stones, a more invasive but extremely effective therapy called percutaneous nephrostolithotomy is generally recommended.

• Procedure - PCNL must be performed under general anesthesia. This procedure involves direct fragmentation of the kidney stone through a small incision made in the flank through which a telescope (called a nephroscope) is passed directly into the kidney. Ultrasonic, electrohydraulic, or laser fragmentation of the stone can then be performed through the nephroscope under direct vision.
  A plastic tube (called a nephrostomy tube) is temporarily left in the kidney, exiting the flank in order to optimize drainage of the urine from the kidney following PCNL.

• Contraindications - Contraindications to PCNL include bleeding tendencies and active urinary infection.

• Postoperative - PCNL often requires a one to two night stay in the hospital. Mild to moderate bleeding in the urine is common after PCN. Patients often have a mild to moderate amount of pain at the site of the nephrostomy tube which is easily managed with oral pain medications.

Open Surgical Techniques

• General/Indications - With the advent of ESWL and PCNL techniques, open surgical procedures on the kidney have been made virtually obsolete. There are, however, specific indications warranting open surgery. These include:
  1. failure of ESWL or PCNL to fragment the entire stone
  2. large stone burden that would require multiple ESWL and/or PCNL procedures
  3. certain anatomic abnormalities of the urinary tract.

• Procedures - All open surgical techniques require a general anesthesia and an incision usually in the flank region overlying the kidney. Because of their more invasive nature, open surgical procedures do result in a greater blood loss during surgery than the above less invasive surgeries, but blood transfusions are rarely needed. Pyelolithotomy is a surgical technique used to remove large stones situated in the renal pelvis (i.e. the main collecting system of the kidney). A incision is made in the renal pelvis in order to remove the large stone. Anatrophic nephrolithotomy is reserved for large stones occupying the entire renal pelvis and extending into the calyces within the substance of the kidney. An incision is made along the long axis of the kidney, thus allowing the kidney to be opened like a book. After all stone fragments are removed, the kidney is sewn back together. A nephrostomy tube or ureteral stent is often left in place to optimize drainage of urine from the kidney and allow for adequate healing. Partial nephrectomy or simple nephrectomy is the surgical removal of a portion or the entire kidney, respectively. This is only performed for long-standing stones which cause recurrent infections, damage to the kidney, thus rendering the kidney nonfunctional.

• Postoperative - Hospital stays range from 3 to five days depending on the type of surgery. Postoperative pain is typically mild to moderate and is easily controlled with intravenous or oral pain medication. An epidural anesthetic can also be used to control postoperative pain.