Surgical Management of Kidney Stones

Pre-Surgical Workup

At this point, pretty much everyone gets a CT, which has the most accurate diagnostic capability. CT will determine stone size, location, and density, to help determine best option. Patients should have a negative UCx or at least adequate treatment for a positive culture related to stent/PCN.

Ureteroscopy (URS)

Percutaneous Nephrolithotomy (PCNL)

Extracorporeal Shock Wave Lithotripsy (ESWL)

Tips for success

Surgical Options (Per AUA Guidelines)

Age Size Location MET Surgery
Adult < 10mm proximal ureter attempt for 4-6 weeks flexible URS
ESWL (2nd line)
distal ureter 50% spontaneous passage
77% passage with a-blockers
> 10mm proximal ureter no benefit
distal ureter
< 20mm non-lower pole total burden no benefit URS/ESWL: SFR decreases with increased stone size
PCNL: no effect of stone size
> 20mm total renal burden PCNL: first line, SFR 70-94%
URS: SFR 75%, better if staged, less complications
ESWL: SFR 19-57%, higher sepsis rate
< 10mm lower pole burden ESWL/URS: equivalent SFR
> 10mm PCNL: highest SFR, highest risk
URS/ESWL: 2nd line
residual stones possible benefit if small/obstructing Treatment may be required if fragments > 2mm and near renal pelvis or ureter
infection stones require treatment
renal stones w/ pain but no obstruction no benefit Treat if no other source of pain, but counsel that pain may not improve after stone removal
ESWL: SFR 0-25% (not recommended)
asymptomatic renal stones no benefit Treatment not required
30-46% chance of stone growth
13%-49% chance of symptomatic stone event
7-26% need for intervention
Treat if likely infectious, high risk profession, or poor follow-up risk
Pediatric ureteral stones benefit if < 10mm URS: SFR 95% (< 10mm), 78% (> 10mm)
ESWL: SFR 87% (< 10mm), 73% (> 10mm)
prestenting not required
renal stones no benefit URS: recommended if < 20mm (SFR 80-85%)
PCNL: recommended if > 20mm (SFR ~90%)
ESWL: SFR 80-85% (< 20mm), 73-83% (> 20mm)
Pregnant any location Okay: a-blockers, narcotics
Not okay: NSAIDs
Situation dependent
Max XRT dose 50 mGy

Emergent Drainage

Criteria for emergent/urgent stent/PCN

Should a patient undergo PCN or stent?

Bottom line: PCN outperforms stent in all parameters (including patient satisfaction), but stent should usually be attempted if IR is unwilling or unable