Not every stone in the kidney or ureter needs an operation – small stones often pass on their own with fluids, exercise and suitable medication. But when a stone is too large to pass, causes repeated attacks of colic, blocks the kidney or does not respond to shock wave lithotripsy, the answer is endoscopic treatment: the stone is reached from the inside, broken up with a laser and removed without a conventional incision.
Endoscopic and laparoscopic treatment of kidney and ureteric stones is one of the main areas of Dr Penev’s work. He performs these procedures at the Department of Urology at Kaspela University Hospital (UMBAL Kaspela), Plovdiv, where all modern endoscopic methods for kidney stone disease are used.
When it is recommended
Endoscopic treatment is considered when:
- the stone in the ureter is larger than about 6–7 mm or has not passed after four to six weeks of conservative treatment;
- the pain keeps coming back or cannot be controlled with painkillers;
- the stone blocks the kidney and causes hydronephrosis – a build-up of urine that damages the kidney;
- the stone in the kidney is larger than 1–2 cm, sits in the lower pole or is too hard for shock wave lithotripsy;
- shock wave lithotripsy has failed or is not suitable;
- the patient has only one kidney or prefers to deal with the problem in one go.
Remember the emergency signs: a stone with a high temperature and shivering means an infected, blocked kidney and a risk of sepsis, and passing no urine with a single kidney or a blockage on both sides is also an emergency. Do not wait for an appointment – go to an emergency department or call 112 (the European emergency number). The first step then is to drain the kidney quickly with a stent or a nephrostomy tube and give antibiotics; the stone is treated once the infection has settled.
How it is done
The procedures are done under general or spinal anaesthetic.
Ureteroscopy (URS) and flexible ureterorenoscopy
A thin endoscope is passed through the urethra and the bladder into the ureter, without any incision. For a stone in the ureter a semi-rigid instrument is used, and for a stone in the kidney a flexible ureterorenoscope, which can reach every calyx of the kidney (retrograde intrarenal surgery, RIRS). The stone is broken up with a laser fibre into dust or small fragments, which are removed with a basket or pass out in the urine. The procedure takes about 30 to 90 minutes and is suitable for stones in the ureter and for kidney stones up to about 2 cm.
Percutaneous nephrolithotomy (PCNL)
For large stones – over 2 cm, staghorn stones (filling the renal pelvis) or multiple stones – access is direct, through an opening in the skin of the lower back about a centimetre across. Under ultrasound and X-ray guidance a channel is made into the renal pelvis, and through it the stone is broken up with a nephroscope and the fragments are removed. At the end a thin drainage tube or a stent is usually left in place.
If needed, Dr Penev inserts a JJ (double-J) stent – a thin tube between the kidney and the bladder that keeps urine draining while the ureter recovers. The stent is removed after one to four weeks with a short procedure.
Preparation
Before a planned procedure you need up-to-date imaging – an ultrasound and a CT scan without contrast, which shows the size, density and position of the stone; a urine test with culture, because the urine must be sterile and any infection is treated beforehand; blood tests including clotting, an ECG and a consultation with an anaesthetist. If you take blood-thinning medication, Dr Penev will tell you when to stop it, in agreement with your cardiologist. On the day of the operation you should not eat or drink for about six hours beforehand.
After the procedure / Results
The hospital stay is usually 1–3 days. In the first few days burning and frequent urination, slightly pink urine and discomfort in the lower back are normal, especially with a stent. Most patients go back to work within a week after ureteroscopy and within two to three weeks after percutaneous nephrolithotomy. Drink enough fluids, keep moving and avoid heavy exertion for the first two weeks. More details in our advice after stone surgery and a JJ stent.
As with any operation, there are risks – infection, bleeding (more often with the percutaneous approach), injury to the ureter and leftover fragments that need a second procedure. They are rare, and Dr Penev will discuss them with you before the procedure. The removed stone is sent for analysis of its composition, and at the follow-up visit with ultrasound after about four weeks he checks whether the kidney is clear and plans prevention.
Where it is done
The procedures are performed at the Department of Urology at Kaspela University Hospital, 64 Sofia St, Plovdiv, which has a high-tech operating theatre suite. The consultation and planning take place at Dr Penev’s private practice in Plovdiv or at Vita Med Medical Centre, Karlovo – see kidney stone consultation.
Price
An initial consultation is €50 and a follow-up consultation €30. The price of endoscopic treatment depends on the method and the length of the hospital stay and is confirmed at the consultation.
A stone that does not pass on its own should not be left for months – a blocked kidney loses function silently. Book an appointment with Dr Penev for an examination and ultrasound, after which he will suggest the most suitable method for your stone.
Frequently asked questions
Will I feel pain during the procedure?
No. Ureteroscopy and percutaneous nephrolithotomy are done under general or spinal anaesthetic, so you feel nothing during the procedure itself. After you wake up there may be burning when passing urine and discomfort in the lower back, which are controlled with painkillers.
What is the difference from shock wave lithotripsy (ESWL)?
In ESWL, shock waves from outside the body break up the stone, and the fragments then have to pass out in the urine on their own – several sessions are often needed. In endoscopic treatment the stone is seen directly, broken up with a laser and removed during the procedure itself, which is why it is preferred for larger, harder or low-lying stones.
Does a JJ stent always have to be inserted?
Not always. With a small stone and a smooth procedure the ureter can be left without a stent. A stent is inserted when the ureter is swollen, the stone was large or infected, or a second procedure is needed – usually for one to four weeks.
Can the stone be removed in one go?
In most cases, yes. With very large, multiple or hard stones, two stages are sometimes planned to protect the kidney and keep complications to a minimum. Dr Penev will tell you beforehand whether this is likely in your case.
Will new stones form?
The tendency remains, and roughly half of patients develop a new stone in the following years if they change nothing. That is why the removed stone is sent for analysis, and Dr Penev gives you individual advice on fluids, diet and, if needed, medication.
The information on this website is for general education and does not replace an examination and consultation with a doctor. If you have urgent symptoms, seek medical help immediately or call 112.