Management of Kidney Stones – Mr Harshawardhan Godbole

After a diagnosis is made ,depending on the stone character and patients presentation, management can be conservative or operative.

Indications for hospital admission include ;

Hirsch Godbole

Article written by Leading Urologist – Mr H Godbole

Fever.
Solitary kidney.
Known non-functioning kidney.
Inadequate pain relief or persistent pain.
Inability to take adequate fluids due to nausea and vomiting.

Initial management of acute presentation

1. Pain control is main stay of management followed by preservation
of renal function and prevention of infection. This can be with NSAIDS ( diclofenac / ibuprofen). Antispasmodic medication as buscopan or opiods.3

2. Anti-emetics and re hydration therapy if vomiting and dehydration is apparent on clinical assessment

Medical expulsive therapy
Conservative management with oral rehydration may be continued for up to four weeks unless the pain is uncontrolled or if the patient develops signs of infection or obstruction.

Surgical Management

Kidney Stone CTIn potential or apparent obstruction from a ureteric stone a JJ stent is usually inserted to bypass the obstruction. It is a thin hollow tube with both ends coiled (pigtail) which sits inside the lumen of the ureter (the tube draining the kidney to the bladder). This alleviates the emergency situation.

Procedures to remove stones include

1. Extracorporeal shock wave lithotripsy (ESWL) – shock waves generated externally are directed and focussed over the stone to break it to small particles. These stone particles should then pass spontaneously. This procedure is performed under local anaesthetic and is a walk in walk out day procedure. Multiple sessions may be required.
2. Ureteroscopy – this involves the use of a camera which is inserted via the urethra and bladder into the ureter up to the obstructing stone. Holmium laser is used to break up the stone and has an excellent success rate in experienced hands. Usually post Ureteroscopy a JJ stent is left in situ which is removed subsequently. This is usually a day procedure under general anaesthetic and patient goes home the same day.
3. Percutaneous nephrolithotomy (PCNL) – used for large stones (>2 cm), staghorn calculi and also cystine stones. This is a major albeit minimally invasive surgery for stones needing inpatient stay which could be up to 3 days.

4. Open surgery – rarely necessary and usually reserved for complicated cases or for those in whom all the above have failed – eg, multiple stones.

References

1. Renal or ureteric colic – acute; NICE CKS, April 2015 (UK access only)
2. Manjunath A, Skinner R, Probert J; Assessment and management of renal colic. BMJ. 2013 Feb 21;346:f985. doi: 10.1136/bmj.f985.
3. Holdgate A, Pollock T; Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004137.
4. Seitz C, Liatsikos E, Porpiglia F, et al; Medical therapy to facilitate the passage of stones: what is the evidence? Eur Urol. 2009 Sep;56(3):455-71. Epub 2009 Jun 21.
5. Honeck P, Wendt-Nordahl G, Krombach P, et al; Does open stone surgery still play a role in the treatment of urolithiasis? Data of a primary urolithiasis center. J Endourol. 2009 Jul;23(7):1209-12. doi: 10.1089/end.2009.0027.

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