Editing AUA: Stone Surgery (2016) (section)

== Other considerations ==
* '''Uncorrected bleeding or patients who require continuous anticoagulation/antiplatelet therapy diatheses:'''
** '''URS should be used as first-line therapy in most patients who require stone intervention'''
* '''Symptomatic caliceal diverticular stones'''
** '''Endoscopic therapy (URS, PCNL, laparoscopic, robotic) should be preferentially utilized i.e. avoid SWL'''
* '''Staghorn stones'''
** '''Should be removed if attendant comorbidities do not preclude treatment.'''
*** '''Risks of untreated staghorn stones:'''
**** '''Deterioration of renal function, including loss of the involved kidney, end stage renal disease'''
**** '''Infectious complications'''
**** '''Mortality'''
*** Medical therapy and supportive care are considerations for those not thought to be operative candidates.
* '''When residual fragments are present, clinicians should offer patients endoscopic (URS or PCNL) procedures to render the patients stone-free, especially if infection stones are suspected.'''
** '''Untreated struvite stones have a high likelihood of stone growth and recurrent infections'''. These “infection stones” may grow to a large size, often filling a large portion or the entire renal collecting system (i.e., staghorn calculus). '''Such stones may cause persistent infection and chronic obstruction, ultimately leading to severe renal damage with the possibility of life-threatening sepsis'''. Removal of suspected infection stones or infected stone fragments may significantly limit the possibility of further stone growth, recurrent UTI, or renal damage. An endoscopic approach, either URS or PCNL, offers the best chance of complete removal of infection stones.
** Non-surgical treatment with antibiotics, urease inhibitors, and other supportive measures only is not considered a viable alternative except in patients otherwise too ill to tolerate stone removal or when the residual fragments cannot be safely retrieved
* '''Stone treatment may be offered for patients with symptomatic (flank pain), non-obstructing, caliceal stones without another obvious etiology for pain.'''
** Whether non-obstructing caliceal stones can be a source of pain is controversial. Since there are published reports of eradication of flank pain with stone removal in this setting, the Panel feels that patients with pain and non-obstructing caliceal stones, without another obvious source of their pain, may be offered surgical intervention for stone treatment. '''The patient must be informed of the possibility that the pain may not improve or resolve after the procedure.'''
* '''Antimicrobial prophylaxis'''
** '''In the absence of a UTI, SWL does not require antimicrobial prophylaxis''' as no invasive procedure is performed
** '''Antibiotic prophylaxis is recommended for ureteroscopic stone removal and PCNL''' and is based primarily on prior urine culture results, the local antibiogram, and in consultation with the current Best Practice Policy Statement on Antibiotic Prophylaxis.
*** A single dose (oral or IV) of an antibiotic that covers gram positive and negative uropathogens is recommended is administered within 60 minutes of the procedure (and re-dosed during the procedure if the case length necessitates)
*** '''2019 AUA Antimicrobial Prophylaxis Guidelines:'''
**** '''Percutaneous renal surgery; e.g. PCNL; clean-contaminated: 1st/2nd gen. Cephalosporin, aminoglycoside''' (Aztreonam¥) '''+ Metronidazole, or Clindamycin'''
**** '''Ureteroscopy, all indications; clean-contaminated: TMP-SMX, 1st/2nd gen. Cephalosporin'''
*** The presence of unsuspected bacteria within stones may be one of the underlying causes for infectious complications after PCNL. It has been reported that many patients with negative voided urine cultures before PCNL have positive kidney stone cultures.
* '''If purulent urine is encountered during endoscopic intervention, stone removal procedures should be aborted, appropriate drainage should be established,''' antibiotics continued, and a urine culture should be obtained.
* '''Stone material should be sent for analysis'''
** An exception would be a patient who has had multiple recurrent stones that have been documented to be of similar stone composition and there is no clinical or radiographic evidence that stone composition has changed.