What are the treatment options for kidney stones?

From the Guidelines

Treatment options for kidney stones should prioritize percutaneous nephrolithotomy (PNL) for most patients, especially those with staghorn calculi, due to its higher stone-free rates and lower morbidity compared to other treatments. For small stones (less than 5mm), watchful waiting with increased fluid intake (2-3 liters daily) is often recommended as they may pass naturally 1. Pain management typically includes NSAIDs like ibuprofen (600-800mg every 6-8 hours) or prescription medications such as ketorolac. Alpha blockers like tamsulosin (0.4mg daily) can relax ureter muscles, facilitating stone passage.

Key Considerations

• For larger stones or those causing severe symptoms, medical intervention becomes necessary, with options including:
  • Extracorporeal shock wave lithotripsy (ESWL) to break stones into smaller fragments
  • Ureteroscopy to remove or break up stones
  • Percutaneous nephrolithotomy for very large stones, requiring a small incision in the back
• Medications can help prevent recurrence for certain stone types, such as potassium citrate for uric acid stones, thiazide diuretics for calcium stones, or allopurinol for uric acid production 1
• Dietary modifications are crucial, including limiting sodium, animal protein, and oxalate-rich foods while maintaining adequate calcium intake and staying well-hydrated to prevent future stones 1

Recent Guidelines

The American Urological Association and Endourological Society guideline from 2016 recommends PNL as the first-line treatment for most patients with staghorn calculi, citing its higher stone-free rates and lower morbidity compared to other treatments 1. The guideline also emphasizes the importance of individualized treatment approaches, taking into account the size, location, and composition of the stone, as well as patient preferences and comorbidities.

Evidence-Based Recommendations

PNL is recommended as the primary treatment for staghorn calculi due to its high stone-free rates and low morbidity 1. For patients with mid or distal ureteral stones, ureteroscopy is recommended as the first-line therapy, with ESWL as an acceptable alternative 1. Routine stenting should not be performed in patients undergoing ESWL, and ureteral stenting after ureteroscopy should be omitted in patients without suspected ureteric injury or other anatomical impediments to stone fragment clearance 1.

From the Research

Treatment Options for Kidney Stones

• Extracorporeal shock wave lithotripsy (ESWL) is a widely used method to treat renal and ureteral stones, which fragments stones into smaller pieces that can pass spontaneously down the ureter and into the bladder 2.
• Medical expulsion therapy (MET) has been investigated as a supplement to observation to improve spontaneous stone passage rates, with alpha-1 blocker therapy showing promise in increasing the efficacy of ESWL to treat renal stones 3.
• Alpha-blockers, such as tamsulosin, silodosin, doxazosin, terazosin, and alfuzosin, may assist in promoting the passage of stone fragments after ESWL, with studies showing improved stone clearance rates and reduced need for auxiliary treatments 4, 2, 5.
• Flexible ureterorenoscopy (F-URS) is a treatment option for lower pole stones of 10-20 mm, with a significantly higher stone-free rate and lower retreatment rate compared to ESWL 6.
• Percutaneous nephrolithotomy (PCNL) is a treatment option for larger stones, with ESWL and F-URS being more suitable for smaller stones 3, 6.

Benefits of Alpha-Blockers

• Alpha-blockers may improve clearance of stone fragments after ESWL, with a risk ratio of 1.16 and 95% confidence interval of 1.09 to 1.23 2.
• Alpha-blockers may reduce the need for auxiliary treatments after ESWL, with a risk ratio of 0.67 and 95% confidence interval of 0.45 to 1.00 2.
• Alpha-blockers may reduce major adverse events, with a risk ratio of 0.60 and 95% confidence interval of 0.46 to 0.80 2.
• Alpha-blockers may reduce stone clearance time, with a mean difference of -3.74 days and 95% confidence interval of -5.25 to -2.23 2.

Comparison of Treatment Options

• F-URS has a significantly higher stone-free rate and lower retreatment rate compared to ESWL for treatment of lower pole stones of 10-20 mm 6.
• ESWL has a higher retreatment rate compared to F-URS, with 60% of patients requiring retreatment compared to 8% 6.
• PCNL is a more invasive treatment option, but may be necessary for larger stones or when other treatment options are not effective 3, 6.