Surgical Management of Stones

1. Clinicians should obtain a non-contrast CT scan on patients prior to performing PCNL.

2. Clinicians may obtain a non-contrast CT scan to help select the best candidate for SWL versus URS.

3. Clinicians may obtain a functional imaging study (DTPA or MAG‐3) if clinically significant loss of renal function in the involved kidney or kidneys is suspected.

4. Clinicians are required to obtain a urinalysis prior to intervention. In patients with clinical or laboratory signs of infection, urine culture should be obtained.

5. Clinicians should obtain a CBC and platelet count on patients undergoing procedures where there is a significant risk of hemorrhage or for patients with symptoms suggesting anemia, thrombocytopenia or infection; serum electrolytes and creatinine should be obtained if there is suspicion of reduced renal function.

6. In patients with complex stones or anatomy, clinicians may obtain additional contrast imaging if further definition of the collecting system and the ureteral anatomy is needed.

23. When residual fragments are present, clinicians should offer patients endoscopic procedures to render the patients stone-free, especially if infection stones are suspected.

24. Stone material should be sent for analysis.

26. Open/laparoscopic/robotic surgery should not be offered as first-line therapy to most patients with stones. Exceptions include rare cases of anatomic abnormalities, with large or complex stones, or those requiring concomitant reconstruction.

36. A safety guide wire should be used for most endoscopic procedures.

37. Antimicrobial prophylaxis should be administered prior to stone intervention and is based primarily on prior urine culture results, the local antibiogram, and in consultation with the current Best Practice Policy Statement on Urologic Surgery Antibiotic Prophylaxis.

38. Clinicians should abort stone removal procedures, establish appropriate drainage, continue antibiotic therapy, and obtain a urine culture if purulent urine is encountered during endoscopic intervention.

41. If initial SWL fails, clinicians should offer endoscopic therapy as the next treatment option.

42. Clinicians should use URS as first-line therapy in most patients who require stone intervention in the setting of uncorrected bleeding diatheses or who require continuous anticoagulation/antiplatelet therapy.

46. In pediatric patients with uncomplicated ureteral stones ≤10 mm, clinicians should offer observation with or without MET using α-blockers.

47. Clinicians should offer URS or SWL for pediatric patients with ureteral stones who are unlikely to pass the stones or who failed observation and/or MET, based on patient-specific anatomy and body habitus.

48. Clinicians should obtain a low-dose CT scan on pediatric patients prior to performing PCNL.

49. In pediatric patients with ureteral stones, clinicians should not routinely place a stent prior to URS.

50. In pediatric patients with a total renal stone burden ≤20mm, clinicians may offer SWL or URS as first-line therapy.

51. In pediatric patients with a total renal stone burden >20mm, both PCNL and SWL are acceptable treatment options. If SWL is utilized, clinicians should place an internalized ureteral stent or nephrostomy tube.

52. In pediatric patients, except in cases of coexisting anatomic abnormalities, clinicians should not routinely perform open/laparoscopic/robotic surgery for upper tract stones.

53. In pediatric patients with asymptomatic and non-obstructing renal stones, clinicians may utilize active surveillance with periodic ultrasonography.

54. In pregnant patients, the clinician should coordinate pharmacological and surgical intervention with the obstetrician.

55. In pregnant patients with ureteral stones and well controlled symptoms, clinicians should offer observation as first-line therapy.

56. In pregnant patients with ureteral stones, clinicians may offer URS to patients who fail observation. Ureteral stent and nephrostomy tube are alternative options, with frequent stent or tube changes usually being necessary.