From the Guidelines
Surgical management of kidney stones should be tailored to the individual patient, considering stone size, location, and patient factors, with options including Extracorporeal Shock Wave Lithotripsy (ESWL), Ureteroscopy (URS), and Percutaneous Nephrolithotomy (PCNL). The choice of procedure depends on various factors, including stone characteristics, patient anatomy, and surgeon expertise, with the goal of achieving complete stone clearance while minimizing complications and recovery time 1. For symptomatic patients with a total non-lower pole renal stone burden ≤ 20 mm, clinicians may offer SWL or URS, as both have acceptable stone-free rates and less morbidity than PCNL 1. However, for symptomatic patients with a total renal stone burden >20 mm, clinicians should offer PCNL as first-line therapy, as it offers a higher stone-free rate than SWL or URS and is less invasive than open surgery or laparoscopic/robotic assisted procedures 1. Some key points to consider include:
- Stone size and location: PCNL is recommended for larger stones (>2 cm) or complex stones, while URS is suitable for mid to lower ureteral stones 1.
- Patient factors: Obesity, skin-to-stone distance, and collecting system anatomy can affect the success of SWL, making PCNL or URS more suitable options in some cases 1.
- Surgeon expertise: The choice of procedure may depend on the surgeon's experience and skill with each technique 1.
- Post-operative care: Pain management, adequate hydration, and sometimes antibiotics are essential for preventing infection and promoting recovery 1. Overall, the most recent and highest quality study 1 provides strong recommendations for the surgical management of kidney stones, emphasizing the importance of individualized treatment plans and careful consideration of stone characteristics, patient anatomy, and surgeon expertise.
From the Research
Surgical Management of Kidney Stones
The surgical management of kidney stones involves several options, including:
- Extracorporeal shock wave lithotripsy (ESWL) 2, 3
- Ureteroscopic lithotripsy (URL) 2, 4
- Percutaneous nephrolithotripsy (PCNL) 2, 3, 4
- Retrograde intrarenal surgery (RIRS) 3
Factors Influencing Treatment Choice
The choice of treatment depends on various factors, including:
- Stone size and location 2, 3, 4, 5
- Stone composition 5
- Patient factors, such as morbid obesity, solitary kidney, and renal insufficiency 5
- Anatomical considerations, such as calyceal diverticula and renal anomalies 5
Treatment Outcomes
The outcomes of these treatments vary, with:
- ESWL being effective for smaller stones (< 10 mm) 2
- URL being suitable for most ureteral calculus cases, but with a higher risk of surgical failure due to difficult entry of the ureteroscope or stone displacement 2
- PCNL being effective for complex upper ureteral stones and large kidney stones (> 20 mm) 2, 3, 4
- RIRS being a viable option for lower pole kidney stones, with similar success rates to ESWL 3
Complications and Morbidity
The complications and morbidity associated with these treatments also vary, with:
- ESWL having a lower risk of complications, but a higher risk of re-treatment and auxiliary procedures 3
- PCNL having a higher risk of complications, but a higher success rate and lower risk of re-treatment 3
- URL and RIRS having a lower risk of complications, but a higher risk of surgical failure and re-treatment 2, 3, 4