Doc: Size, location matter in kidney stone treatment
Dear Dr. Roach: My urologist found two big kidney stones in my right kidney, too large to pass naturally. I thought that the option would then be to “crush” them to sand with laser or ultrasound and then flush out the sand by drinking lots of water.
However, my urologist says that I am too big for this to work (I weigh close to 300 pounds), as they would not be able to focus the laser properly. So, his preferred option is to surgically remove the stones when/if they become a painful problem. Right now, we are monitoring them twice a year with CAT scan and ultrasound checks. (The other alternative he suggested, of going up through my penis to crush the stones, sounds completely unappealing to me.)
Wouldn’t a surgical alternative also damage the kidney, if he has to cut into the kidney to take out the stones? It sounds rather risky to me. I would much prefer a laser solution that crushed the stones to sand without cutting into me or my kidney.
Dear P.R.: I don’t have enough information to recommend the optimal treatment to remove your particular stones, since knowing the size and location of the stones in the kidney is necessary to make that determination. I can tell you that laser lithotripsy has been successfully used in people up to 420 pounds, according to a 2009 study, and ultrasound lithotripsy has been used in people over 300 pounds in an earlier study. Complication rates are higher in heavier people, due to difficulty getting the focus correct, as you suggested.
Ten to 20 percent of all stones still require surgical removal, and this can be done endoscopically in some cases. Surgical stone removal is safe and effective in most cases, but has the potential for complications, like all procedures. I’d recommend a second opinion from someone who has experience in performing the procedure.
Dear Dr. Roach: I have painful adhesions due to the removal of an exploded appendix. You addressed the issue of adhesions in a previous article, where you stated, “Unfortunately, the only methods I know to prevent adhesions pertain to surgical technique.” What is the “surgical technique” that you mention? My surgeon did not know what you might be referring to.
Dear R.P.: I’m sorry that I wasn’t more clear, but the details of the techniques wouldn’t make a lot of sense to a casual reader. I don’t have any surprises for your surgeon, either: gentle tissue handling, laparoscopic techniques when feasible, physical barriers, such as hyaluronic acid sheets or possibly polyethylene glycol adhesion spray barrier.
The problem with a ruptured appendix is that the damage is done before the surgeon operates. The material that comes out of the appendix sets up the potential for adhesions in the future, which is why we work so hard to prevent rupture.
Email questions to ToYourGoodHealth@med.cornell.edu.