February 1, 2021 Author : Bruno Graça Many stones, when less than 5 mm and lodged in the ureters, are expelled without surgery. When this does not happen, the symptoms and its severity, the location and dimensions of the stones, and the patient preference, determine the best treatment approach. In the treatment of kidney stones there are to consider : The treatment of renal colic, if it occurs; The treatment of calculus. Treatment of renal colic The treatment of renal colic aims to eliminate symptoms . It may include several interventions, chosen according to the specifics of the case and the responses to the measures implemented: Restriction of fluids so as not to aggravate kidney distention and pain; Immersion in hot water or application of heat in the lower back (water bag); Analgesic medication administered orally, intramuscularly or intravenously; Expulsive medication for ureteral stones, when they are in the terminal region and are up to 6 mm; Surgical placement of a JJ stent to unblock the ureter and relieve symptoms in refractory cases; Semi-rigid ureterorenoscopy. Calculus treatment The purpose of the stone treatment is to destroy it and / or eliminate its cause . The options depend mainly on the location, dimensions and, in some cases, the type of stone. Kidney stone Vigilance without any treatment can be an option: In renal microlithiasis (stones less than 5 mm); For stones up to 10 mm, when they are in the lower region of the kidney; The treatment of stones lodged in the kidneys can be done by: Alkalizing medication for urine in uric acid stones; Extracorporeal shock wave lithotripsy (LEOC); Flexible ureterorenoscopy; Percutaneous kidney surgery; Laparoscopic or robotic surgery. Stone in the ureter In ureteral stones, surveillance can also be an option when the stones are less than 6 mm and there are no important symptoms. Usually, analgesic, anti-inflammatories, and relaxing ureter medications are associated. The treatment of stones housed in the ureter can be done by: Extracorporeal shock wave lithotripsy; Semi-rigid or flexible ureterorenoscopy; Laparoscopic or robotic surgery. Renal lithiasis surgery JJ stent placement The placement of the JJ stent allows to immediately unblock the ureter, resolve colic, and restore renal function. It is the most frequent urological procedure in the urgent treatment of renal colic , creating space between the stone and the inside of the ureter for an effective drainage of urine. It does not treat the stone, but it allows preparing the ureter for definitive treatment through ureterorenoscopy. The most frequent complications may be the presence of blood in the urine, persistent urinary complaints such as increased urinary frequency, urinary urgency, discomfort in the lower abdomen and low back pain at the time of urination (urine may rise through the ureter in abdominal effort). Urinary tract infection can also arise, worsening existing symptoms. Alternatively, when it is not possible to place a JJ stent, a percutaneous nephrostomy can be placed, that is, a thin tube in the kidney that passes through the skin in the lumbar region to eliminate urine. Percutaneous nephrostomy resolves colic and restores kidney function. Extracorporeal shock wave lithotripsy (LEOC) LEOC is a non-invasive ambulatory treatment , performed under analgesia or anesthesia. It is mostly used for kidney stones up to 1-2 cm and has a success rate of around 80% -85%. The most frequent complications may be renal colic if a JJ stent has not been placed previously, the presence of blood in the urine and urinary infection. Serious renal trauma can rarely occur, requiring transfusions and rest or even emergency surgery. In the ureter the application of LEOC is not usual. It is mainly used in ureter stones closest to the kidney . Since it may not resolve renal obstruction or colic right away or in the days ahead, it is not used very often. Semi-rigid ureterorenoscopy Semi-rigid ureterorenoscopy is a minimally invasive surgery performed through the urethra. The semi-rigid ureterorrenoscope runs through the ureter and allows, under vision, to fragment the stone with a laser or to extract it with forceps or a probe. It is a very effective technique. As a rule, a JJ stent is left at the end of the procedure to avoid residual obstruction due to edema or sands. The semi-rigid ureterorenoscopy can be programmed or performed urgently , with or without hospitalization, depending on the severity of the clinical situation, always under anesthesia. The most frequent complications can be the appearance of blood in the urine, trauma to the ureter and urinary infection, which can be localized or systemic leading to sepsis. Flexible ureterorenoscopy Flexible ureterorenoscopy is a minimally invasive surgery performed through the urethra. The flexible ureterorrenoscope runs through the ureter into the kidney allowing to explore the entire renal excretory system and, under vision, fragment with laser the ureter or kidney stone or extract it with forceps or probe. It is a very effective technique and is used in stones up to 2-3 cm. As a rule, a JJ stent is left at the end of the procedure to avoid residual obstruction due to edema or sands. The flexible ureterorenoscopy is generally programmed and performed with hospital stay , always under anesthesia. The most frequent complications can be the appearance of blood in the urine, trauma to the ureter and kidney and urinary infection, which can be localized or systemic leading to sepsis. Percutaneous kidney surgery Percutaneous kidney surgery is a minimally invasive surgery , in which the kidney is accessed through the skin in the lumbar region. The stone is then visualized, fragmented and extracted. It is a very effective technique and used in stones larger than 2-3 cm. As a rule, a JJ stent is left in the end of the procedure to avoid residual obstruction due to edema or sands. Percutaneous lumbar drainage may remain for a few days, usually 1-3 days, depending on the clinical situation. It is a technically demanding surgery, which needs adequate experience and expertise to obtain the best results. It is usually done during hospital stay, always under anesthesia and the most frequent complications are the appearance of blood in the urine, trauma to the kidney and urinary infection that can be localized or systemic leading to sepsis. Rarely, urinary fistula may form, or severe kidney trauma may occur, requiring transfusions and rest or even urgent surgery, or damage to other organs (intestine or blood vessels). Currently, urologist can perform minipercutaneous surgery to operate through orifices up to 50% smaller than those used in traditional percutaneous surgery. Laparoscopic or robotic surgery Laparoscopic or robotic kidney surgery is used very rarely in the treatment of stones and only when there is a failure of less invasive techniques or there is a need to correct a concomitant anatomical anomaly, for example in the ureteropelvic junction syndrome. It needs hospital stay and is performed always under anesthesia. The most frequent complications are the appearance of blood in the urine and urinary infection that can be localized or systemic leading to sepsis. Rarely, urinary fistula may form, damage to other nearby organs (for example, intestine or blood vessels) or conversion to traditional open surgery. Prevention of kidney stones Renal lithiasis is a chronic disease with a familial predisposition. Cure can never be achieved if a reversible cause is not identified. Therefore, the prevention of renal lithiasis is essentia l. This includes general or specific measures if metabolic changes are detected. Since about 50% of patients with renal colic will have a new episode in the next 5 years, it is necessary to decrease this risk by : Oral hydration (with water) in order to urinate at least 2 liters per day; Drink water at least every 2 hours; Reinforce fluid intake when doing physical activity and during the night; Citrus juices (orange and lemon) are also recommended; Meals should be light, frequent and varied; Salt, meat and refined sugar intake should be limited. When there are metabolic changes , it may be necessary to resort to a specific diet. It may also be necessary to involve other medical specialties , such as nephrology or endocrinology. Learn more about the type of kidney stones and its diagnosis . Meet the urology team from Hospital da Luz network. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
