From the Guidelines
Not all stones in the renal collecting system require treatment, and the decision to treat depends on several factors including stone size, location, symptoms, and patient-specific considerations. The most recent and highest quality study, 1, published in 2021, provides a qualitative review of clinical guidelines for medical and surgical management of urolithiasis, highlighting the importance of considering stone size, location, and patient symptoms when deciding on treatment.
Key Considerations for Treatment
- Stone size: Stones smaller than 5mm often pass spontaneously and may be managed with conservative measures, while larger stones (>10mm) may require intervention.
- Stone location: The location of the stone in the renal collecting system can impact treatment options, with stones in the renal pelvis or upper and middle calyx potentially being treated with extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL).
- Symptoms: Patients with symptomatic stones, such as those causing obstruction, persistent pain, or recurrent urinary tract infections, require intervention.
- Patient-specific considerations: Factors such as kidney function, overall health, and patient preferences should be taken into account when deciding on treatment.
Treatment Options
- Extracorporeal shock wave lithotripsy (ESWL)
- Ureteroscopy with laser lithotripsy
- Percutaneous nephrolithotomy (PCNL) for very large stones
- Conservative measures, such as increased fluid intake and pain management, for asymptomatic small stones
Monitoring and Prevention
- Patients with asymptomatic small stones may be monitored with periodic imaging.
- The composition of stones also matters, with uric acid stones potentially dissolving with urine alkalinization using potassium citrate, and calcium-based stones potentially benefiting from dietary modifications and thiazide diuretics to prevent recurrence.
- Adequate hydration remains essential for all patients with kidney stones to reduce the risk of new stone formation, as supported by the study 1 published in 2023.
From the Research
Treatment of Stones in the Renal Collecting System
Stones in the renal collecting system can be treated using various methods, including:
- Extracorporeal shock wave lithotripsy (ESWL) 2, 3, 4, 5
- Percutaneous nephrolithotomy (PCNL) 2, 6, 4, 5
- Ureterorenoscopy (URS) 6, 5
- Combined approaches, such as URS and ESWL 5
Factors Influencing Treatment Choice
The choice of treatment depends on several factors, including:
- Stone size and location 2, 6, 4
- Stone composition 2
- Patient factors, such as morbid obesity, solitary kidney, and renal insufficiency 2
- Presence of hydronephrosis and other anatomic variables 2
Efficacy of Treatment Options
- ESWL is effective for smaller stones (< 10 mm) 4
- PCNL achieves better results than ESWL for medium-size stones (10-20 mm) 4
- URS is a practical option for kidney stones 20 to 40 mm 6
- Combined approaches, such as URS and ESWL, can be effective for large renal stone burdens 5