Why should a patient with a kidney stone see a urologist rather than a nephrologist?

Why See a Urologist Rather Than a Nephrologist for Kidney Stones

Patients with kidney stones should see a urologist because urologists provide the definitive surgical interventions (ureteroscopy, shock wave lithotripsy, and percutaneous nephrolithotomy) that are required for stone removal, while nephrologists should be consulted for complex metabolic evaluation and medical management of recurrent stone disease. 1, 2

Primary Role of Urologists in Kidney Stone Management

Urologists are the primary specialists for acute stone intervention and surgical management:

• Ureteroscopy (URS) achieves 90% stone-free rates for ureteral stones and is the first-line surgical therapy for mid and distal ureteral stones requiring intervention 1
• Shock wave lithotripsy (SWL) has the lowest morbidity and complication rates, though lower stone-free rates (72%) compared to URS, and is appropriate for stones ≤10 mm 1, 2
• Percutaneous nephrolithotomy (PCNL) is the first-line therapy for renal stones >20 mm, achieving stone-free rates of 87-94% 2, 3

When Nephrologists Should Be Involved

Nephrologists play a critical role in specific clinical scenarios:

• Advanced chronic kidney disease (eGFR <30 mL/min/1.73 m²) requires nephrologist consultation for management of kidney disease progression and discussion of renal replacement therapy 1
• Recurrent stone formers benefit from comprehensive metabolic evaluation including 24-hour urine studies to guide medical prevention strategies 4, 5
• Complex metabolic disorders such as primary hyperparathyroidism, renal tubular acidosis, or cystinuria require nephrologist expertise 4
• Uncertainty about kidney disease etiology or difficult management issues (electrolyte disturbances, resistant hypertension) warrant nephrologist referral 1

Practical Algorithm for Referral Decisions

For acute symptomatic stones:

• Refer to urology for stones requiring intervention (failed medical expulsive therapy after 4-6 weeks, stones >10 mm, or patient preference for earlier intervention) 1
• Urgent urology referral is mandatory for obstructing stones with suspected infection, as urgent drainage with stent or nephrostomy is required before definitive treatment 2, 3

For stone prevention and metabolic management:

• Refer to nephrology when eGFR <30 mL/min/1.73 m² or when recurrent stones occur despite standard preventive measures 1, 5
• High-risk patients (family history, solitary kidney, malabsorption, intestinal disease) benefit from nephrologist-directed metabolic testing 6, 4

Common Pitfalls to Avoid

Do not delay urologic referral when conservative management fails after 4-6 weeks, as complete unilateral ureteral obstruction beyond this timeframe risks irreversible kidney injury 1

Do not refer to nephrology alone for acute obstructing stones requiring surgical intervention—urologists must perform the definitive procedures 1, 2

Do not overlook the need for both specialists in patients with recurrent stones and CKD, as this represents a complex condition requiring multidisciplinary care from both urologists (for stone removal) and nephrologists (for kidney preservation and metabolic management) 1, 4