Laser kidney stone treatment: what the procedure and recovery are like

Laser stone treatment (laser lithotripsy) is an endoscopic procedure. The urologist passes a thin instrument, a ureteroscope, through the urethra and the bladder up to the stone in the ureter (the tube that carries urine from the kidney to the bladder) or in the kidney. A thin laser fibre is passed through the instrument and used to break the stone into tiny pieces or into dust. No cut is made in the skin, although in everyday speech this procedure is often called kidney stone surgery.

The general name for this kind of procedure is ureteroscopy (URS for short). For a stone in the lower and middle part of the ureter, a semi-rigid ureteroscope is most often used. For a stone in the upper part of the ureter and in the kidney itself, a flexible instrument is most often used, which can reach the calyces (the small chambers inside the kidney). In the medical literature, this method is called flexible ureterorenoscopy (FURS or RIRS).

The procedure is most often recommended when a stone cannot pass on its own, when it blocks the ureter, or when pain and infections keep coming back. Laser treatment is one of several treatment options. Depending on the size, position and composition of the stone, other options in general include monitoring, treatment with medicines, breaking up the stone with shock waves from outside the body, or a procedure through a small opening in the back. The Maja Hospital urology price list includes endoscopic procedures for breaking up stones, while shock wave treatment and the procedure through the back are not listed. The method is chosen after an examination and scans, not in advance.

Everything starts with a consultation with a urologist. The urologist looks at your existing medical reports and scans. The first scan is usually an ultrasound. Before the procedure is planned, a CT scan without contrast is also most often done, because it shows the exact size, number and position of the stones. Preparation before the procedure most often includes:

• a urine test and a urine culture, because a urinary tract infection needs to be cleared before the stone is broken up
• basic blood tests and, if needed, an ECG and an opinion from an internal medicine specialist
• a talk with the anaesthetist about the type of anaesthetic and about the medicines you take regularly, especially blood thinners. Do not stop these medicines on your own; stop them only if the doctor tells you to.
• telling the doctor if you are pregnant or could be pregnant, and about any allergies to medicines, contrast agents or latex

When a stone blocks the ureter and there is also an infection with a high temperature, breaking up the stone is postponed. The urologist first makes sure the urine can drain, with a stent or a thin tube passed through the skin into the kidney (a nephrostomy), and treats the infection, and the stone is broken up later.

Sometimes it only becomes clear during the procedure that the ureter is narrow and the instrument cannot safely reach the stone. In that case, the urologist fits a temporary stent and schedules the stone treatment for one to several weeks later, once the ureter has widened. This does not happen with every patient.

You come in for the procedure having fasted (nil by mouth), as instructed by the anaesthetist. After admission and a check of your test results, the usual course is as follows:

• the anaesthetic, most often general or spinal (numbing you from the waist down), decided on by the anaesthetist and the urologist
• the urologist passes the ureteroscope through the urethra and the bladder up to the stone
• the laser breaks up the stone; larger fragments are removed with a small basket if needed, and tiny ones pass out in the urine in the days after the procedure
• at the end, the urologist assesses whether a temporary stent is needed, and sometimes a catheter is also left in the bladder for a short time
• waking up and monitoring until the patient can pass urine without difficulty

How long the procedure takes depends on the size, number and position of the stones, so it is not the same for every patient. With a larger stone or several stones, a second treatment at a new appointment is sometimes needed. It is worth asking the urologist about this possibility before the procedure. The length of the hospital stay is decided by the doctor, depending on how the procedure went and how the patient is afterwards.

Patients' experiences vary, because they depend on the size of the stone, the length of the procedure and whether a stent was left in. Even so, the following are most common in the first few days:

• pink urine, especially after exertion, which gradually becomes lighter
• stinging when passing urine and a more frequent urge to pass urine
• mild pain or a feeling of tightness in the side (loin), especially when passing urine if a stent was left in
• small fragments of stone passing out in the urine

These symptoms are usually temporary and settle with the painkillers prescribed by the doctor and enough fluids. You should not drive for at least 24 hours after an anaesthetic, so it is a good idea for someone to drive the patient home. Gentle activity and walking are encouraged, and heavier physical exertion should be put off until the doctor says otherwise.

A stent (J-J stent, also called a double-J stent) is a thin, soft tube placed inside the ureter, running from the kidney to the bladder. It is fitted so that urine can drain freely while the ureter heals and while tiny fragments pass out. Not every patient gets one. The urologist decides on this during the procedure, based on the findings.

While the stent is in place, you may have a more frequent urge to pass urine, stinging, occasional pink urine and discomfort in the side when passing urine or during exertion. A stent most often stays in for a few days to a few weeks. It is usually removed with a short procedure through the urethra (cystoscopy), under local anaesthetic. Sometimes a stent is fitted with a string that comes out through the urethra, and it is then removed by pulling the string. This is done only at the time and in the way set by the urologist, and the string should not be touched until then.

The stent must not be forgotten. If it stays in too long, it can become coated with deposits, cause an infection, become harder to remove and damage the kidney. That is why it is a good idea to agree the removal date before you are discharged from hospital.

After the procedure, you are usually advised to drink enough fluids, spread evenly throughout the day, so that your urine stays pale. This helps tiny fragments pass more easily and reduces stinging. To prevent a new stone, doctors often advise around two and a half to three litres of fluid a day. The exact amount is set by the doctor, especially for people with heart or kidney disease, who sometimes need to limit how much fluid they drink.

Dietary advice depends on the type of stone. That is why it is useful to keep a fragment of the stone if one passes, because an analysis of its composition shows which changes to your diet make sense.

Going back to work depends on the type of work and on whether a stent was left in. For lighter work, returning is often possible after a few days, and for physically demanding work, later. The urologist gives a recommendation based on how your recovery goes and the type of work you do, while sick leave is decided by your GP (your registered family doctor).

Like any procedure, laser stone treatment carries certain risks. The most common ones are temporary: blood in the urine, stinging when passing urine and discomfort caused by the stent. Less often, a urinary tract infection with a high temperature, remaining stone fragments that sometimes mean a repeat procedure is needed, or an injury to the wall of the ureter may occur. Rarely, there may be a more serious infection that spreads to the blood (sepsis) and needs urgent hospital treatment, or a later narrowing of the ureter. There are also the general risks of anaesthesia. Before the procedure, the urologist and the anaesthetist explain the risks in each individual case.

Some symptoms are not part of a normal recovery and need to be checked quickly. If you notice any of the following signs, contact the urologist or the nearest emergency department, and outside working hours call the emergency medical service on 194:

• a temperature above 38 °C or shivering
• severe pain in the side (loin) that does not ease after the prescribed painkillers
• being unable to pass urine, or passing very little urine
• dark red urine or blood clots
• persistent nausea and vomiting

A high temperature or shivering after stone treatment can be a sign of a serious urinary tract infection, which can spread to the blood (sepsis). In that case, do not wait for your booked follow-up appointment, but contact a doctor without delay. Before you are discharged, it is a good idea to ask whom to contact if these signs appear.

The first follow-up appointment is most often in the first few weeks after the procedure. The urologist then uses ultrasound, an X-ray or a CT scan to check whether any stone fragments remain and whether urine drains normally from the kidney. If a stent was left in, the follow-up is often combined with its removal. For people whose stones keep coming back or who have a higher risk of a new stone forming, additional blood and urine tests may also be done, and on the basis of these the doctor gives advice on preventing a new stone.

The price depends on the position and size of the stone, on whether a repeat procedure is needed and on whether a stent is fitted and removed. A consultation and a follow-up appointment with an Assistant Professor (Docent) or Professor of urology are separate items in the price list. The urologist can only determine the exact amount after an examination and scans. Items from the urology price list are shown below the text.