Treatment of 2.3cm Nephrolithiasis

Percutaneous nephrolithotomy (PCNL) should be offered as first-line therapy for a 2.3cm kidney stone. 1

Rationale for PCNL as First-Line Treatment

For renal stones with a total burden >20mm (2cm), PCNL provides the highest stone-free rates compared to other treatment modalities 1
PCNL offers a higher stone-free rate than shock wave lithotripsy (SWL) or ureteroscopy (URS) and is less invasive than open surgery or laparoscopic/robotic assisted procedures 1
The success rate of PCNL is less dependent on stone composition, density, and location compared to other treatment options 1
In a randomized controlled trial comparing PCNL to URS for stones >2cm in the renal pelvis, PCNL achieved a 94% stone-free rate compared to 75% with URS 1

SWL should not be offered as first-line therapy for stones >20mm due to significantly reduced stone-free rates and increased need for multiple treatments 1, 2
Studies have consistently shown that SWL has poor outcomes for stones of this size, with stone-free rates declining to as low as 10% when stone burden exceeds 20mm 1
While URS can be considered for smaller stones, its efficacy decreases significantly with increasing stone burden 1

Before stone treatment, urine microscopy and culture should be obtained to exclude or treat urinary tract infection 1
If infection is suspected with an obstructing stone, urgent decompression of the collecting system via percutaneous nephrostomy or ureteral stenting is strongly recommended before definitive stone treatment 1
Perioperative antibiotic prophylaxis should be offered to all patients undergoing endourological treatment 1

Medical management should be implemented after stone removal to prevent recurrence 1, 2
Increased fluid intake to achieve at least 2L of urine output per day is recommended 1, 3
Based on stone composition and metabolic evaluation, pharmacologic therapy may include:
- Thiazide diuretics for patients with high urinary calcium 2
- Potassium citrate for patients with low urinary citrate 2
- Allopurinol for patients with hyperuricosuria and calcium oxalate stones 2

For patients who fail or are unlikely to have successful results with PCNL, alternative approaches include laparoscopic, open, or robotic-assisted stone removal 1
If the affected kidney has negligible function, nephrectomy may be considered 1
In cases where the stone is causing obstruction with signs of infection, drainage of the collecting system must take priority over stone removal until the infection is resolved 1, 4

PCNL, while effective, carries risks including bleeding, infection, and injury to surrounding structures 1
Stent discomfort following the procedure can be managed with alpha-blockers and anti-muscarinic therapy 1
Careful monitoring for sepsis is essential, especially in patients with infected stones or those who develop infection during treatment 1, 4

Stone analysis should be performed to guide prevention strategies 1
Patients should be counseled on dietary modifications based on stone composition 1
Regular follow-up imaging is necessary to ensure complete stone clearance 1
Long-term preventive measures should be implemented to reduce recurrence risk 1, 3