What is the recommended treatment for multiple 1 cm (centimeter) stones in the urinary tract and kidney diagnosed by ultrasound?

From the Guidelines

The recommended treatment for multiple 1 cm stones in the urinary tract and kidney diagnosed by ultrasound is extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy with laser lithotripsy, as these options have acceptable stone-free rates and less morbidity than percutaneous nephrolithotomy (PCNL) for cumulative stone burdens <20 mm. For patients with multiple 1 cm stones, the total stone burden is 20 mm or less, which falls into the category where ESWL or ureteroscopy (URS) may be offered as treatment options, according to the American Urological Association/Endourological Society guideline 1. The choice between ESWL and URS depends on various factors including stone location, patient symptoms, and local expertise. Some key points to consider in the management of these patients include:

• ESWL is less invasive and can be used for stones in the kidney, but its success rate declines with increasing stone burden and is dependent on factors like stone composition and density 1.
• URS is associated with a lower likelihood of repeat procedures compared to ESWL, allowing patients to become stone-free quicker 1.
• For stones in the ureter, URS may be preferred, where a thin scope is inserted through the urethra to locate and remove stones or break them with a laser.
• Medication management includes pain control with NSAIDs or opioid analgesics, and alpha-blockers like tamsulosin may help stones pass by relaxing ureter muscles.
• Patients should increase fluid intake to 2-3 liters daily to promote stone passage and prevent new formation, as recommended by the American College of Physicians for preventing recurrent nephrolithiasis 1.
• Dietary modifications, such as reducing sodium intake, limiting animal protein, and maintaining normal calcium consumption, are also important for preventing recurrent kidney stones, especially for calcium-based stones 1. Follow-up imaging is essential to confirm complete stone clearance, and the treatment choice ultimately depends on stone location, composition, patient factors, and local expertise.

From the Research

Treatment Options for Multiple 1 cm Stones in Urinary Tract and Kidney

The treatment for multiple 1 cm stones in the urinary tract and kidney diagnosed by ultrasound can vary depending on several factors, including stone size, location, and patient's overall health.

• The American Urological Association (AUA) guidelines recommend the following treatment options for kidney stones:

Treatment Modalities

• Extracorporeal Shock Wave Lithotripsy (ESWL): a non-invasive treatment that uses shock waves to break up the stones into smaller pieces that can then pass out of the body in the urine 2, 3.
• Ureteroscopy: a minimally invasive procedure where a small scope is inserted through the urethra and bladder to remove the stones 2, 3.
• Percutaneous Nephrolithotomy (PCNL): a minimally invasive procedure where a small incision is made in the back to insert a scope and remove the stones 3.
• Active Monitoring: a non-invasive approach where the patient is monitored for any changes in symptoms or stone size, and treatment is only provided if necessary 3.

Factors Influencing Treatment Selection

• Stone size and location: ESWL is often recommended for stones smaller than 2 cm, while PCNL is recommended for larger stones 3.
• Stone density: stones with higher density (Hounsfield unit value > 677) are more likely to be successfully treated with mini-PNL, while stones with lower density are more likely to be successfully treated with RIRS 4.
• Patient's overall health: patients with certain medical conditions, such as bleeding disorders or uncontrolled urinary tract infections, may not be suitable for certain treatments 3.

Success Rates and Complications

• ESWL has a success rate of around 71-84% for stones smaller than 2 cm, with a low complication rate 2.
• Ureteroscopy has a success rate of around 79-84% for stones smaller than 2 cm, with a low complication rate 2.
• PCNL has a success rate of around 90-100% for larger stones, but has a higher complication rate compared to ESWL and ureteroscopy 3.