Kidney/ Ureter/ Bladder Stones: treatments at UC Urology

Shockwave lithotripsy (ESWL)

ESWL, developed in the mid-1980’s, revolutionized treatment of kidney stones. The process consists of using a series of shock waves aimed at the stone to break it up into small fragments. The shock waves are generated by a lithotripter, and are focused precisely by x-ray to achieve maximum intensity at the stone causing the stone to fracture into small particles that can pass out of the kidney. ESWL is the only non-invasive treatment for kidney stones. It requires no incision and is usually performed as an outpatient procedure under general anesthesia. For stones that are larger than one inch in diameter, a stent (tube) may be inserted in the kidney to reduce the probability of blockage of the ureter by stone fragments as they pass. The ESWL procedure offers a non-invasive technique of pulverizing stones into fragments that can pass through the ureter. Depending upon the size of the stone and its position in the kidney, successful fragmentation of the stones in one treatment session is expected in 50-70% of patients. ESWL works best for patients with small stones that can easily be seen by x-ray.

Ureteroscopy

Ureteroscopy entails the insertion of a small telescope into the bladder and up the ureter. Once a stone is encountered, it can be fractured using laser energy delivered via a small glass fiber. Fragments of stone are removed by grasping with a stone "basket". Typically, a soft ureteral stent is left in the ureter to prevent blockage by stone fragments or swelling of the ureteral tissues. This stent is removed in the office under local anesthesia 2 weeks after the procedure. Depending upon the circumstance, patients may go home the same day or may be admitted overnight to ensure pain is controlled by oral analgesics. Ureteroscopy can treat stones in the ureter and in the kidney, including stones that are not visible by x-ray imaging. Ureteroscopy can be used for patients who are not candidates for other treatments such as those who must take blood thinners, the morbidly obese, and women who are pregnant.

Percutaneous nephrostolithotomy

PCNL entails the placement of a hollow tube into the kidney through a small (1 inch) incision in the back. PCNL is ideal for removing large (≥ 3/4 inch stones.) The procedure is performed under XRay (Flouroscopy) or Ultrasound guidance. This access to the kidney allows the use of an ultrasonic lithotriptor- a rigid instrument that vibrates and pulverizes the stone into granules that are suctioned from the kidney through the center channel of the instrument. Larger fragments can be removed through the access tube using graspers.

PCNL offers the best treatment for removal of large stone volume, including infected staghorn stones, to achieve a stone-free kidney after a single minimally invasive procedure. Occasionally, a second PCNL procedure may be indicated in patients whose large stone burden can not be removed in one procedure. Determination of successful stone removal requires a CT scan without contrast. In most cases, the nephrostomy tube that is inserted to drain the kidney will be removed the following day. The hospital stay is typically between 1-2 days with minimal postoperative pain or discomfort.

Laparoscopic pyelolithotomy/ ureterolithotomy

Laparoscopic surgery for kidney or ureteral stone disease is indicated in the small percentage of patients whose stone disease is not suitable for treatment with endoscopic surgery (PCNL, Ureteroscopy, ESWL), usually due to a large stone burden or associated structural abnormalities of the kidney, and in patients who have failed previous endoscopic procedures. Laparoscopic stone surgery is usually in the form of laparoscopic pyelolithotomy (kidney stone) or laparoscopic ureterolithotomy (ureteral stone). The procedure is performed by using specially designed instruments inserted through 3-4 small skin incisions as compared to the large incision of traditional surgery. The surgeon performs the surgery while watching the magnified images of the operative field on a monitor with the help of a telescope inserted into the patient’s abdomen. In laparoscopic pyelolithotomy, the kidney is freed from its surrounding attachments to define the anatomy. An incision in made in the renal pelvis (upper portion of the tube connecting the kidney to the bladder) and the stone is removed from within the kidney. The incision in the renal pelvis is repaired with suture. Laparoscopic ureterolithotomy is a similar procedure performed for large, impacted stones in the ureter. After establishing access for laparoscopy, the ureter is separated from surrounding structures and the stone located. We incise the ureter at the level of the stone and remove the stone. The advantage compared to open surgery is obviously shorter hospital stay, less pain or bleeding, quicker recovery and return to normal activity.

Cystolitholapaxy

Cystolitholapaxy is an endoscopic procedure in which a special telescopic instrument (cystoscope) is inserted into the bladder through the urethral opening at the tip of the penis in males or near the vaginal opening in females. The magnified images from the surgical field are transmitted by the telescope onto a television monitor which allows the surgeon to perform the procedure with greater precision and visual control. The bladder stone is then fragmented using specialized instruments inserted through the cystoscopy (cystolithotrite) or by using laser or ultrasound energy to fragment the stone. The stone fragments are then removed through the cystoscope. This is a minimally invasive procedure with siginificant advantages of faster recovery, decreased pain and no scar for the patient.

The University of Cincinnati Urology Division is one of the leading urology programs, not just in Cincinnati, but in the U.S. UC Urology provides quality health care using the most advanced technology and state-of-the-art diagnostic treatments. Many of our urologists are recognized in multiple national and local "Best Doctors" and "Top Doctors" listings. We provide minimally invasive surgical treatments which include laparoscopic, robot-assisted laparoscopic and endourologic procedures as well as comprehensive care for all urologic conditions.