Treatment Options for Kidney Stones
For kidney stones, treatment should be tailored based on stone size, location, and composition, with surgical intervention recommended for large (>20mm) or symptomatic stones that cannot pass spontaneously. 1
Initial Management Approach
- Increased fluid intake (2.5-3.0 L/day) and achieving urine output >2.0-2.5 L/day is the cornerstone of prevention for all stone types 2
- Medical expulsive therapy (MET) is first-line for uncomplicated distal ureteral stones ≤10mm that don't pass with observation 3
- Alpha-blockers (particularly tamsulosin 0.4mg daily) increase stone clearance rates for ureteral stones 5-10mm without lithotripsy 4
Surgical Management Options Based on Stone Size
Small Stones (<10mm)
- Either shock wave lithotripsy (SWL) or ureteroscopy (URS) may be offered as first-line treatment 1
- URS provides higher stone-free rates (90% vs 72%) but slightly higher complication rates compared to SWL 5
Medium Stones (10-20mm)
- For most locations: URS or SWL are appropriate first-line options 1
- For lower pole stones: URS or PCNL are recommended (success rates: SWL 58%, URS 81%, PCNL 87%) 5
- Alpha-blockers as adjunctive therapy post-lithotripsy significantly improve stone clearance for stones 10-20mm 4, 6
Large Stones (>20mm)
- Percutaneous nephrolithotomy (PCNL) should be offered as first-line therapy due to significantly higher stone-free rates 1, 5
- Open/laparoscopic/robotic surgery should not be offered as first-line therapy except in rare cases with anatomic abnormalities or those requiring concomitant reconstruction 1
Medical Management Based on Stone Type
Calcium Stones
- Thiazide diuretics and/or potassium citrate should be offered to patients with recurrent calcium stones when other metabolic abnormalities are absent or addressed 1
- Allopurinol should be offered to patients with recurrent calcium oxalate stones who have hyperuricosuria and normal urinary calcium 1
Uric Acid Stones
- Potassium citrate should be offered to raise urinary pH to an optimal level (target pH 6.0) 1
- Allopurinol should not be routinely offered as first-line therapy 1
Cystine Stones
- Potassium citrate should be offered to raise urinary pH to an optimal level (target pH 7.0) 1
- Cystine-binding thiol drugs (e.g., tiopronin) should be offered to patients unresponsive to dietary modifications and urinary alkalinization, or those with large recurrent stone burdens 1
Special Considerations
- For obstructing stones with suspected infection, urgent drainage of the collecting system with a stent or nephrostomy tube is mandatory before definitive treatment 5
- If purulent urine is encountered during endoscopic intervention, abort the procedure, establish drainage, continue antibiotics, and obtain a urine culture 1
- Stone material should be sent for analysis to guide prevention strategies 1
Follow-up Monitoring
- Obtain a 24-hour urine specimen within six months of treatment initiation to assess response to therapy 1
- After initial follow-up, obtain annual 24-hour urine specimens to assess patient adherence and metabolic response 1
- Periodic blood testing is necessary to assess for adverse effects in patients on pharmacological therapy 1
Prevention Strategies
- Dietary management includes sufficient calcium (1000-1200 mg/day), limited sodium (2-5g NaCl/day), limited animal proteins (0.8-1.0g/kg/day), and increased citrus fruits 2
- Maintain normal BMI and ensure adequate fluid compensation when working in high-temperature environments 2
- Avoid vitamin C and vitamin D supplements in patients prone to calcium stones 2