What is the best course of treatment for a 57-year-old male with painless hematuria, bilateral renal calculi (kidney stones), and right-sided renal collecting system dilation?

Management of Painless Hematuria with Bilateral Renal Calculi and Right-Sided Collecting System Dilation

The optimal management for this 57-year-old male with painless hematuria, bilateral renal calculi, and right-sided renal collecting system dilation in the lower pole calices should include CT urography followed by urologic consultation for likely percutaneous nephrolithotomy or ureteroscopy for stone removal. 1

Initial Diagnostic Evaluation

• CT urography is the recommended initial imaging test for patients with painless hematuria and suspected urolithiasis, as it offers superior sensitivity (94.1%) for detecting upper urinary tract pathology compared to other imaging modalities 2
• CT without contrast can accurately identify stone burden, location, and degree of obstruction, which are critical factors in determining appropriate management 1
• The presence of collecting system dilation in the right kidney suggests obstruction that requires intervention, particularly when associated with hematuria 1
• While ultrasound initially detected the stones and hydronephrosis, it has limited sensitivity (75% overall, only 38% for ureteral stones) and cannot fully characterize the extent of disease 1

Treatment Considerations

Stone Characteristics and Obstruction

• The right-sided collecting system dilation in the lower pole calices indicates partial obstruction that requires intervention to prevent progressive renal damage 1
• Bilateral renal calculi require comprehensive management planning, with priority given to the obstructed right kidney 3
• Stone size, location, and composition (which can be determined by CT) are critical factors in selecting the appropriate intervention 1

Treatment Options

1. Percutaneous Nephrolithotomy (PCNL):

   • First-line treatment for larger stones and those causing obstruction 1
   • Technical success rates approach 95-100% for dilated collecting systems 1
   • Allows for direct visualization and complete stone removal 1

2. Ureteroscopy with Stone Extraction:

   • Appropriate for smaller stones and those in accessible locations 1
   • Can be performed with laser lithotripsy for stone fragmentation 1

3. Shock Wave Lithotripsy (SWL):

   • Generally not recommended as monotherapy for complex stones or those causing obstruction 1
   • May be considered as part of combination therapy for smaller stone burden 1

4. Temporary Drainage:

   • Percutaneous nephrostomy (PCN) may be needed if there is evidence of infection or significant obstruction before definitive treatment 1

Management Algorithm

1. Complete CT urography to fully characterize:

   • Stone burden (size, number, location)
   • Degree of obstruction
   • Renal function
   • Presence of any additional pathology 1, 4

2. Laboratory evaluation:

   • Renal function tests to assess kidney damage
   • Urine culture to rule out infection 1

3. Urologic consultation for definitive management:

   • For the right kidney with collecting system dilation:
     • PCNL is likely the most appropriate intervention for complete stone removal and relief of obstruction 1
   • For the left kidney without obstruction:
     • Treatment can be planned based on stone size and location 1

4. Post-intervention follow-up:

   • Imaging to confirm stone clearance
   • Metabolic evaluation to prevent recurrence 1

Special Considerations

• Painless hematuria with stones requires thorough evaluation to exclude other causes, particularly malignancy 4, 5
• The incidence of renal cancer in patients with hematuria is approximately 1.4% in those with macroscopic hematuria and 0.4% in those with microscopic hematuria 5
• CT urography has higher sensitivity than ultrasound for detecting both stones and potential malignancies 4, 2
• Bilateral stone disease may indicate a metabolic disorder requiring additional evaluation after stone treatment 1, 3

Common Pitfalls to Avoid

• Relying solely on ultrasound for evaluation of hematuria and stones, as it has limited sensitivity for detecting ureteral stones and small renal masses 1, 5
• Delaying treatment of obstructing stones, which can lead to irreversible renal damage 1
• Using shock wave lithotripsy as monotherapy for complex stones, which has lower success rates than PCNL-based approaches 1
• Failing to evaluate for underlying metabolic causes of bilateral stone disease 1, 3