What is the management of a 10mm renal pelvis stone in a patient with a history of nephrolithiasis (kidney stones)?

From the Guidelines

Management of a 10mm renal pelvis stone in a patient with a history of nephrolithiasis should be conservative with supportive and medical therapy, as the stone size and location suggest a low likelihood of spontaneous passage, but invasive management may not be immediately necessary.

Key Considerations

• The patient's history of nephrolithiasis increases the risk of recurrence and complications, such as ureteral obstruction and hydronephrosis 1.
• Stone size and location are important determinants of stone passage and the need for invasive management, with larger and more proximally located stones being associated with lower rates of spontaneous passage 1.
• Imaging, such as CT abdomen and pelvis without IV contrast, can be useful in evaluating the patient and assessing the need for invasive management 1.
• Conservative management with supportive and medical therapy, such as pain management and hydration, is often the initial approach for patients with renal colic and a stone size of 10mm 1.

Invasive Management

• Invasive management, such as percutaneous nephrolithotomy or ureteroscopy, may be necessary if the patient experiences severe symptoms, such as intractable pain or vomiting, or if there are signs of obstruction or infection 1.
• The decision to proceed with invasive management should be based on individual patient factors, such as the severity of symptoms, the presence of complications, and the patient's overall health status 1.

Imaging and Diagnosis

• CT abdomen and pelvis without IV contrast is a useful imaging modality for evaluating patients with suspected renal colic and can help identify the presence and location of a stone, as well as any potential complications, such as hydronephrosis 1.
• The use of contrast-enhanced CT may be helpful in evaluating other etiologies of flank pain and can provide additional information about the stone and surrounding tissues 1.

From the Research

Management of 10mm Renal Pelvis Stone

• The management of a 10mm renal pelvis stone in a patient with a history of nephrolithiasis depends on various factors, including the presence of symptoms, obstruction, and infection 2.
• For asymptomatic renal stones, observational studies have revealed that approximately 50% of stones will progress, but most will not require surgery 3.
• However, stones >15 mm in diameter and located in the renal pelvis are at highest risk of progression, and surgical treatment may be considered 3.
• For a 10mm stone, the risk of progression is lower, but it is still important to monitor the stone and assess for any signs of obstruction or infection 3.
• Initial treatment may include analgesics and medical expulsive therapy, and most patients will pass their stone spontaneously within 3 days 4.
• If the stone does not pass spontaneously, surgical options such as extracorporeal shock wave lithotripsy, percutaneous lithotripsy, or ureteroscopic laser lithotripsy may be considered 2.

Diagnostic Imaging and Stone Analysis

• Computed tomographic scan of the abdomen and pelvis without contrast and ultrasound of the kidneys, ureters, and bladder are common diagnostic imaging modalities used for diagnosis 4.
• Stone analysis is also important, as it can help identify the type of stone and guide treatment and prevention strategies 5, 2.

Prevention and Metabolic Evaluation

• High fluid intake is a mainstay of prevention, and metabolic evaluation may indicate other appropriate preventive measures, such as dietary salt and protein restriction, and use of thiazide diuretics, neutral phosphate, potassium citrate, allopurinol, and magnesium salts 2.
• Metabolic evaluation is particularly important for patients with recurrent stones, as it can help identify underlying causes and guide prevention strategies 2.