What is the recommended management for an 8mm symptomatic urinary calculi?

From the Guidelines

For an 8mm symptomatic urinary calculus, the recommended management is ureteroscopy (URS) as the first-line therapy, due to its higher stone-free rates compared to extracorporeal shock wave lithotripsy (ESWL) 1. This approach is based on the American Urological Association/Endourological Society guideline, which suggests that URS is associated with significantly higher stone-free rates in a single procedure compared to SWL, particularly for patients with stones less than 10mm in size 1. While ESWL is an acceptable alternative, with the least morbidity and lowest complication rate, its stone-free rate is lower than URS, with a reported 72% stone-free rate for ESWL compared to 90% for URS 1. The choice between URS and ESWL should be based on stone location, composition, and patient factors, with URS being the preferred option for mid or distal ureteral stones 1. Pain management should include NSAIDs such as ibuprofen 600mg every 6 hours or ketorolac 10mg every 6 hours, with opioids like hydrocodone/acetaminophen 5/325mg every 4-6 hours reserved for breakthrough pain, and adequate hydration of 2-3 liters of fluid daily should be maintained. It is also important to note that routine stenting should not be performed in patients undergoing URS or ESWL, unless there are specific indications such as suspected ureteric injury or ureteral stricture 1. Overall, the goal of treatment is to achieve a stone-free state, minimize morbidity, and prevent potential complications such as kidney damage, infection, or sepsis.

Some key points to consider in the management of an 8mm symptomatic urinary calculus include:

• Ureteroscopy is the preferred treatment option due to its higher stone-free rates compared to ESWL 1
• ESWL is an acceptable alternative, but may require multiple sessions for complete clearance 1
• Pain management should include NSAIDs and opioids as needed, with adequate hydration maintained 1
• Routine stenting should not be performed unless there are specific indications 1
• The goal of treatment is to achieve a stone-free state, minimize morbidity, and prevent potential complications 1

From the Research

Management of 8mm Symptomatic Urinary Calculi

The management of 8mm symptomatic urinary calculi involves several treatment options, including shock wave lithotripsy and ureteroscopy.

• The goal of treatment is to achieve complete stone clearance with minimal patient morbidity 2.
• Shock wave lithotripsy and ureteroscopy have become standards of care for ureteral calculi, with the optimal choice of treatment depending on various factors such as stone size, composition, and location, as well as clinical patient factors, equipment availability, and surgeon capability 2.
• For stones less than 10mm, both shock wave lithotripsy and ureteroscopy provide excellent stone-free rates, ranging from 86% to 90% 2.
• Ureteroscopy is preferred over shock wave lithotripsy in patients with pregnancy or bleeding diathesis, and provides optimal stone clearance in patients with proximal ureteral calculi more than 10mm 2.

Treatment Options

• Ureteroscopic laser lithotripsy is a minimally invasive treatment modality that can treat large intrarenal calculi with the potential to decrease morbidity while maintaining a high level of efficacy 3.
• Flexible ureteroscopy and laser lithotripsy can successfully treat patients with stones >2cm with a high stone-free rate and a low complication rate 4.
• Active fragment extraction after ureteroscopic laser lithotripsy can improve stone clearance rates, with overall success rates of 54%, 84%, and 95% at fragment thresholds of 0,2, and 4mm, respectively 5.
• The choice of treatment ultimately depends on the specific characteristics of the patient and the stone, as well as the availability of equipment and the expertise of the surgeon 2, 6.

Key Considerations

• Stone size is an important factor in determining the optimal treatment approach, with larger stones requiring more invasive procedures such as percutaneous nephrolithotomy (PCNL) 6.
• The location of the stone is also an important consideration, with stones in the proximal ureter or renal pelvis potentially requiring different treatment approaches than those in the distal ureter 2.
• The use of sensitive postoperative imaging, such as noncontrast spiral CT, can help to evaluate stone clearance rates and detect any residual fragments 5.