What are the treatment options for internal calculus, such as kidney or gallstones?

Treatment Options for Internal Calculus (Kidney and Gallstones)

The treatment of internal calculi depends on stone size, location, composition, and patient factors, with options ranging from conservative management to surgical intervention.

Kidney Stones Treatment

Conservative Management

• For ureteral stones <10 mm with controlled symptoms, observation with periodic evaluation is an appropriate initial treatment option 1
• Medical expulsive therapy (MET) with alpha-blockers is recommended for uncomplicated ureteral stones ≤10 mm, particularly for distal ureteral stones 1, 2
• MET should be limited to a maximum of 6 weeks to avoid kidney injury 2
• Patients should be counseled on MET risks, including drug side effects and "off-label" use 1
• Patients choosing observation or MET should have well-controlled pain, no clinical evidence of sepsis, and adequate renal function 1
• Periodic imaging is required to monitor stone position and assess for hydronephrosis 1

Surgical Management for Ureteral Stones

• For ureteral stones >10 mm, surgical treatment is typically required 1
• Both shock wave lithotripsy (SWL) and ureteroscopy (URS) are acceptable first-line treatments 1
• URS yields significantly higher stone-free rates with a single procedure but has higher complication rates 1
• For distal ureteral stones >10 mm, URS is recommended as first-line treatment 1
• For proximal ureteral stones, URS is generally recommended regardless of stone size 1

Surgical Management for Kidney Stones

Based on stone size and location:

• For stones <10 mm: Active surveillance or SWL 2
• For stones 10-20 mm in renal pelvis or upper/middle calyx: SWL or flexible URS 1, 2
• For stones 10-20 mm in lower pole: Flexible URS or percutaneous nephrolithotomy (PCNL) 1
• For stones >20 mm: PCNL is the first-line treatment 1, 2
• For staghorn calculi: PCNL is generally recommended; SWL monotherapy may be considered only for small volume staghorn calculi with normal collecting system anatomy 1

Special Considerations

• For patients with bleeding disorders, URS is the first-line therapy 2
• Infected stones require immediate drainage, antibiotic therapy, and culture 2
• For cystine staghorn stones, SWL monotherapy should not be used 1
• Complete stone removal is recommended for infection-related (struvite) stones to prevent recurrence 2

Prevention of Recurrence

Fluid and Dietary Recommendations

• Increase fluid intake to achieve urine volume of at least 2.5 liters daily 2, 3
• Maintain normal dietary calcium intake (1,000-1,200 mg/day) 2
• Limit sodium intake to ≤2,300 mg/day 2
• Reduce animal protein intake to 5-7 servings per week 2
• Increase potassium-rich foods 2
• Reduce sucrose/carbohydrate intake 2
• Choose beverages associated with lower stone risk (coffee, tea, wine, beer, orange juice) 2

Pharmacological Therapy

• For hypocitraturic calcium stone formers: Potassium citrate is first-line therapy 2
• For hyperuricosuria and calcium stones: Allopurinol (300 mg daily) if hyperuricosuria persists after alkalization 2
• For hypercalciuria: Thiazide diuretics 4, 5

Monitoring and Follow-up

• Stone analysis should be obtained at least once when available 2
• For high-risk or recurrent stone formers, 24-hour urine collection analyzing volume, pH, calcium, oxalate, uric acid, citrate, sodium, potassium, and creatinine 2
• Follow-up 24-hour urine specimen within six months of initiating treatment 2
• Annual follow-up with 24-hour urine specimen 2
• Periodic blood testing for patients on pharmacological therapy 2

Complications of Treatment

SWL and URS have different complication profiles that should be considered when selecting treatment:

• SWL complications include sepsis (2-5%), steinstrasse (stone street formation, 4-8%), stricture (0-2%), ureteral injury (1-2%), and UTI (4-6%) 1
• URS complications include sepsis (2-4%), stricture (1-4%), ureteral injury (3-6%), and UTI (2-4%) 1

Pediatric Considerations

• SWL monotherapy or percutaneous-based therapy may be considered for children with staghorn calculi 1
• Stone-free rates using SWL monotherapy in children are higher than in adults for large renal stones 1
• Complications in pediatric patients should be carefully considered, with SWL having risks of bleeding (5%), pain (18%), retention (2%), and sepsis (4%) 1

The treatment approach should be tailored based on stone characteristics, patient factors, and available expertise, with the goal of achieving complete stone clearance while minimizing complications and preventing recurrence.