Urology treats urinary tract diseases in all genders and male reproductive issues, covering the kidneys, bladder, prostate, urethra, from infections to complex cancers.
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For a significant proportion of patients, invasive surgery is not the first line of defense. The management of ureteral stones is dictated by size, location, and symptoms. For rocks smaller than 10mm (and particularly those under 6mm) that are not causing infection or unrelenting pain, a conservative approach is often adopted. This is known as Medical Expulsive Therapy (MET).
MET works by using medicines called alpha-blockers, which relax the muscles in the lower ureter. This helps stop painful spasms but still lets the ureter push the stone along. The medicine makes it easier for the stone to move into the bladder. MET can help stones pass faster and reduce the need for pain medicine. Patients are also told to drink plenty of fluids to help push the stone out.
When a stone is unlikely to pass (too large), fails to pass after a trial of MET, or causes unmanageable pain, surgical intervention is required. The current gold standard for mid and distal ureteral stones, and increasingly for proximal stones, is Ureteroscopy (URS).
This is a minimally invasive endoscopic procedure. A thin, semi-rigid, or flexible fiberoptic scope is inserted into the urethra, passed through the bladder, and advanced directly up the ureter to the stone. No incisions are made. Once the stone is visualized, a laser fiber (typically a Holmium: YAG fiber) is passed through the scope. The laser delivers rapid pulses that vaporize the stone matrix and fragment the crystal structure into dust or tiny gravel.
This procedure uses a precise laser to break up the stone without harming the ureter’s lining. After the stone is broken into pieces, larger fragments are removed with a small wire basket. Ureteroscopy is very successful and can clear the stone right away.
Extracorporeal Shockwave Lithotripsy (ESWL or SWL) is a non-invasive option, primarily used for stones in the upper ureter or kidney. It involves generating high-energy acoustic shockwaves outside the body and focusing them onto the stone using fluoroscopic (X-ray) or ultrasound guidance.
SWL works by sending shockwaves through the body. These waves pass safely through soft tissue but break up the hard stone into smaller pieces. The fragments then need to pass out of the body on their own. SWL does not work as well for very hard stones or stones low in the ureter, and it is less suitable for very large stones.
There are specific scenarios in which the immediate goal is not stone removal but organ salvage. If a ureteral stone causes a complete obstruction in the presence of a urinary tract infection, the stagnant urine becomes purulent (pus), creating an abscess-like condition called pyonephrosis. This is a urological emergency that can lead to rapid sepsis and death.
In these cases, the priority is decompression. This is achieved either by placing a ureteral stent (a hollow plastic tube) internally via cystoscopy to bypass the stone, or by placing a percutaneous nephrostomy tube directly through the back into the kidney to drain the infection externally. Definitive stone treatment is delayed until the patient is stable and the infection has cleared.
The double-J ureteral stent is a ubiquitous device in stone surgery. It is a thin, hollow tube with coils at both ends (one in the kidney, one in the bladder) to prevent migration. Stents are often placed after ureteroscopy to prevent the ureter from swelling shut due to the trauma of instrumentation (edema). They ensure urine drainage from the kidney to the bladder while the ureter heals.
Although stents are important for safety, they can cause side effects like pain in the side during urination, frequent urination, and blood in the urine. Doctors talk to patients about these temporary symptoms and make sure the stent is removed on time to prevent new stones from forming on it.
For very large stones that have been stuck for a long time and cannot be treated with other methods, doctors may use laparoscopic or robotic surgery. This means making small cuts in the abdomen to open the ureter and remove the stone. Although this is less common now, it is still important for difficult cases.
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A ureteral stent is a thin, flexible plastic tube placed inside the ureter to hold it open. After stone surgery, the ureter often swells due to irritation. The stent ensures that urine can continue to flow from the kidney to the bladder despite this swelling, preventing severe pain and kidney damage. It is typically temporary and removed after a few days or weeks.
The Holmium laser used in lithotripsy is exact. Its energy is absorbed by water and the stone, penetrating only a fraction of a millimeter. This allows the surgeon to break the stone while working very close to the ureteral wall without causing thermal injury to the tissue, provided proper technique and safety margins are maintained.
If a stone is going to pass with Medical Expulsive Therapy (alpha-blockers), it typically happens within 4 to 6 weeks. If the stone has not passed by this time, or if pain becomes unmanageable, surgery is usually recommended to prevent long-term damage to the kidney function.
While shockwave lithotripsy is non-invasive (no cutting), the shockwaves hitting the body can be painful. The procedure is usually performed under sedation or light anesthesia to ensure the patient remains still and comfortable. Afterwards, passing the stone fragments can also cause renal colic pain similar to passing a natural stone.
Open or laparoscopic surgery is very rarely needed today due to the advancement of ureteroscopy and lasers. It is reserved for exceptional cases in which the stone is large, impacted (stuck) for a long time, causing the ureter to grow into it, or when the patient has complex anatomy that prevents endoscopic access.
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