What are the treatment recommendations for renal calculi less than 10mm?

From the Guidelines

For renal calculi less than 10mm, the initial approach is typically conservative management with observation, as symptoms are often controlled and spontaneous passage is likely. This approach is supported by the 2007 guideline for the management of ureteral calculi, which suggests that observation with periodic evaluation is an option for initial treatment in patients with newly diagnosed ureteral stones less than 10mm and controlled symptoms 1.

Key Considerations

• The American Urological Association/Endourological Society guideline recommends that clinicians offer definitive stone treatment if observation with or without medical expulsive therapy (MET) is not successful after four to six weeks, or if the patient/clinician decide to intervene sooner based on a shared decision-making approach 1.
• For patients with mid or distal ureteral stones who require intervention, ureteroscopy (URS) is recommended as first-line therapy, as it is associated with significantly higher stone-free rates in a single procedure compared to shock wave lithotripsy (SWL) 1.
• SWL is an acceptable alternative, with the least morbidity and lowest complication rate, but a lower stone-free rate compared to URS 1.

Treatment Options

• Conservative management with observation and periodic evaluation for patients with controlled symptoms and stones less than 10mm.
• URS as first-line therapy for patients with mid or distal ureteral stones who require intervention.
• SWL as an alternative to URS, with consideration of the patient's preferences and individual factors.

Additional Recommendations

• Patients should be counseled on the risks and benefits of each treatment option, including the potential for repeat procedures and complications.
• Routine stenting should not be performed in patients undergoing SWL, and placement of a ureteral stent prior to URS should not be performed routinely 1.
• Patients with suspected cystine or uric acid ureteral stones should be treated with URS 1.

Quality of Life and Morbidity Considerations

• The treatment approach should prioritize minimizing morbidity and mortality, while also considering the patient's quality of life and individual preferences.
• Clinicians should inform patients that URS has a higher stone-free rate, but may be associated with more morbidity compared to SWL 1.

From the Research

Treatment Recommendations for Renal Calculi Less Than 10mm

• The treatment for renal calculi less than 10mm often involves watchful waiting or medical expulsive therapy, with the goal of facilitating the passage of the stone through the urinary tract 2, 3, 4.
• Alpha-blockers, such as tamsulosin, have been shown to be effective in increasing stone clearance rates for ureteral stones, but their benefit for renal stones less than 10mm is less clear 2, 5.
• A study found that alpha-blockers performed better for stones 10 to 20 mm, while there was no difference for stones <10 mm 2.
• Another study suggested that tamsulosin may facilitate expulsion of retained residual fragments after shock wave lithotripsy, shorten time to reach stone-free, and decrease pain scores, but may not affect the need for add-on analgesics 6.
• Patient decision-making for asymptomatic renal calculi is influenced by various factors, including previous stone experience and treatment, and patients often rely on their physician to educate them on treatment alternatives 4.
• The use of alpha-blockers as medical expulsive therapy for ureteral stones may increase stone clearance, but also slightly increases the risk of major adverse events, and their effectiveness may vary with stone size 5.