Editing AUA: Stone Surgery (2016) (section)

=== Symptomatic ===
* '''Total stone burden ≤20mm'''
** '''Non-lower pole stone'''
*** '''Recommended options: SWL or URS'''
**** '''Treatment options for patients with a <20 mm non-lower pole renal stone burden include SWL, URS, and PCNL'''. Of these, PCNL stone-free rates are the least affected by stone size, while stone-free rates of both SWL and URS decline with increasing stone burden. However, '''for stone burdens <20mm, stone-free rates of both URS and SWL are acceptable and have less morbidity compared to PCNL'''.
** '''Lower pole stone'''
*** '''≤ 10 mm'''
**** '''Recommended options: SWL or URS'''
***** An RCT found that there was no significant difference between the stone-free rates with URS vs. SWL. Intraoperative complications were higher with URS, and patient-derived QoL measures were better with SWL in this trial.
***** '''CT imaging parameters should be used for patient selection.'''
*** '''> 10mm'''
**** '''Recommended options: PCNL (preferred) or URS; SWL not recommended'''
***** '''Clinicians should inform patients with lower pole stones >10 mm in size that PCNL has a higher stone-free rate but greater morbidity [than URS].'''
***** '''PCNL should be considered the primary treatment'''
* '''Stone burden > 20 mm'''
** '''Recommended options: PCNL (first-line) or URS (option); SWL not recommended as first-line'''
*** Significantly reduced stone-free rates and increased need for multiple treatments for SWL compared to PCNL for patients with a total renal stone burden > 20 mm
**** Success of SWL is dependent on several other factors, including obesity, skin-to-stone distance, collecting system anatomy, stone composition and stone density/attenuation, which could also contribute to lower stone-free rates
**** The benefit of a higher stone-free rate must be weighed against the increased invasiveness and risk of complications for PCNL compared to URS or SWL.
***** 15% overall complication rate with PNCL, majority categorized as Clavien Grade I. '''Bleeding necessitating blood transfusion (7%) is the most common complication'''
**** The risk of ureteral obstruction from stone fragments (steinstrasse) increases
* '''Staghorn calculi'''
** '''PCNL is the first-line treatment'''