Kidney and Ureteral Stone Treatment - Doç. Dr. Serdar Yalçın

Kidney and Ureteral Stone Treatment

Modern Approaches in Urology: Endoscopic Laser Surgery, Percutaneous Stone Surgery, Robotic and Laparoscopic Techniques

Urinary stone disease is one of the most common urological conditions encountered today. Stones that develop in the kidneys or ureters may lead to severe pain, blood in the urine, infection, loss of kidney function, and significant impairment of quality of life.

Hot climates, insufficient fluid intake, genetic predisposition, dietary habits, and metabolic factors all contribute to an increased risk of stone disease. In countries with warm climates such as Türkiye, urinary stone disease is particularly common.

Thanks to technological advances in modern urology, the majority of urinary stones can now be treated using minimally invasive techniques and laser technologies through closed surgical approaches.

According to current European Association of Urology (EAU) guidelines, treatment selection should be individualized based on:

• stone size,
• stone location,
• stone hardness,
• urinary tract anatomy,
• presence of infection,
• kidney function,
• and the patient’s overall health condition.

What Symptoms Do Kidney and Ureteral Stones Cause?

The most common symptoms include:

• sudden severe flank pain,
• pain radiating to the groin,
• blood in the urine,
• nausea and vomiting,
• frequent urination,
• burning during urination,
• fever and infection.

Some stones may remain completely asymptomatic and be detected incidentally during imaging studies.

Does Every Stone Require Surgery?

No.

Some small stones may pass spontaneously. In particular:

• small distal ureteral stones,
• patients with controlled symptoms,
• and cases without infection or kidney damage

may be managed with close follow-up and medical therapy.

However:

• large stones,
• stones that fail to pass,
• infected stones,
• obstructing stones,
• and stones causing persistent pain

may require active treatment.

Modern Treatment Options for Kidney and Ureteral Stones

Today, most stone treatments are performed using minimally invasive techniques. The most appropriate method is selected according to the characteristics of the stone and the individual patient.

ESWL (Extracorporeal Shock Wave Lithotripsy)

ESWL is based on the principle of fragmenting stones using shock waves generated outside the body.

It may be particularly suitable for:

• small kidney stones,
• selected ureteral stones.

However:

• it is not suitable for every type of stone,
• success rates may be lower in very hard stones,
• larger stones may require multiple treatment sessions.

With the development of modern endoscopic laser technologies, the use of ESWL has decreased in some advanced centers.

Endoscopic Laser Stone Surgery (URS – RIRS)

One of the most important advances in modern stone treatment is endoscopic laser surgery.

In this technique:

• the urinary tract is accessed through the natural urinary channel,
• miniature endoscopic instruments are advanced to the stone,
• the stone is fragmented using laser energy,
• stone fragments are removed.

The procedure used for ureteral stones is called:

URS (Ureterorenoscopy)

The procedure performed inside the kidney using flexible endoscopes is called:

RIRS (Retrograde Intrarenal Surgery).

Holmium laser and next-generation thulium fiber laser technologies now allow highly effective stone fragmentation.

This method is particularly valuable for:

• medium-sized kidney stones,
• ureteral stones,
• multiple stones,
• lower pole stones,
• selected patients using blood thinners.

Percutaneous Stone Surgery (PCNL)

One of the most effective treatment options for large kidney stones is Percutaneous Nephrolithotomy (PCNL).

In this technique:

• a small access tract is created through the back into the kidney,
• direct access to the stone is achieved,
• the stone is fragmented and removed using specialized instruments.

PCNL is particularly effective for:

• large stone burden,
• staghorn stones,
• complex kidney stones,
• very hard stones.

With advances in technology, smaller-caliber systems such as:

• mini-PCNL,
• ultra-mini PCNL,
• micro-PCNL

are now available.

These developments may help:

• reduce bleeding risk,
• accelerate recovery,
• decrease postoperative discomfort.

In modern centers, safe percutaneous access is performed under fluoroscopic and ultrasonographic guidance.

Laparoscopic and Robotic Stone Surgery

Not every stone can be treated endoscopically.

In certain situations such as:

• anatomical strictures,
• large impacted ureteral stones,
• diverticular stones,
• stones associated with ureteropelvic junction (UPJ) obstruction,
• failed endoscopic procedures,
• complex anatomical abnormalities,

laparoscopic or robotic surgery may be required.

In these procedures:

• surgery is performed through small abdominal incisions,
• stones may be removed directly,
• anatomical correction can be performed during the same operation when necessary.

Robotic surgery, in particular, offers high-definition visualization, precise dissection, and reconstructive advantages, making it an important option in selected complex stone cases.

Which Treatment Is Best for Which Patient?

There is no single “best treatment” for all patients.

The most appropriate treatment should be selected according to:

• stone size,
• stone location,
• stone hardness,
• kidney anatomy,
• presence of infection,
• patient age,
• overall health status.

For this reason, personalized treatment planning is extremely important in urinary stone disease.

Can Kidney Stones Recur?

Yes.

Urinary stone disease is a chronic condition with a tendency to recur.

Therefore, simply removing the stone is not enough; the underlying causes of stone formation should also be investigated.

For patients with recurrent stones:

• metabolic evaluation,
• stone analysis,
• dietary modification,
• increased fluid intake,
• preventive medical therapies when necessary

play an important role.

The Main Goal of Modern Stone Surgery

Today, the goal of modern stone treatment is not only to remove the stone.

The primary objectives are:

• preserving kidney function,
• preventing infection,
• achieving maximum stone-free rates with minimal trauma,
• ensuring rapid recovery,
• maintaining quality of life.

With ongoing advances in laser systems, flexible endoscopy, miniaturized percutaneous technologies, and robotic surgery, stone treatments continue to become safer and more effective every year.

Conclusion

Today, kidney and ureteral stones can be treated successfully in most patients using modern minimally invasive techniques.

Endoscopic laser surgery, RIRS, URS, percutaneous stone surgery (PCNL), and in selected situations laparoscopic or robotic surgery are applied in a personalized manner according to stone characteristics and patient anatomy.

The foundation of successful stone treatment includes proper patient selection, appropriate technology, experienced surgical expertise, and modern urological principles focused on preserving kidney function.

Assoc. Prof. Dr. Serdar Yalçın
Urology Specialist
Acıbadem Bodrum Hospital

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