Stones

Page updated Winter 2021.
DisclaimerMedicine 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 resources. 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 resources. 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 if it is > 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.

Nephroectomy

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.