Recent advances and evolving trends in the management of renal stone disease

Kidney stone disease is a common problem in the primary care practice of urological clinics. India is a tropical country with wide temperature variations and different food habits with other cultures; there is an increased rate of renal stone disease. Approximately 10 to 20 per cent of all kidney stones require surgical removal, which is determined based on the presence of symptoms and the size and location of the stones.

The overall goals of surgical stone management are relief of patient discomfort, clearance of infection, and reversal of kidney function impairment associated with kidney or ureteral stones. The benefits of surgical stone removal must be weighed against the risk for morbidity and complications considering each patient scenario. Following surgical stone removal, patients should expect to experience improved quality of life, such as resolving pain associated with kidney stones or preventing future symptomatic stone episodes.

The main indications for surgical treatment of stones include pain, infection, and symptoms associated with urinary tract obstruction. No specific surgical therapy is required for asymptomatic stones, particularly those less than 5 mm in diameter. However, surgical stone removal may be reasonable for patients with asymptomatic stones who are frequent travellers or pilots, those considering pregnancy, or those who wish to avoid symptomatic stone episodes requiring emergency surgery.The optimal approach to managing kidney and ureteral stones depends upon the stone’s size, location, and composition or hardness. In addition, other patient comorbidities (such as concurrent infection, obesity, bleeding diathesis, or pregnancy) and patient preferences may also impact the choice of therapy. Sometimes, the stone surgery can be an emergency where the patient has acute infection, or acute renal failure with obstruction and any attempt to break the stone in these situations can lead to septicemia and life-threatening conditions.

In the elective setting of treatment of stone disease, the surgical management mainly depends on the location of the stone, its hardness and size. All these factors influence and help in choosing the best available modalities for treatment in these patients. With advancements in medical science and the available armamentarium, we can choose between minimal invasive procedures like ESWL (extracorporeal shock wave lithotripsy), ureteroscopy, percutaneous nephrolithotomy (PCNL), laparoscopy and robotics. The energy sources that can help break the stone can be pneumatic lithotripsy or the most advanced lasers, which can help fine dust the stone and remove large fragments to prevent a recurrence. In addition to the above, there are multiple other factors like obesity, pregnancy, bleeding diathesis, abnormal anatomy, and infection stones, which can challenge the urologist to increase the chance of a stone-free rate. With the advent of high-energy modalities like laser, availability of broad-spectrum antibiotics, and increased screening and patient awareness, we can increase the chances of stone-free rates, decrease recurrences and improve patients’ quality of life. Despite all the advances, we must remember the 5-10% chance of recurrences due to patient habitus, genetic conditions and lifestyle habits. The literature has shown that adequate hydration, decreased salt intake and red meat, evaluation of your stone composition, and metabolic workup can help reduce the events of renal stone and its recurrences.

Therefore, it is always appropriate to consult your urologist if you are a known case of the renal stone disease for proper evaluation and treatment to decrease the complications of infection, prevent renal failure and can also guide you to prevent recurrences and the best treatment modality which suits you.

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