Q: My brother has a small 7 mm stone in lower calyx of his left kidney. This is producing hydronephrotic changes in the kidney, calcinosis of the right kidney parenchyma, multiple rectal ulcers (inflammatory, not malignant) and hyperkeratosis producing corns on various parts of his body. These are often treated with corn caps. He has been under treatment with postural exercises for the kidney stone and Mesacol for rectal ulcers for last 3 months. Lot of confusion has risen as to what should be the further step. Will it be ESWL or PCNL? Being a doctor, I am scared about PCNL, because I have seen catastrophes during PCNL. Please advise me further on this scenario. What is the remedy?

A:In view of the persistent symptoms of pain in the left flank area and hydronephrotic changes on imaging studies, your brother would require urological intervention for the stone removal. This should preferably be done by Extracorporeal Shock Wave Lithotripsy (ESWL). The choice of intervention for stones varies with the location and size of the stone. ESWL is usually reserved for the stone measuring less than 2 cm both for renal pelvic and upper ureteric stones. The most common complication of ESWL is pain related to obstruction in the renal pelvis area and ureter arising from the persistent stone fragments measuring less than 4-5 mm. With the newer machines, most patients tolerate the procedure reasonably well. The shock waves may also damage parenchymal components, including the blood vessels and, to a lesser and transient degree, the tubules. However, all these are reversible effects with no clear data on the long term impact on the underlying renal function. Extremely large or complex stones, or stones resistant to shock wave lithotripsy, may require removal using a percutaneous approach namely Percutaneous Nephrolithotomy (PNL). Based on the limited clinical information provided including a significant finding of nephrocalcinosis (deposition of calcium and oxalate or phosphate in the renal tubules and interstitium [the areas between the tubules]) involving the right kidney, one would require determining the possible presence of biochemical abnormalities predisposing to stone formation. This would include 24-hour urine studies, chemical analysis of stone composition, underlying renal function test, urine analysis and serum calcium and uric acid level. The results of these tests would help in delineating the underlying disease process accounting for kidney stone while also help guide the therapy to prevent recurrent stone disease. All this needs to be done under the guidance of a nephrologist.