From the Guidelines
The best treatment for this 38-year-old woman with an 8 mm stone in a right upper pole calyceal diverticulum causing intermittent flank pain is either Shock Wave Lithotripsy (SWL) or Ureteroscopy (URS), as both options are acceptable for symptomatic patients with a total non-lower pole renal stone burden ≤ 20 mm. According to the American Urological Association/Endourological Society guideline 1, for cumulative stone burdens <20 mm, stone-free rates for both URS and SWL are acceptable and have less morbidity than PCNL.
Key Considerations
- The stone size is 8 mm, which is well within the recommended threshold for SWL or URS 1.
- The location of the stone is in a calyceal diverticulum, which may pose technical challenges for URS, but SWL can be effective in such cases.
- PCNL is generally recommended for stone burdens >20 mm 1, but it may not be necessary for smaller stones like in this case.
Treatment Options
- SWL: This is a non-invasive procedure that uses shock waves to break up the stone into smaller fragments that can then pass out of the body in the urine. SWL is a good option for smaller stones like in this case 1.
- URS: This is a minimally invasive procedure that involves using a small scope to visualize the stone and then removing it or breaking it up with a laser. URS is also a good option for smaller stones, but it may be technically more challenging for upper pole diverticula 1.
Expected Outcomes
- Both SWL and URS have acceptable stone-free rates for smaller stones like in this case 1.
- The patient can expect a relatively quick recovery time, with most patients able to return to normal activities within a few days to a week after the procedure.
- The choice between SWL and URS will depend on the patient's individual circumstances and the surgeon's preference 1.
From the Research
Treatment Options for 8 mm Stone in Caliceal Diverticulum
- The patient has an 8 mm stone in a caliceal diverticulum, which is a complex condition requiring careful consideration of treatment options.
- According to the study by 2, mini percutaneous nephrolithotomy (mini-PCNL) is a versatile tool for removing kidney stones, including those in caliceal diverticula.
- The study by 3 suggests that flexible ureteroscopy can be an option for stones located in the diverticular neck or a diverticulum, but the size of the stone and the anatomy of the diverticulum must be considered.
Considerations for Treatment
- The size of the stone (8 mm) is relatively small, but its location in a caliceal diverticulum makes it a challenging case.
- The study by 4 compared the outcomes of PCNL, flexible ureteroscopy, and extracorporeal shock wave lithotripsy (ESWL) for lower pole stones of 10-20 mm, and found that PCNL provided a higher stone-free rate than flexible ureteroscopy and ESWL.
- However, the study by 3 suggests that ESWL can be considered as an option for stones between 10 and 20 mm in size, if the anatomy is favorable.
Recommended Treatment
- Based on the available evidence, mini-PCNL (2) or flexible ureteroscopy (3) may be considered as treatment options for the 8 mm stone in the caliceal diverticulum.
- The choice of treatment will depend on the individual patient's anatomy and the surgeon's expertise.
- Further evaluation and discussion with a urologist are necessary to determine the best course of treatment for this patient.