Kidney Stone Surgery

Introduction

If you have been told that you need surgery for a kidney stone, you are probably already familiar with how painful and disruptive stones can be. The good news is that most kidney stone procedures today are minimally invasive. They do not involve large cuts, hospital stays are usually short, and most people return to normal activities within a few weeks.

This guide is written for people who already have a diagnosis of kidney stones and are now planning treatment. It explains what kidney stone surgery is, when it is needed, the main procedures used today, how to prepare, what happens during and after surgery, the risks involved, and how to lower the chance of new stones forming in the future.

Treatment decisions depend on the size, number, location, and type of stones, as well as your overall health. Use this article as background to help you ask better questions of your urologist (a doctor who specialises in the urinary tract and male reproductive system).

What Is Kidney Stone Surgery?

Many small stones pass on their own with fluids, pain relief, and sometimes a medication that relaxes the ureter. “Kidney stone surgery” refers to the group of procedures used when stones cannot pass on their own or when they are causing problems that need active treatment.

Modern kidney stone surgery is mostly done without open cuts. Doctors use shock waves from outside the body, thin scopes passed through natural openings, or keyhole tunnels into the kidney. The aim is the same in each case: to break the stone into small fragments or remove it, restore normal urine flow, and protect kidney function.

Why Is Kidney Stone Surgery Performed?

A urologist may recommend a procedure when one or more of the following is true:

• The stone is too large to pass naturally. Stones larger than about 6 to 7 millimetres often do not pass on their own, and stones larger than 10 millimetres almost always need help.
• The stone is causing severe or repeated pain that is not controlled with medication.
• Urine flow is blocked. A stone stuck in the ureter can cause the kidney to swell (hydronephrosis), which can damage kidney function if left untreated.
• There is infection with a blocked kidney. This is a medical emergency. The kidney must be drained urgently, usually with a stent or a tube placed through the back, and the stone is treated later.
• Stones are damaging kidney function or affecting a single working kidney.
• The stone has not moved after a reasonable trial of conservative treatment.
• Stones are recurrent or very large, such as staghorn stones that fill the inner spaces of the kidney.

Common symptoms that bring people to surgery include severe pain in the side or back, pain radiating to the lower abdomen or groin, blood in the urine, nausea and vomiting, frequent or burning urination, and fever if there is infection. By the time surgery is being planned, most readers will already have had these symptoms investigated.

Who Is a Candidate?

Most people with stones that meet the criteria above are candidates for one of the modern minimally invasive procedures. The choice between procedures depends on several factors that your urologist will weigh up:

• Stone size. Small stones are often treated with shock wave therapy or a flexible scope. Larger stones, especially those above 2 centimetres, often need a keyhole procedure through the back.
• Stone location. Stones in the lower ureter are easier to reach with a scope from below. Stones in the lower part of the kidney can be harder to clear with shock waves.
• Stone composition. Some stones, such as cystine stones and certain calcium stones, are very hard and resist shock waves. Laser energy works on almost any stone type.
• Kidney anatomy. Variations in the shape of the kidney or ureter can make some approaches easier or harder.
• Number of stones and whether they are on one or both sides.
• Body size. Shock wave therapy is less effective in people with higher body weight because the waves lose energy travelling through tissue.
• Other medical conditions, such as bleeding disorders, pregnancy, uncontrolled urinary infection, or use of blood thinners.
• Previous stone treatments and what has worked or not worked before.

Pregnancy, active untreated infection, and uncorrected bleeding problems usually mean some procedures are postponed or replaced with safer alternatives, such as temporary drainage with a stent.

Alternatives to Surgery

Surgery is not always the first step. For many smaller stones, doctors may try non-surgical options first.

Watchful Waiting with Medical Expulsive Therapy

For stones smaller than about 5 to 6 millimetres, especially those in the lower ureter, doctors often allow time for the stone to pass on its own. This may involve:

• Drinking plenty of fluids
• Pain medication, often anti-inflammatory drugs
• An alpha-blocker medication (such as tamsulosin) to relax the ureter and help the stone pass — this is called medical expulsive therapy
• Strainers to catch the stone for analysis

Most stones that are going to pass do so within four to six weeks.

Dissolution Therapy for Uric Acid Stones

Pure uric acid stones can sometimes be dissolved by making the urine less acidic with medication (potassium citrate) and treating the underlying cause. This is not effective for calcium-based stones, which make up most kidney stones.

Temporary Drainage

If a stone is blocking the kidney and causing infection or severe pain but immediate stone removal is not safe, the urologist may place a ureteral stent (a thin tube from the kidney to the bladder) or a nephrostomy tube (a drain through the back into the kidney). This relieves the blockage. The stone is treated later, in a more controlled setting.

If conservative measures fail, or if the stone is too large from the start, surgery becomes the next step.

Surgical Approaches

Several procedures fall under the umbrella of kidney stone surgery. Each has its own strengths and is suited to different stone situations. Current guidelines from the American Urological Association (AUA) and the European Association of Urology (EAU) describe how these approaches are matched to stone size and location.

Extracorporeal Shock Wave Lithotripsy (ESWL)

ESWL uses shock waves generated outside the body to break stones into small fragments that pass out in the urine. You lie on a table while a machine delivers focused waves to the stone, guided by X-ray or ultrasound imaging.

ESWL is commonly used for:

• Stones smaller than about 2 centimetres in the kidney
• Stones in the upper ureter
• People who prefer to avoid anaesthesia involving instruments inside the body

It is usually performed under sedation or light anaesthesia. There are no incisions and no scopes are inserted. The downsides are that very hard stones may not break well, results can be lower for stones in the lower part of the kidney, and more than one session may be needed.

Ureteroscopy and Retrograde Intrarenal Surgery (RIRS)

Ureteroscopy uses a thin scope passed through the urethra and bladder, up the ureter, to reach the stone. When the scope is flexible and reaches the kidney itself, this is called retrograde intrarenal surgery, or RIRS. A laser fibre is passed through the scope to break the stone into very small fragments or dust. Larger fragments can be removed with a small basket.

Ureteroscopy and RIRS are commonly used for:

• Stones in the ureter at any level
• Kidney stones up to about 2 centimetres
• Stones that are hard or in locations where shock waves work less well
• Patients on blood thinners that cannot easily be stopped

There are no external cuts. A temporary ureteral stent is often placed at the end of the procedure to help the kidney drain while the area heals.

Percutaneous Nephrolithotomy (PCNL)

PCNL is a keyhole procedure used for large or complex kidney stones. The urologist makes a small cut, about 1 centimetre, in your back. A tract is created into the kidney, and a tube is placed through which instruments can reach the stone. The stone is broken using a laser, ultrasound, or pneumatic energy, and the fragments are removed directly.

PCNL is commonly used for:

• Stones larger than 2 centimetres
• Staghorn stones that fill the collecting system
• Complex stones that have not cleared with other procedures
• Stones in the lower part of the kidney where shock waves work less well

Mini-PCNL and micro-PCNL are newer versions that use smaller instruments, which can mean less bleeding and faster recovery for selected patients. Major guidelines describe PCNL as the preferred approach for large kidney stones because it offers the highest chance of complete stone clearance in a single procedure.

Laparoscopic and Robotic-Assisted Surgery

Laparoscopic and robotic procedures use several small cuts and a camera to reach the kidney or ureter from outside the urinary tract. These approaches are uncommon and are reserved for situations where the other techniques are not suitable, for example:

• Very large stones combined with anatomical abnormalities
• Stones where simultaneous surgery on the kidney itself is needed
• Failed previous endoscopic procedures

Open Surgery

Traditional open surgery, with a larger cut in the side, is rarely needed today. It is mostly reserved for very complex cases that cannot be handled by the methods above, or where other approaches are not available. Most patients with stones can be treated with one of the minimally invasive options.

Other Procedures Sometimes Discussed

You may come across the names TURP (transurethral resection of the prostate) and HoLEP (holmium laser enucleation of the prostate). These are operations on the prostate gland and are not used to treat kidney stones, although the same laser equipment used in HoLEP is also used during ureteroscopy and RIRS to break stones.

Preparing for Kidney Stone Surgery

Preparation depends on the procedure, but most patients go through a similar set of steps in the weeks before surgery.

Tests and Imaging

Your urologist will usually arrange:

• Urine tests to check for infection. An active urinary infection must usually be treated before surgery.
• Blood tests to check kidney function, blood counts, and clotting.
• Imaging, most often a non-contrast CT scan, which gives a detailed map of stone size and location. Ultrasound and plain X-rays may also be used, especially for follow-up.

Medication Review

Tell your team about all medications you take, including herbal supplements. Blood thinners such as aspirin, clopidogrel, warfarin, and newer anticoagulants may need to be adjusted or stopped for a period before surgery. Do not stop these on your own — your urologist and the prescribing doctor should decide together.

People with diabetes may need to adjust their diabetes medications around the day of surgery. People on steroids or with other chronic conditions may need additional planning.

Anaesthesia Assessment

Most stone procedures are done under general anaesthesia, although some can be done under spinal or sedation. You will usually meet the anaesthesia team, who will review your medical history and explain what to expect.

Day Before and Day of Surgery

You will be asked to stop eating and drinking for several hours before surgery. Follow the exact instructions you receive, as they affect the safety of anaesthesia. Bring a list of your medications, identification, and arrangements for someone to accompany you home after discharge.

What Happens During Kidney Stone Surgery

What follows is a general picture. The exact steps depend on the procedure chosen.

During ESWL

You lie on a special table. Sedation or light anaesthesia is given. The lithotripter machine is positioned against your skin over the stone. Imaging confirms the stone’s location, and pulses of shock waves are delivered, usually for about 30 to 60 minutes. The fragments then need to pass naturally in the urine over the following days and weeks.

During Ureteroscopy and RIRS

1. General or spinal anaesthesia is given.
2. A thin scope is passed through the urethra into the bladder and up the ureter.
3. The scope reaches the stone. For kidney stones, a flexible scope is used.
4. A laser fibre passed through the scope breaks the stone into fragments or dust.
5. Fragments may be removed with a small basket, or left to pass naturally.
6. A ureteral stent is often placed at the end to help drainage while the ureter heals.

The procedure usually takes between 45 minutes and 2 hours, depending on stone size and location.

During PCNL

1. General anaesthesia is given.
2. A small cut, about 1 centimetre, is made in the skin of your back.
3. A thin needle, then a series of dilators, create a tract through the muscle into the kidney.
4. A tube (sheath) is placed, through which a nephroscope reaches the stone.
5. The stone is broken using laser, ultrasound, or pneumatic energy, and the pieces are removed through the tract.
6. At the end of the procedure, a small drainage tube (nephrostomy) and/or a ureteral stent may be left in place, depending on findings.

Hospital Stay

• ESWL: Usually a day procedure with discharge the same day.
• Ureteroscopy / RIRS: Often same day or one overnight stay.
• PCNL: Typically 1 to 3 days in hospital, sometimes longer if a drainage tube is in place.

The First Week

Most people feel tired and sore for the first few days. Common things to expect include:

• Blood in the urine, which can look pink or red and usually settles over a few days. Fragments and tiny clots may also pass.
• A burning feeling when urinating or a feeling of needing to urinate often, especially if a stent is in place.
• Mild back or side discomfort, particularly after PCNL or ESWL.
• Some bruising around the entry site after PCNL.

Pain is usually controlled with simple painkillers. Drink plenty of water unless your doctor advises otherwise. Avoid heavy lifting, strenuous exercise, and contact sports during this period.

Living with a Ureteral Stent

• You may feel a tugging or pressure in the side or lower abdomen, especially when urinating.
• You may need to urinate more often and feel some urgency.
• Mild blood in the urine can come and go.

Stents are usually removed in a short outpatient procedure after 1 to 4 weeks. It is important not to forget about a stent — a stent left in for too long can cause serious problems, including encrustation and infection.

Weeks Two to Four

Most people return to office work within a week or two. Heavier physical work usually waits 3 to 4 weeks, especially after PCNL. Stone fragments may continue to pass during this period, particularly after ESWL.

When to Call Your Doctor

Contact your urology team promptly if you experience:

• Fever or chills
• Severe or worsening pain
• Heavy or persistent bleeding in the urine
• Inability to pass urine
• Persistent nausea or vomiting
• Worsening pain at the entry site after PCNL

Risks and Complications

Kidney stone surgery is generally safe, but every procedure has possible risks. Talking through these with your urologist before surgery helps you make an informed decision and recognise problems early if they occur.

General Risks

• Bleeding, usually mild but occasionally needing transfusion, especially with PCNL.
• Infection, ranging from urinary infection to, rarely, sepsis. The risk is higher when stones contain bacteria.
• Pain, which is usually manageable but can be significant in the first days.
• Reaction to anaesthesia.

Procedure-Specific Risks

• ESWL: bruising of the skin, small areas of bleeding around the kidney, fragments getting stuck as they try to pass (called a steinstrasse, or “stone street”), and the need for repeat sessions.
• Ureteroscopy and RIRS: injury or narrowing of the ureter, perforation, infection, and stent-related discomfort.
• PCNL: bleeding requiring transfusion, injury to nearby organs such as the bowel or the pleural lining around the lung, and rarely, the need for further procedures to control bleeding.
• All procedures: residual stone fragments may remain and require further treatment.

Major guidelines describe PCNL as having higher complication rates than ureteroscopy or ESWL, balanced by its higher chance of clearing large stones in one go. The right balance depends on your specific stone and situation.

Outcomes and Repeat Procedures

Stone-free rates — the chance of being completely free of stones after surgery — depend strongly on the procedure, the stone size, and the stone location.

• For small to moderate stones treated with ureteroscopy or RIRS, most patients become stone-free in one session, though small fragments occasionally remain and may pass later.
• For large kidney stones treated with PCNL, complete clearance in one session is achieved in a high proportion of patients, with some needing a second look or a smaller follow-up procedure.
• ESWL works well for many small stones, but more than one session may be needed, especially for harder stones or those in the lower part of the kidney.

Personalised estimates of success and recurrence risk are best discussed with your own urologist, who can review your imaging and previous history.

Life After Kidney Stone Surgery

If a stone is removed or passed, it can be sent for analysis. Knowing the stone’s composition — calcium oxalate, calcium phosphate, uric acid, struvite, or cystine — helps guide prevention. People with recurrent stones, stones at a young age, family history, or unusual stone types are often offered a metabolic evaluation, which usually includes:

• Blood tests for calcium, uric acid, kidney function, and other markers
• A 24-hour urine collection that measures volume, calcium, oxalate, citrate, uric acid, and pH

The results may point to a specific cause that can be treated, such as low urine citrate, high calcium excretion, or a metabolic condition.

Hydration

The single most effective change for most people is drinking more fluid. Major guidelines recommend a fluid intake that produces about 2.5 litres of urine per day for most adults. Water is the best choice. Citrus drinks such as lemon water can be helpful for some stone types.

Diet

Dietary advice depends on stone type and overall health, but common patterns include:

• Reducing salt intake, which lowers calcium loss in the urine
• Moderating animal protein intake
• Eating a normal amount of dietary calcium, rather than a low-calcium diet (which can paradoxically increase stone risk)
• Limiting foods very high in oxalate if calcium oxalate stones are recurrent
• Reducing intake of sugary drinks

A dietitian familiar with stone disease can tailor advice to your stone type.

Medications for Prevention

If lifestyle changes are not enough, or if metabolic testing shows specific problems, your urologist may consider medications such as thiazide diuretics for high urine calcium, potassium citrate for low urine citrate, or allopurinol for high uric acid. These are individual decisions made between you and your doctor.

Follow-Up

Follow-up usually involves a visit a few weeks after surgery to check healing, remove any stent, and review imaging. People with a history of stones are often followed with periodic ultrasound or low-dose CT scans to catch new stones early, when they are easier to treat.

Kidney Stone Surgery in Children

Children also develop kidney stones, although less commonly than adults. The principles of treatment are similar, but a few differences are worth knowing:

• Causes: Children with stones are more likely to have an underlying metabolic or genetic cause, so a thorough evaluation is standard.
• Procedures: ESWL, ureteroscopy, and mini- or micro-PCNL are all used in children. Smaller instruments designed for paediatric anatomy are used.
• Anaesthesia: Almost all stone procedures in children are done under general anaesthesia.
• Recovery: Children generally recover quickly, but follow-up and prevention are particularly important because lifetime stone risk is higher in those who form stones early.

Paediatric stone care is best delivered by teams familiar with both stone disease and children, often involving a paediatric urologist and paediatric nephrologist (kidney doctor).

Frequently Asked Questions

Is kidney stone surgery painful?

You will not feel pain during the procedure itself because of anaesthesia or sedation. Afterwards, most discomfort is mild to moderate and is managed with simple painkillers. Ureteral stents can cause bothersome symptoms, but these resolve once the stent is removed.

How long does the surgery take?

ESWL usually takes 30 to 60 minutes. Ureteroscopy and RIRS typically take 45 minutes to 2 hours. PCNL takes 1 to 3 hours, depending on stone complexity. The total time in the hospital, including preparation and recovery, is longer.

Will I need a stent after surgery?

Stents are common after ureteroscopy and RIRS, and sometimes after PCNL. They help the urinary tract drain while it heals. Stents are usually removed in a short outpatient procedure within 1 to 4 weeks.

How soon can I return to work?

Most people doing desk work return within a few days to about two weeks. Heavier physical work usually waits 3 to 4 weeks, especially after PCNL. Your urologist will give individual advice based on your job and the procedure you had.

Can kidney stones come back after surgery?

Yes. Stone disease tends to recur, especially without changes in fluid intake and diet. The risk can be reduced significantly with hydration, dietary changes, and, in some cases, medication. Regular follow-up helps catch new stones early.

Can I drive after surgery?

Most people can drive again within a few days for ESWL and ureteroscopy, and a little longer after PCNL. Avoid driving while taking strong pain medications or if you feel weak.

Do I need to follow a special diet?

Diet recommendations depend on the type of stones you form. A general approach for most people includes plenty of fluids, less salt, moderate animal protein, and normal calcium intake. More specific advice should be based on stone analysis and a metabolic evaluation if one has been done.

What is a staghorn stone?

A staghorn stone is a large stone that fills part or all of the kidney’s inner collecting system, taking on a branched shape. These stones often need PCNL, sometimes combined with other procedures, and are important to treat because they can damage the kidney and harbour infection.

Can stones be treated during pregnancy?

Stones in pregnancy are usually managed conservatively where possible, with hydration and pain relief. If treatment is needed, ureteroscopy can often be done safely. ESWL is generally avoided during pregnancy. Care is coordinated between urology and obstetrics.

Conclusion

Kidney stones can be one of the most painful experiences people go through, but the way they are treated has changed dramatically. Most stones today are managed without large cuts, using shock waves, fine scopes, or keyhole tunnels into the kidney. Hospital stays are usually short, and most people return to normal life within a few weeks.

The right procedure for any individual depends on the size, number, and location of the stones, the type of stone, kidney anatomy, and overall health. These are decisions best made in conversation with a urologist who has reviewed your imaging and history.

Treating the stone you have now is one step. Lowering the chance of new stones — through hydration, diet, follow-up imaging, and, where helpful, medication — is the other. Together, they offer most people lasting relief and better long-term kidney health.