From the Guidelines
For symptomatic patients with kidney stones, the treatment of choice depends on the size and location of the stone, with PCNL being the preferred option for stones larger than 20mm, and SWL or URS for smaller stones. The American Urological Association recommends that in symptomatic patients with a total non-lower pole renal stone burden ≤ 20 mm, clinicians may offer SWL or URS 1. However, for cumulative stone burdens <20 mm, stone-free rates for both URS and SWL are acceptable and have less morbidity than PCNL. Key considerations for treatment include:
- Stone size: PCNL is recommended for stones larger than 20mm due to its higher stone-free rate compared to SWL or URS 1.
- Stone location: For lower pole stones, SWL or URS is recommended for stones ≤ 10 mm, while endoscopic approaches are preferred for larger stones 1.
- Patient factors: Obesity, skin-to-stone distance, collecting system anatomy, stone composition, and stone density/attenuation can affect the success of SWL 1. In general, the goal of treatment is to achieve a stone-free state with minimal morbidity and mortality, while also considering the patient's quality of life. Treatment options for kidney stones include:
- Watchful waiting for small stones
- Pain management with NSAIDs or prescription medications
- Medical intervention with ESWL, URS, or PCNL for larger stones or those causing severe symptoms
- Prevention strategies such as increased fluid intake, dietary modifications, and medication to prevent recurrence based on stone composition 1.
From the Research
Treatment Options for Kidney Stones
- Shock wave lithotripsy (SWL) 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, 3, 4.
- Alpha-blockers may assist in promoting the passage of stone fragments after SWL, and may improve clearance of stone fragments, reduce the need for auxiliary treatments, and reduce major adverse events 2, 5, 3.
- The use of alpha-blockers without lithotripsy may also be beneficial for ureteral stones ≤10 mm, and for renal or ureteral stones >10 mm after lithotripsy 5.
Effectiveness of Alpha-Blockers
- Alpha-blockers may increase stone clearance rate, with a pooled absolute risk difference of 16% in favor of the alpha-blocker group 3.
- The use of alpha-blockers may also reduce expulsion time, with a pooled mean difference of 8 days in favor of the alpha-blocker group 3.
- Tamsulosin is the most widely used alpha-blocker, and has been shown to be effective in assisting stone clearance after SWL 2, 5, 3.
Comparison of Treatment Options
- Percutaneous nephrolithotomy (PNL) and retrograde intrarenal surgery (RIRS) may be more effective than SWL for lower-pole renal stones, particularly for stones >10 mm 4.
- The choice of treatment option depends on the size and location of the stone, as well as the patient's overall health and medical history 4, 6.
Prevention and Management
- Lifestyle modifications, such as increased fluid intake, may help prevent kidney stone recurrence 6.
- Medical expulsive therapy with an alpha-blocker, and follow-up imaging, may be used to manage kidney stones conservatively 6.
- Patients with recurrent kidney stones should be screened for risk of stone recurrence, and may require additional metabolic assessment and tailored preventive measures 6.