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Kidney stone treatment

  Just over three weeks ago, I was diagnosed with kidney stones
  for the first time in my life (37 yrs). X-ray, CT, and
  ultrasound exams have confirmed its location in the left distal
  ureter (near the entrance to the bladder) but disagree on the
  size of the stone (US:7mm, X-ray:4-5mm). On US and CT exams,
  doctors note mild to medium hydronephrosis. There has been no
  evidence of infection.
  During these three weeks, I've been to the ER several times
  with acute attacks and have been hospitalized twice. During
  this time, the stone has remained in essentially the same place.
  I'm currently being treated with analgesics (and fluids) in the
  hopes that the stone will pass on its own. If not, two
  treatment options have been suggested: lithotripsy and
  cystoscopy (removal with a basket).
  1. How long is it advisable to wait before treating such a
  stone?
  2. What is considered the normative treatment for a stone of
  this size and location? lithotripsy, cystoscopic removal, or
  something else?
  3. When removing a stone from the ureter using a cystoscope,
  what kind of anasthesia is typically used?
  4. I have been told to watch for certain symptoms indicating
  the need for urgent treatment, namely fever or other signs of
  infection. Should I be looking out for anything else?
  Specifically, should I be concerned about a gradual
  disappearance of symptoms (other than a dull, intermittent
  lower back pain on the side of the stone) while tests continue
  to show the presence of a stone in the same location?
  Thank you in advance for your time and attention.
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Dear Jeff,
Let me attempt to answer each of your questions.
Having had to go to the emergency room for pain relief as frequently as you have stated, you have reached the point where a definitive treatment is called for, namely cystoscopic/ureteroscopic removal of the stone.
It is not unreasonable to expect a stone, 6mm or smaller, to pass on its own over time, if the patient can tolerate the pain and doesn't need to seek emergency care more than once or twice.  The normal treatment following a course of observation for the stone size and location you have described is cystoscopic removal via basket, as you have mentioned.  
Removal of a stone from the ureter often entails the use of a cystoscope at first to inspect the bladder and the ureter involved, following which, a ureteroscope is used (a smaller, finer caliber scope) to enter the ureter and remove the stone.  The use of general OR spinal anesthesia is okay in the case of a stone in the lower ureter.  If ureteroscopy has to be done in the upper ureter, general anesthesia is preferred.
Signs and symptoms of concern include fever and chills, nausea and vomiting, low urine output, increasing pain that is not relieved by oral pain medication.  A gradual disappearance of symptoms may indicate a passage of the stone.  Given that your stone is causing mild to moderate hydronephrosis, the gradual resolution of symptoms may also indicate that the degree of obstruction (caused by the stone) has decreased.   Chronic obstruction may cause intermittent flank pain,  as opposed to the pain of acute obstruction.   Whatever changes you note,  however, are best evaluated and verified by X-ray.  Furthermore, you should continue to strain all your urine in order to be able to catch the stone, should it pass.  
Continue with increased fluid intake, especially water.  It is of crucial importance for you to be seen by a urologist.
This information is provided for general medical educational purposes only.  Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition.  More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653-6568).
Sincerely,
HFHS M.D.-BE
*keyword: obstruction with stone




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