What are the treatment options for Nephrolithiasis (kidney stones)?

From the Guidelines

Management of kidney stones requires a multifaceted approach based on stone size, location, and composition, with the primary goal of minimizing morbidity, mortality, and improving quality of life. For small stones (less than 5mm), conservative management with increased fluid intake of 2-3 liters daily is recommended to promote spontaneous passage, as supported by the American College of Physicians guideline 1. Pain control is essential using NSAIDs like ibuprofen (600-800mg every 6-8 hours) or, if needed, opioid analgesics. Medical expulsive therapy with alpha-blockers such as tamsulosin (0.4mg daily) can relax ureter muscles and facilitate stone passage.

Treatment Options

• For larger stones (>10mm) or those causing severe symptoms, procedural interventions are necessary, including:
  • Extracorporeal shock wave lithotripsy (ESWL)
  • Ureteroscopy with laser lithotripsy
  • Percutaneous nephrolithotomy for very large stones
• The American Urological Association guideline recommends offering percutaneous nephrolithotomy (PCNL) as first-line therapy for symptomatic patients with a total renal stone burden >20 mm 1.
• For patients with symptomatic ≤10 mm lower pole renal stones, SWL or URS can be offered as first-line therapy 1.

Prevention Strategies

• Maintaining hydration sufficient to produce at least 2 liters of urine daily is universally recommended for all stone types 1.
• Dietary changes include reducing dietary oxalate, reducing dietary animal protein and other purines, and maintaining normal dietary calcium.
• Pharmacologic monotherapy with a thiazide diuretic, citrate, or allopurinol can be used to prevent recurrent nephrolithiasis in patients with active disease in which increased fluid intake fails to reduce the formation of stones 1.

Follow-up and Monitoring

• Regular follow-up with urinalysis and imaging helps monitor for recurrence, which affects about 50% of patients within 5-10 years without preventive measures.
• The most recent guideline from the American College of Radiology 1 emphasizes the importance of imaging in the diagnosis and management of kidney stones, highlighting the need for a comprehensive approach to minimize morbidity and mortality.

From the Research

Treatment Options for Nephrolithiasis (Kidney Stones)

• Extracorporeal shock wave lithotripsy (ESWL) is a common treatment option for kidney stones, which uses shock waves to disintegrate stones in the kidney and upper urinary tract 2.
• Percutaneous nephrolithotomy (PCNL) is another minimally invasive modality for kidney stones, which involves making a small incision in the back to insert a scope and remove the stone 2, 3.
• Retrograde intrarenal surgery (RIRS) is also a minimally invasive approach, which involves inserting a scope through the urethra and bladder to remove the stone 2, 3.
• Alpha-blockers may be used as adjuvant medical expulsive therapy to promote the passage of stone fragments after shock wave lithotripsy (SWL) 4.
• Minimally invasive percutaneous nephrolithotomy (miniperc) and micropercutaneous nephrolithotomy (microperc) are also contemporary management approaches for medium-sized renal stones 5.

Factors Affecting Treatment Outcomes

• The success of treatment at three months was significantly greater in the PCNL compared to the ESWL group 2.
• Stone size and location can affect the choice of treatment, with ESWL being more effective for smaller stones and PCNL being more effective for larger stones 2, 5.
• Renal function, as measured by estimated glomerular filtration rate (eGFR), can affect the stone-free rate after ESWL for proximal ureteric stones, with higher eGFR being associated with higher stone-free rates 6.
• Gender and stone width can also affect the stone-free rate after ESWL, with male gender and larger stone width being associated with lower stone-free rates 6.

Complications and Adverse Events

• PCNL is associated with more complications than ESWL, although the overall complication rate is low 2.
• Alpha-blockers may reduce the need for auxiliary treatments and major adverse events after SWL, although the certainty of evidence is low 4.
• Clavien I to II complications are common in the miniperc group, although no serious complications were noted in any of the groups evaluated 5.