Page updated Winter 2023.

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, Smith's Textbook of Endourology, 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 take or 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           


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


Frequency: 3-5 Hertz

Energy: 1.0-2.0 Joule


Laser Fiber: 200 Micron


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


Lower Pole >10 mm 


Lower Pole ≤ 10 mm 


Caliceal Diverticular Stones


Laparoscopic or robotic stone removal.

Asymptomatic Non-obstructing Caliceal Stones

Active Surveillance

Bleeding Diatheses 


Purulent Urine

Stone removal procedures should be aborted.


Urine culture

Antibiotic therapy


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


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


Ureteral Stones


If symptoms are well controlled.


For patients who fail observation. Options are:


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.


Ureteral Stones

Management is similar to adults.

Renal Stones

Renal stone burden ≤20mm: 


Renal stone burden >20mm: 


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