“Go big or go small”: Current and emerging tools in kidney stone management

It’s an exciting time for stone disease, according to Brian R. Stork, MD. In a recent interview with Urology Times®, Stork offered his thoughts on recent advancements in the field and outlined potential opportunities for further development.

Brian R. Stork, MD

He explained that although efforts to elucidate the causes of kidney stone formation remain ongoing, several new treatment modalities have emerged in recent years to improve the management of this condition. Stork described these new advancements as “going big or going small,” referring to trends ranging from the emergence of novel access sheaths to efforts centered on the miniaturization of scopes.

As with many fields, a particularly exciting development is the integration of artificial intelligence (AI), which Stork says has implications for both patients and urologists. From his perspective, he says the sky’s the limit.

Stork is an assistant professor in the department of urology at the University of Michigan in Ann Arbor.

Urology Times: Could you touch on the current treatment options in kidney stone disease?What are your considerations when you're choosing between these different treatment modalities?

Dr. Stork: Over the course of my career, stone treatments have evolved, and it's exciting because they continue to evolve. When I first started, our main modality was shock wave lithotripsy, which is still a great modality for some patients with smaller stones in the kidney. But we've seen an explosion in the availability of ureteroscopy over the past decade or 2, both rigid and flexible ureteroscopy, and also some real advancements in percutaneous nephrolithotomy.

I would say for most cases, as a general urologist, I'm using ureteroscopy for stones in the ureter and in the kidney. For larger stones, maybe stones greater than 1.5 cm to 2 cm, I start to think more about percutaneous nephrolithotomy. I have a partner that does these tubeless in a lot of cases, which is friendly for the patients. That can be an outpatient surgery now, where it used to be that we'd have to keep them overnight and leave a nephrostomy tube in. The technology in the field of stone management is exciting, and I think it offers patients a lot more options than what they've had in the past.

Urology Times: What novel therapies or technologies are on the horizon that you're excited about seeing?

Dr. Stork: It's a fantastic time to be a urologist who treats kidney stones. I think all urologists are a little bit of technology geeks, and the technology is changing so rapidly it's hard to keep up with. I've been told by my endourology colleagues that the future is to either go big or go small. What they mean by that [in terms of] going big, there are some access sheaths now that allow us to irrigate the stone fragments out as we're dusting them with the laser. We can not only break up the stone, but we can remove the pieces with irrigation. On the small side, there are smaller and smaller scopes that provide for direct in-scope suction. These scopes are very tiny compared to what we used to use, allow us to break up the stone, and irrigate out the pieces all in 1 procedure.

On the horizon, there is a technology called ultrasonic propulsion and burst wave therapy that may allow us to treat smaller stones in the office without anesthesia. So, it's great time to be a urologist, and if you have to be a kidney stone patient, now is a great time to be a kidney stone patient.

Urology Times: How do you see AI or machine learning impacting kidney stone management in the future?

Dr. Stork: I think the sky's the limit. We don't have any way right now to calculate the dose of radiation that stone patients have had in the past. Stone patients may have had multiple CT scans in the past within our health care system, and there's no way to calculate those dosages over time and be able to advise the patient on how much radiation they've received and if we should choose a different imaging modality to try to avoid more radiation. Oftentimes, when we get a report from a radiologist about a CT scan, there are pieces of information that are missing, maybe Hounsfield units, that type of thing. We think that AI might be able to help standardize those reports a little bit and help us as surgeons have better information.

I think for patients, AI has opened the door for patient education. Traditionally, I've sent patients to the Urology Care Foundation for their information. We have a new program called Well Prept that sends information to patients ahead of time. But I think when patients get on the internet now, those AI programs do a nice job of summarizing medical conditions—within reason. AI is exciting for us to be able to provide better care for our patients, but it's also exciting for patients to be able to learn more about their condition in ways that they couldn't in the past.

Urology Times: What are some of the biggest gaps in our current understanding of kidney stone disease that warrant further research?

Dr. Stork: Our ability to impact patients' lifestyles to avoid developing kidney stones in the first place is an exciting area of future research. We spend a lot of our time researching surgical options, but I'm a prevention guy. There are water bottles now that tell you when to drink water. There are new medications, the GLP-1 inhibitors, that can help people lose weight and lead a healthier lifestyle. Once they start losing weight, we can counsel them about exercise and better nutrition. These are exciting opportunities to affect the average [patient with] kidney stones.

Of course, there are a lot of things we don't know about why kidney stones form in the first place and how to prevent them. That research has been ongoing for decades. But as a urologist, that personal connection and being able to work with patients to help prevent kidney stones is an exciting opportunity, as is the opportunity to use advanced practice providers who are interested in stone prevention and have more time to dial in with patients and work with them to try to achieve their goals, as far as health, and our collective goals, as far as kidney stone prevention.