Other Treatments

Surgery is usually needed if the stone is too large to pass on its own, if there are indications that it is growing, or if it is blocking the urine flow and causing urinary tract infection or damaging the kidney. Until recently, the procedure to remove a stone was a very painful, major surgery that required a 4- to 6-week recovery period. Today, treatments for stones are much less invasive and major surgery is performed in less than 2% of patients.

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The primary methods of stone removal are the following:

• Extracorporeal shock wave lithotripsy (ESWL). In general, ESWL is the first choice for small stones (less than one centimeter) in the upper ureter. (One 2000 trial attempted to determine whether ESWL offered any advantage for treating very small stones that caused no symptoms; no benefit was detected.)
• Percutaneous nephrolithotomy (PNL). PNL can be used for very large stones in the upper tract, when ESWL fails, for kidney transplant patients, or when there are structural abnormalities in the kidney or surrounding area. It is the preferred procedure for drug-resistant cystine stones, which are usually resistant to shock wave therapy. For small staghorn calculi in normal or near normal kidneys, either ESWL or PNL is usually effective. For complicated conditions involving staghorn calculi, however, experts usually recommend PNL followed by ESWL (called a sandwich procedure) or a repeat PNL procedure.
• Ureteroscopy. For stones in the lower tract, ureteroscopy is generally the best procedure, although lithotripsy is also usually feasible and patients ordinarily prefer it.
• Standard open surgery (nephrolithotomy) may be required if any of these procedures fail or are not appropriate, or in special cases, such as when the patient is very obese.

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