How do you manage large kidney and ureteral stones?

“Distal stones we treat medically first, then with ureteroscopy. Proximal stones we usually treat with ESWL, sometimes percutaneous treatment, depending on the stone’s location and size. If the stone is very large and in a location where ESWL is less likely to be successful, you think harder about doing the percutaneous approach. We generally only use ureteroscopy on distal stones.

We do a lot of ESWL. There’s a tendency to do multiple ESWLs, even where the percutaneous procedure is equally appropriate and requires only one treatment. When you describe both procedures, patients decide ESWL sounds like a better way to go. ESWL is less traumatic and the results are good.”

Geoffrey Engel, MD

Elk Grove Village, IL

“For ureteral stones, my primary treatment approach is ureteroscopy.

We had the first lithotripter on the West Coast and patients expected the least invasive treatment, but we found that a good third of stones did not respond. Stones in the ureter for any prolonged period did not respond well to shock wave lithotripsy regardless of the amount of energy used.

Eventually, we decided that we would treat all stones in the ureter that couldn’t be pushed up with a ureteroscope, breaking them up with direct-contact lithotripsy. Then, the holmium laser became available and worked so well that we eventually treated virtually all ureteral stones with the laser.

If patients don’t have spontaneous stone passage, I discuss lithotripsy-and quote a success rate between 50% and 90%-and ureteroscopy, with basically 100% success. Nine out of 10 patients opt for the endoscopic approach.

For kidney stones larger than 3 cm or the branched stones, PCNL is clearly the treatment of choice, but with better metabolic evaluations and medical management, very big stones are not as common anymore.”

Gerhard Fuchs, MD

Beverly Hills, CA

“It depends on how big the stone is. Bigger stones of course we do percutaneously. I discuss shock wave lithotripsy versus ureteroscopy with the patient for smaller stones. I tell them ureteroscopy probably has a higher chance of clearing the stones but shock wave is probably the safest.

If it were me, I would probably try shock wave before ureteroscopy. But some people say, ‘I want one-and-done;’ the answer to that is ureteroscopy.

Most people do try shock wave, but I’m very open about it and let them know that we probably have a higher chance of getting rid of the stones with the ureteroscopy. It’s just a more involved procedure, unfortunately.

My experience with shock wave lithotripsy is probably a little better than what textbooks and articles report. We probably only have to repeat ESWL or go to ureteroscopy about 20% of the time.”

Marc David Benevides, MD

Cary, NC

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