2. surgical therapy

Kidney stones can be shattered by shock waves generated outside the body without damaging the surrounding tissue. The shock waves are generated in different ways: either by underwater spark discharge, pulsed laser beams or by conversion of electromagnetic energy. The resulting shock waves must be focused so that the highest effectiveness is achieved in the area of the stone (shock wave therapy).The tensile and compressive forces acting on it cause it to disintegrate into individual particles the size of a grain of sand, which can be excreted with the urine without any problems.

ESWL can destroy urinary stones up to 2.5 cm in size regardless of their location. The exact location must first be known from previous ultrasound or X-ray examinations. In this way, the stone is moved to the focal point of the shock waves.

A water bath or water or gel pad serves as a mediator between shock waves and the body. Occasionally a light local anaesthetic is necessary, as some patients feel the incoming shock waves as a “blow to the back”. The ESWL reaches its technical limits if the patient weighs more than 145 kg or is too short (<120 cm).

Under no circumstances may shock wave therapy be performed at Complications are rare. Especially larger urinary stones, in particular, can leave so-called stone streets after they are shattered, which must be removed endoscopically. Bruising can occur in the kidney area, which usually improves on its own.

Only in the case of extremely large bruises in the kidney capsule may it become necessary to remove them. Parts of the shattered stones can become trapped in the ureter and cause colic. A ureteral splint can be inserted as a preventive measure to avoid the accumulation of urine.

Following ESWT, urinary tract infections can occur, often if there are so-called infectious stones, in which bacteria were trapped inside. Under certain circumstances, preventive antibiotics can prevent this. Anticoagulant medication such as ASA should be discontinued 8 days before the treatment in order to avoid bleeding complications (see above).

Untreated or untreatable blood clotting disorder
Pregnancy
Untreated urinary tract infection
Aneurysms (bulging of the blood vessels)

In percutaneous therapy (through the skin) kidney stone shattering, the renal pelvis is punctured through the abdominal skin under ultrasound or X-ray control. After the puncture canal has been stretched slightly, an endoscope can be inserted. Either the kidney stone can then be removed by means of a salvage forceps, which is also inserted, or it is too large for this, which makes a shredding by means of forceps or similar necessary.

The fragments are then removed individually. In principle, kidney stones of any size can be treated in this way, but for stones that almost or completely fill the renal pelvis (so-called effusion stones), a combination of ESWL and PNL therapy is recommended. The procedure is performed under local anesthesia in a prone or lateral position.

After completion of the procedure, a bladder catheter should be inserted to ensure urine drainage. The complication rate of this therapy is very low. Possible complications include perforation of the renal pelvis, bleeding, infection or fistula formation (connection of the urinary drainage system to the intestine or skin).

In a short anaesthesia, a laser probe is placed in front of the stone with the help of an endoscope, which is then shattered by high-energy light impulses (so-called laser lithotripsy). Afterwards the remains are flushed out or removed with forceps. Sometimes it is necessary to install an additional ureteral splint.

Laser lithotripsy

In this therapy, the kidney stone/urinary stone is also removed during an endoscopic (tube camera) examination. For this purpose, the patient is placed in a supine position with spread legs (so-called lithotomy position). The endoscope is then advanced into the bladder via the urethra.

Now the openings of the ureters are searched for and, if necessary, first expanded using a ureter catheter or guide wire. Next, the ureters are searched for the kidney stone. Once this is found, there are several possible procedures.

The stone can either be crushed by means of sound waves and then suctioned off, or it can be crushed by shock waves (e.g. by laser) and then removed with grasping forceps. This is an alternative to ESWL, which offers the possibility of immediately expanding existing narrowings of the ureter and thus eliminating future sources of problems. This method is recommended for kidney stone urinary stones larger than 5 mm, severe, uncontrollable colic or kidney stones that do not come off despite conservative therapy.

It is also used in cases of increasing urinary stasis or existing urinary tract infections.Deep and very tight urinary stones can also be removed in this way or pushed back into the renal pelvis for subsequent removal using ESWL. Complications such as urinary tract infections, perforation of the ureter or secondary bleeding are rare. A urinary diversion makes sense if colic cannot be controlled with medication.

One can use ureteral stents, also known as double J-catheters or ureter stent, to keep the ureter open. These are plastic tubes that run in a J-shape, like a curly tail. This allows the tube to be held in the bladder and renal pelvis.

It can be advanced into the renal pelvis during a cystoscopy. However, splints are usually only used for a short time. If used permanently, they should be changed every 3-6 months.

Another therapy to remove kidney stones is the use of a sling that passes through the urethra and bladder to the renal pelvis and then removes the stones. However, this method is no longer frequently used because of the increased risk of injury to the ureters. In exceptional cases the method is used for stones in the lower third of the ureter.