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Some people are genetically prone to kidney stone formation. A majority of patients, however, form stones due to consistent low urine volume (dehydration) or dietary factors. If the urine is overly concentrated, crystals can easily form in the urine and make kidney stones. To avoid forming new stones, patients should drink enough fluid to produce 2 liters of urine per day. The most common dietary contributors are a high salt or high oxalate diet. This typically results in too much calcium being excreted in the urine. This is not related to how much calcium is consumed, but rather how well the intestines and kidneys handle calcium. It is important to take in a normal amount of calcium in the diet. In addition to limiting sodium intake, it is important to limit oxalate rich foods. This list can be extensive, but the most common offenders are tea, dark sodas, tree nuts, and leafy greens. Additionally, diets high in animal protein put patients at risk for stone formation. Bowel conditions and being overweight are risk factors as well. Finally, some medications may increase your risk of stone formation.

Most people do not have symptoms until the stone blocks urine flow from the kidney. Early symptoms typically include low grade discomfort, using the bathroom more frequently than usual, blood in the urine, or mild nausea. As the kidney becomes more obstructed by the stone, pain typically escalates and patients often have nausea and vomiting. Fever with an obstructing kidney stone is a medical emergency.

While some “silent” kidney stones are found incidentally on imaging for other disease processes, most kidney stones are diagnosed on plain x-ray, ultrasound, or CT scan. Multiple methods of imaging may be used to help determine size and location and aid in surgical planning.

• X-ray: This is the oldest method of diagnosing kidney stones. Because a lot of stones are made of calcium, they can show up on x-ray in a similar fashion to bones. Sometimes we have limited visualization because of bowel gas or altered anatomy, and sometimes the stones are not dense enough to be visible on plain x-ray. This test is still very helpful because it is what is used during surgery to help locate the stone.
• Ultrasound: Ultrasound is another way to limit radiation exposure and to potentially diagnose kidney stones. While it is not a perfect test for this, it does help determine if stones are potentially present and if the kidney is suffering from any functional blockage.
• CT scan: CT is the most sensitive test for diagnosing kidney stones. It also gives the most anatomic detail. It does have higher levels of radiation exposure than traditional x-ray or ultrasound, but we have the technology to perform low dose CT scans and limit patient exposure. Most patients can expect to undergo a CT scan if they are presenting with sudden flank pain that is suggestive of kidney stones.

Some stones are small enough to pass independently without surgical intervention. For these type of stones, we often prescribe medications to help increase the odds of spontaneous passage. Flomax is an example of this class of medication.

The type of procedure used to treat kidney stones is dictated by stone size, location, whether or not it can be seen on plain x-ray, comorbid medical conditions, etc. The most commonly used methods to treat stones are described below. They are all generally performed under general anesthesia

• ESWL (extracorporeal shockwave lithotripsy): This is often what you hear being referred to as “lithotripsy.” Shock wave energy is focused to target the stone. Repetitive “shocking” of the stone breaks it into very small pieces or dust. We do this under x-ray visualization, but the shock waves are delivered through the skin of the flank or abdomen. Patients typically go home on the same day as their procedure. Some patients require a small stent to be placed in the ureter to help facilitate passage of stone fragments.
• Ureteroscopy: This procedure involves passing a very small scope into the ureter or kidney by entering through the urethra and bladder. Lasers or baskets are then used to fragment and/or remove the stone. A temporary stent is usually placed after this procedure.
• PCNL (percutaneous nephrolithotomy): This procedure is best for very large stones of the kidney. Once stones are of a certain size, ureteroscopy and ESWL can be very labor intensive and can require as many as 4-5 different operations to help patients become “stone free.” Typically, this procedure requires 1 overnight stay in the hospital. A very small tube is placed into the kidney, and while the patient is under general anesthesia, the tract into the kidney is dilated. This allows for larger scopes to be used to retrieve much larger fragments of stone. Typically, a small tube is left in the kidney for 1-5 days postoperatively.
• Other types of surgery: It is rare to require other forms of surgery for kidney stones, but occasionally open, laparoscopic, or robotic procedures are utilized.

In rare instances, patients can suffer long term kidney damage from avoiding treatment of kidney or ureteral stones. This typically causes chronic blockage of the kidney, which leads to renal failure. Additionally, stones can lead to chronic infection, pain, and even irritation that can lead to pre-malignant or cancerous changes. Having multiple stones puts patients at risk for strictures of the urinary tract.

Some people are prone to forming multiple stones recurrently despite medical or surgical intervention. These patients often have an abnormality in the way their kidneys concentrate urine. Most of these patients can expect to undergo blood testing and a 24-hour urine test to further investigate their stone formation. Often times these workups result in the need for medications to help prevent future stone formation or growth.