What is the best course of action for an 18-year-old woman who gave consent for cystoscopy (cystoscopy) only, and a stone was identified during the procedure?

From the Guidelines

The best course of action for an 18-year-old woman who gave consent for cystoscopy only, and a stone was identified during the procedure, is to complete the cystoscopy without removing the stone, then discuss findings and treatment options with the patient while she is fully awake and able to provide informed consent. This approach respects patient autonomy and informed consent principles, as performing stone removal without specific consent would constitute a breach of medical ethics and potentially expose the provider to legal liability for performing a procedure beyond the scope of the original consent.

According to the American Urological Association/Endourological Society guideline, part II 1, if a stone is identified, the clinician should offer definitive stone treatment after discussing the treatment options with the patient. The treatment options may include extracorporeal shock wave lithotripsy (ESWL), ureteroscopy with laser lithotripsy, or percutaneous nephrolithotomy, depending on stone characteristics.

Some key points to consider when discussing treatment options with the patient include:

• The location and size of the stone
• The potential consequences if the stone is left untreated, such as urinary tract infections, kidney damage, or worsening pain
• The potential complications of each treatment option
• The importance of increased fluid intake to help with stone passage if appropriate
• Pain control with NSAIDs like ibuprofen 600mg every 6 hours or ketorolac 10mg every 6 hours

The physician should also inform the patient that ureteroscopy (URS) has a greater stone-free rate in a single procedure compared to shock-wave lithotripsy (SWL), but SWL has the least morbidity and lowest complication rate 1. The patient should be fully informed and able to provide consent for the chosen treatment option, taking into account the potential benefits and risks of each procedure.

From the Research

Informed Consent and Stone Identification

• The patient, an 18-year-old woman, has given consent for a cystoscopy only, and a stone was identified during the procedure 2.
• The initial consent was limited to the cystoscopy procedure, and the patient's consent for further treatment of the stone is required 3.

Treatment Options for Kidney Stones

• Kidney stones are a common and painful urological disorder, and treatment options include extracorporeal shockwave lithotripsy, ureteroscopy, or percutaneous nephrolithotomy 4.
• Medical expulsion therapy (MET) has been investigated as a supplement to observation to improve spontaneous stone passage rates 5.
• The use of alpha-1 blockers, such as tamsulosin, has been studied as an adjunctive medical therapy to increase the efficacy of extracorporeal shockwave lithotripsy (ESWL) for renal stones 6, 5.

Next Steps

• The patient should be fully informed about the identified stone, treatment options, and the risks and benefits associated with each option 2, 3.
• The patient's consent should be obtained for any further treatment or procedures, and the patient should be given the opportunity to ask questions and consider their options 2, 3.
• The healthcare provider should ensure that the patient's informed consent is obtained before proceeding with any treatment or procedure 2, 3.