Surgical Management of Kidney Stones

Measuring lower pole anatomy, from Campbell's

Pre-Surgical Workup

Workup

Counseling

Renal stone size affecting surgery choice

Anatomic considerations

Lower pole location complicates surgeries

Surgery options

Percutaneous Nephrolithotomy (PCNL)

Ureteroscopy (URS)

Extracorporeal Shock Wave Lithotripsy (ESWL)

Summary AUA Guidelines

Age Size Location MET Surgery
Adult < 10mm proximal ureter attempt for 4-6 weeks flexible URS
ESWL (2nd line)
mid-ureter
distal ureter 50% spontaneous passage
77% passage with a-blockers
> 10mm proximal ureter no benefit
mid-ureter
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?

Follow-Up

After surgery

Long-term

Lower tract stones

Bladder stones

Urethral stones

Sources: