What is the treatment for a lower pole kidney stone causing pain?

Treatment of Lower Pole Kidney Stone Causing Pain

For symptomatic lower pole kidney stones ≤10 mm, either shock wave lithotripsy (SWL) or ureteroscopy (URS) should be offered as first-line treatment options. 1, 2

Treatment Based on Stone Size and Location

Lower Pole Stones ≤10 mm

• SWL or URS are both appropriate first-line treatment options with comparable stone-free rates 1
• Patient-derived quality of life measures tend to be somewhat better with SWL in this size range 1
• Intraoperative complications may be slightly higher with URS, though not statistically significantly so 1

Lower Pole Stones >10 mm

• SWL should NOT be offered as first-line therapy due to significantly lower success rates 1
• For stones 10-20 mm, URS or PCNL are recommended with median success rates of 81% for URS and 87% for PCNL (compared to only 58% for SWL) 1, 2
• For stones >20 mm, PCNL should be offered as first-line therapy due to superior stone-free rates 1, 2

Urgent Considerations

• In patients with obstructing stones and suspected infection, urgent drainage of the collecting system with a stent or nephrostomy tube is mandatory before definitive stone treatment 1, 2
• Delay definitive stone treatment until infection is controlled with appropriate antibiotics 1

Procedural Considerations

For SWL

• Success depends on factors including obesity, skin-to-stone distance, collecting system anatomy, stone composition, and stone density 1
• Patients selected for SWL should have favorable parameters to maximize stone-free rates 1
• Routine stent placement before SWL is not recommended 1

For URS

• Flexible or semi-rigid ureteroscopes can be used depending on stone location 2
• Laser lithotripsy is preferred for stone fragmentation during flexible URS 2
• Routine stent placement after uncomplicated URS is not recommended 1

For PCNL

• Flexible nephroscopy should be routinely performed during PCNL to access stone fragments that migrate to inaccessible areas 2
• Normal saline irrigation must be used during PCNL to prevent electrolyte abnormalities 1, 2
• Nephrostomy tube placement after uncomplicated PCNL is optional 1
• For patients with contraindications to PCNL (e.g., anticoagulation that cannot be discontinued, anatomic deformities), staged URS is a viable alternative 1

Pain Management During Treatment

• NSAIDs are recommended as first-line treatment for acute kidney stone pain 3, 4
• Opioids should be reserved as second-choice analgesics when NSAIDs are contraindicated or ineffective 3, 4
• Alpha-blockers (e.g., tamsulosin) may help with stone passage and can reduce stent discomfort 1, 4

Prevention of Recurrence

• Increased fluid intake to achieve urine volume of at least 2.5 L daily 5, 6
• Dietary modifications based on stone composition and metabolic abnormalities 7, 5
• Medical therapy tailored to specific metabolic abnormalities identified through 24-hour urine collection 7, 5

Special Considerations

• In patients with negligible kidney function in the affected kidney, nephrectomy may be considered 1, 2
• For patients who fail or are unlikely to have successful results with SWL and/or URS, alternative approaches including laparoscopic, open, or robotic-assisted stone removal may be offered 1