Ureteral Stones           

Observation

Uncomplicated ureteral stones ≤10 mm 

α-blockers  maybe given.

We may observe the patient for four to six weeks before any intervention. 

Ureteroscopy (URS)

First line for mid or distal ureteral stones.

An option for upper ureteral stone especially > 10 mm. 

For suspected cystine or uric acid stones.

Compared to SWL, URS has a better chance of achieving stone-free status with a single procedure, but has higher complication rates.

We may offer α-blockers and antimuscarinic therapy to reduce stent discomfort, if one is placed.  

Shock Wave Lithotripsy (SWL)

An option for upper ureteral stones.

Holmium Laser Setting for TUL

Stone Dusting

Frequency: 20 Hertz

Energy: 0.2 Joule, hard stones: 0.4 Joule

Popcorn Effect

Frequency: 10 Hertz

Energy: 1.0 Joule

Fragmentation

Frequency: 3-5 Hertz

Energy: 1.0-2.0 Joule

Supplies

Laser Fiber: 200 Micron

C-Arm

22 French Cystoscope

30-degree Lens

Rigid Ureteroscope

Flexible Ureteroscope

Pressure Bag

Saline for Irrigation

Irrigation Tubes

Camera, Light Source and Cable

Open-End Flexi-Tip Ureteral Catheter, 5 Fr

Contrast Dye and Saline

10 and 20 cc Syringes

Glidewire, Straight, 0.038

Glidewire, Straight, 0.035

Bard Solo Flex, Straight, 0.038

Dual-Lumen Ureteral Catheter

Flexor Ureteral Access Sheath, OD: 11.5 Fr, ID: 9.5 (with STORZ Flex X Flexible Ureteroscope

Halo, Nitinol Tipless Basket, 1.5 Fr

Stone Graspers

4.7 or 6 or 7 Fr X 24 or 26 or 28 cm JJ Ureteral Stent

14 and 16-French Foley

Goldberg Device

Plastic Clips

Kidney Stones

>20 mm 

Percutaneous nephrolithotomy (PCNL)

Non-lower Pole ≤ 20 mm

SWL or URS

Lower Pole >10 mm 

PCNL

Lower Pole ≤ 10 mm 

SWL or URS 

Caliceal Diverticular Stones

URS or PCNL

Laparoscopic or robotic stone removal.

Asymptomatic Non-obstructing Caliceal Stones

Active Surveillance

Bleeding Diatheses 

URS 

Purulent Urine

Stone removal procedures should be aborted.

Drainage

Urine culture

Antibiotic therapy

α-blockers

May be prescribed to facilitate passage of stone fragments following SWL.

Nephrectomy

If involved kidney has negligible function.

Medical Therapy

For dose of medications click here. 

Recurrent Calcium Stones  

Thiazide diuretics- if high urine calcium, or normal work up.

Potassium citrate- if low urinary citrate or normal work up.

Allopurinol- if there is hyperuricosuria.

Uric Acid Stones

Potassium citrate

Cystine Stones

Potassium citrate

Tiopronin - is a cystine-binding drug.

For patients who did not respond to citrate

Pregnancy

Ureteral Stones

Observation

If symptoms are well controlled.

Intervention

For patients who fail observation. Options are:

URS 

Stent or nephrostomy. 

Frequent stent or tube change is needed.

Considerations in Pregnancy

Ultrasound is the preferred method of imaging in pregnancy.

MRI is the second-line imaging modality.

Use of 1.5 T is currently recommended, as there is not enough data for 3 T.

Gadolinium is not routinely recommended in pregnancy.

SWL is contraindicated in pregnancy.

PCNL is contraindicated in pregnancy.

Pediatrics

Ureteral Stones

Management is similar to adults.

Renal Stones

Renal stone burden ≤20mm: 

SWL or URS 

Renal stone burden >20mm: 

PCNL or SWL

If SWL is utilized, internalized ureteral stent or nephrostomy tube should be placed.

Active surveillance

For patients with asymptomatic and non-obstructing renal stones.

Ureteroscopic Stone Fragmentation Adverse Events (Per Literature)

Failure to access the stone: 1%–8%

Intraoperative bleeding severe enough to abort the procedure: <2%

Delayed kidney bleeding: < 1%

Kidney hematoma: <1%

UTI/sepsis: <5%, <2%

Silent hydronephrosis: <1%–2%

Ureteral stricture: 0.5%–4%

Ureteral perforation: <4%

Ureteral avulsion: <1