Stones

Page updated Winter 2021.

Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable sources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original sources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

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.


Medical Therapy


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.

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.


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.


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.