What are Kidney Stone Procedures?

Kidney stones start as tiny crystals of minerals that stick together when urine is concentrated. This happens with dehydration. Crystals build into stones as more minerals deposit, similar to how a pearl builds in an oyster.

Your doctor has recommended that you have a kidney stone procedure. This video is intended to help you understand treatment options you may be considering.

First, let’s review some information about your body and why a procedure may be needed. The normal body has two kidneys, in the middle of the back, under the lowest ribs.  The kidneys filter and clean blood to make urine. Ureters drain urine from the kidneys to the bladder.

The bladder empties urine from the body through another tube called the urethra. The urinary tract includes all of these structures the kidneys, ureters, bladder, and urethra. Kidney stones start as tiny crystals of minerals that stick together when urine is concentrated. This happens with dehydration. Crystals build into stones as more minerals deposit, similar to how a pearl builds in an oyster.

Most small stones pass out of the body, carried by urine. Larger stones tend to remain in the kidney or become stuck as they move down the ureter. About 1 in 10 people are affected by kidney stones in their lifetime. Dehydration, family history, and some medical conditions increase the risk of stone formation.

Symptoms and problems often begin when urine flow is blocked by a stone. This can lead to severe pain, complicated infection, and blood in the urine. These problem stones are a risk for kidney damage. Many of these stones eventually pass without surgery.

This is called expectant management. Medications may be prescribed for pain, infection, and to help the stone pass. Rest, heat, and ice may also be recommended. It can take days to weeks for some small stones to pass on their own.

Surgical treatment can be necessary,

• when a small stone doesn’t pass with expectant management,…
• for stones too large to pass on their own,…
• any stone causing infection with fever, and…
• for uncontrolled pain, especially with nausea and vomiting.

Stones larger than half a centimeter are more likely to need intervention.
Some stones need more than one surgery, especially stones larger than 2 centimeters.

Procedures for managing kidney stones that may be considered include:

• cystoscopy,
• ureteroscopy,
• stent placement,
• PCNL, and
• ESWL

We will discuss each of these in more detail to get a better understanding of how, when, and why they may be used.
Most of these procedures are performed using scopes, long instruments with a light, and a camera.
The surgeon uses different scopes for different functions, to see and operate on places inside the urinary tract.
Cystoscopy is the most basic procedure on the list. The surgeon uses a scope to look inside the urethra and bladder for stones and other problems.

When needed, guidewires and dilators are passed through the cystoscope into the ureter.
During a ureteroscopy, a thinner scope is used. This is guided further, through the bladder, into the ureter, and sometimes up to the kidney.

Once kidney stones are reached, other tools are used to break the stones apart and pull the pieces out.
Large stones in the kidney, and high in the ureter can require a more invasive approach.

A PCNL procedure is done using a scope, guided through a tube in the back, directly into the kidney.
A guidewire is inserted before surgery using x-ray guidance to map where the tube should be placed during surgery.
This may be done in a separate radiology suite or in the operating room just before surgery.

In the operating room, dilators are placed over the guidewire to create a passage to the kidney. A tube is placed to hold this open.
The surgeon guides a scope through the tube to see the stone. Other tools are used to break the stone apart and remove the pieces.
ESWL is known as lithotripsy.  This non-invasive procedure is often useful for stones in the kidney.
An x-ray device is used to pinpoint the kidney stone location and a water-filled lithotripsy device, is positioned against the skin over the kidney and aimed at the stone.

Pulses of shock waves are directed at stones to break them into tiny pieces so they can pass out of the body.
These pulses create a tapping noise, and sensation on your back, as hundreds of bursts are used at a time.
Patients can have bruising and soreness in their back from the shock waves.

Placement of a temporary stent is often a necessary step before, during or after the procedures we have discussed so far.
This thin, straw-like tube is passed through a cystoscope into the ureter then guided up to the kidney.  The curl at each end holds the stent in place.

Stents keep the kidney draining.  They are temporary but may be needed for days or weeks. Stents can relieve stone pain, and dilate the ureter to help a stone pass.  Stents are placed while an infection is being treated before a stone can be removed. Stents are also needed while the ureter heals after some procedures.
The most appropriate procedures for you depend on the size and location of the stone or stones, the severity of the blockage, and your other medical conditions.

Before your surgery, understand which procedures are planned or may become necessary to treat your kidney stone.
Now let’s look closer at each of the procedures we have been discussing.
Anesthesia medications are given as appropriate for each procedure.

A cystoscopy begins with a scope being gently guided through the urethra to the bladder.
The surgeon looks carefully for stones, tumors, or other problems. Both ureteral openings are inspected.

To proceed to a ureteroscopy, a guidewire is threaded through the cystoscope into the ureter.
A ureteroscope is guided by the wire in the ureter, to the stone.
The stone may be broken into smaller pieces using a laser.
Which are then held by graspers, and gently pulled out.

Next, a stent may be placed using a scope. The stent is guided into the ureter then gently passed up to the kidney.
Strings may be left hanging for stent removal later.

A Foley catheter may be placed to drain urine.

To start a PCNL procedure, you are positioned on your side or belly.
The kidney stone is viewed with an x-ray machine.
A guidewire is inserted into the kidney to the stone.
To place the tube, dilators are placed over the wire to make a larger path for the guide tube.

A small incision is needed to pass the tube into the kidney, over the wire.
The wire is pulled and a scope is passed through the tube to see and work on the stone.
A variety of tools may be used to break the stone into pieces.
Graspers are used to pull the pieces out through the tube.

When the kidney is clear, a drain is placed.
The guide tube is removed.
The site is checked for bleeding.
The skin is closed and a dressing placed.

If another view of your bladder, ureteroscopy, or stent placement is needed, you may be repositioned, to place a ureteral stent and a foley at the end of the PCNL procedure.

A lithotripsy procedure is begun by marking the skin over the affected kidney (before anesthesia).
The position of the kidney stone or stones is pinpointed with an x-ray machine.
The lithotripsy device is positioned then pulses of energy are directed at the kidney stone, ideally breaking it into tiny pieces.
X-rays are used to be sure the stone pieces appear small enough to pass through the ureter.

More pulses from the lithotripsy device may be needed.
When the stones’ pieces are made as small as possible with the device, this part of the procedure is ended.

If another view of your bladder, ureteroscopy, or stent placement is needed you may be repositioned while under anesthesia.

Now let’s learn about what to expect after surgery and what you can do to help.

After surgery, “speak up” and tell your care team if you have more than expected pain or problems.
They will be watching for early rare complications.
Patients often go home the same day as their procedure unless they have a PCNL surgery.

A hospital stay is usual for monitoring the temporary drains and assisting with patient care and pain control.

After kidney stone surgery you may experience back pain near the kidney, called flank pain, bladder irritation, blood in the urine, and constipation from anesthesia and pain medications.

Many patients have a temporary drain and/or stent in place after their procedure, these can cause some discomfort, bladder spasms, and small clumps of blood in the urine.

Home care instructions for drains and stents include suggestions to manage these symptoms and plans for their removal.
With kidney stone procedures, narcotic, opioid, pain medication, is most effective the first 1 to 2 days.

After that narcotic medication worsens constipation and has other side effects.
For this reason, you may receive a limited number of tablets with your prescription.
Use all medication with care and only as instructed by your surgeon.

The best way to manage pain and prevent problems is to drink water throughout the day, to flush traces of stones and blood;
• avoid soda, caffeine, and alcohol; and
• rest as needed
Reclining with a heating pad or ice can be very helpful.
Both heat and ice must be used carefully and as instructed to avoid accidental injury.  Always place a towel first against the skin. Never sleep on, or with a heating pad.

All surgery has some risk of complication.  Rare but serious problems related to kidney stone procedures can include damage to the kidney, ureter, bladder or other nearby structure, bleeding, and infection.
Let’s review some risks that are more specific to each procedure.

Cystoscopy risks are rare but include

• possible injury to the urethra or bladder,
• bleeding, and
• urinary tract infection.

If a ureteroscopy is performed, the risks also include

• residual stones,
• a tear or hole in the ureter,
• scar tissue called a stricture making the ureter narrow,
• stent pain,
• infection and bleeding.

Sometimes another procedure is needed to correct some problems.
PCNL procedure risks also include the rare possibility of serious infection, major bleeding requiring blood transfusions, and damage to a nearby organ, such as the colon.

To repair these problems a more invasive open procedure can be required, even rarely leading to the removal of the kidney.
But the most common risks after PCNL are of pain from the stent and drains, and residual stones if the stone could not be completely removed.

The least invasive procedure lithotripsy has risks that include, tiny stone pieces piling up in the ureter, that can require another procedure to treat.

Rarely a large bruise on the kidney can form. And very rarely an increase in blood pressure has been seen in some patients after many lithotripsy procedures.

There appears to be no significant effect on diabetes although this was a concern years ago.

A patient’s personal risk of complications is related to,

• their overall health,
• the size and location of their kidney stone or stones
• and the experience of their surgeon.

The larger the stone the more difficult it will be to remove.
Additional surgery at a later date can be needed following any kidney stone procedure, most often to remove stone pieces called residual stones, to remove or place a stent, and/or place a new stent.

A blood clot or DVT can form in the legs or pelvis during or after any surgery.
It can cause a lung complication called a PE or pulmonary embolism. Steps are taken by your care team to help avoid this complication.

  • Call your doctor if you have trouble with diarrhea, vomiting, or worsening constipation.
  • Call if you cannot urinate or are constantly leaking. If you have a stent, it may have moved out of position.
  • Call if you have a fever, back or belly pain that is getting worse even with heat, rest and medication. 
  • Call 911 if you have chest pain, shortness of breath, dizziness, bleeding that doesn’t stop, and any other sign that you may be having a complication from the procedure.

Hospital admission, medication, or surgery may be needed to correct some problems.

You can help your body heal, eat healthy foods.  Avoid junk food, sugary drinks and don’t smoke

Smoking and high blood sugar both slow healing.

Up to 50% or 1 in 2 people that have a kidney stone, will develop another within 5 years.
To prevent more stones, continue to drink plenty of water every day.

Learn about your stone type.
If needed, you may collect pieces of stone with a strainer when you urinate for testing.
Some stones can be dissolved or prevented with medication.

As always, ask if you have questions.

To avoid cancellation or complications from anesthesia or your procedure, your job as the patient is to
• not eat, drink or chew gum after midnight, the night before the procedure unless you are given different instructions
• take only medications you were told to on the morning of the procedure with a sip of water
• follow instructions regarding aspirin and blood thinners before surgery,
• and arrive on time

You should be ready to verify or confirm your list of medical problems and surgeries, all of your medications, including vitamins and supplements, your current smoking, alcohol, and drug use, and all allergies, especially to medications, latex, and tape.
All surgery and anesthesia have a small but possible risk of serious injury, even some problems very rarely leading to death.
It is your job to speak up and ask your surgeon if you still have questions about why this surgery is being recommended for you, the risks, and alternatives.

This video is intended as a tool to help you to better understand the procedure that you are scheduled to have or are considering. It is not intended to replace any discussion, decision making or advice of your physician.