From the Guidelines
For patients with a non-obstructing kidney stone, the treatment approach should be based on the size and location of the stone, with the goal of minimizing morbidity, mortality, and improving quality of life. When considering treatment options, it's essential to evaluate the stone's size and location to determine the most effective approach.
- For symptomatic patients with a total non-lower pole renal stone burden ≤ 20 mm, clinicians may offer Shock Wave Lithotripsy (SWL) or Ureteroscopy (URS), as both options have acceptable stone-free rates and less morbidity than Percutaneous Nephrolithotomy (PCNL) 1.
- The choice between SWL and URS depends on various factors, including stone composition, density, and location, with URS associated with a lower likelihood of repeat procedures compared to SWL 1.
- For symptomatic patients with a total renal stone burden >20 mm, clinicians should offer PCNL as first-line therapy, as it offers a higher stone-free rate than SWL or URS and is less invasive than open surgery or laparoscopic/robotic-assisted procedures 1.
- In patients with total renal stone burden >20 mm, clinicians should not offer SWL as first-line therapy, due to significantly reduced stone-free rates and increased need for multiple treatments compared to PCNL 1.
- For patients with symptomatic ≤10 mm lower pole renal stones, clinicians should offer SWL or URS, as both options have similar stone-free rates and patient-derived quality of life measures 1.
- However, clinicians should not offer SWL as first-line therapy to patients with >10 mm lower pole stones, as endoscopic approaches offer substantial benefits over SWL with regard to stone-free rate, despite a moderate associated increase in risk 1.
From the Research
Treatment Options for Non-Obstructing Kidney Stones
- The current German and European guidelines recommend active surveillance for patients with asymptomatic kidney stones if no interventional therapy is mandatory because of pain or medical factors 2.
- For symptomatic non-obstructing kidney stones, treatment options include extracorporeal shockwave lithotripsy (ESWL), ureterorenoscopy (URS), and percutaneous nephrolithotomy (PNL) 2, 3.
- Medical expulsive therapy (MET) is considered first-line therapy if stones do not resolve with observation, and is recommended for patients with uncomplicated distal ureteral stones 10 mm in diameter or less 3.
- Alpha-blockers, such as tamsulosin, have been shown to be effective in assisting stone clearance after ESWL, with a pooled absolute risk difference of 16% in favor of the tamsulosin group 4.
- Alpha-blockers have also been shown to be beneficial for ureteral stones ≤10 mm treated without lithotripsy, and for renal or ureteral stones >10 mm treated with lithotripsy 5, 6.
Benefits and Risks of Treatment Options
- Active surveillance is a viable option for asymptomatic kidney stones, with the benefit of avoiding unnecessary intervention 2.
- Alpha-blockers have been shown to increase stone clearance rates, reduce stone expulsion time, and decrease the need for hospitalization and surgical intervention 5, 6, 4.
- However, alpha-blockers may also increase the risk of major adverse events, such as dizziness and hypotension 6, 4.
- ESWL, URS, and PNL are effective treatment options for symptomatic non-obstructing kidney stones, but may be associated with risks such as bleeding, infection, and damage to surrounding tissues 3.