Editing AUA: Stone Surgery (2016) (section)

==== Intervention ====
* '''In patients with obstructing stones and suspected infection, clinicians must urgently drain the collecting system with a stent or nephrostomy tube and delay stone treatment'''
** Definitive management of the stone should not be undertaken until sepsis has resolved and the infection has been treated with an appropriate course of antibiotic therapy.
* '''Clinicians should offer reimaging to patients prior to surgery if passage of stones is suspected or if stone movement will change management'''
** ≈10% risk of negative URS for ureteral stones < 4 mm in a distal ureteral location
** '''Other factors that influence the decision to re-image a patient include time interval since prior imaging, pain, and presence of obstruction/hydronephrosis'''
** Reimaging should focus on the region of interest and limit radiation exposure to uninvolved regions
* '''<span style="color:#ff0000">Approach: URS vs. SWL for ureteric calculi</span>'''
** '''The patient should be informed of the advantages and disadvantages of SWL and URS''' (anesthesia requirements, stone-free rates, need for additional procedures, and associated complications of each procedure)
*** '''SWL is the procedure with the least morbidity and lowest complication rate'''
**** 2012 Cochrane Review comparing SWL and URS identified 7 RCTs '''significantly lower complication rate for SWL compared to URS'''
***** '''Ureteral perforation occurs significantly more frequently during URS than SWL'''
***** '''No difference with regard to UTI, sepsis, ureteral stricture, or ureteral avulsion'''
*** '''URS has a greater stone-free rate in a single procedure'''
**** '''Stone-free rates are higher for URS than SWL for all ureteral stones EXCEPT proximal ureteral stones >10 mm in size where stone-free rates are comparable'''
*** '''Patients should be informed about the possible need for stent placement after URS, and less commonly, after SWL, because this may influence their decisions'''
** '''<span style="color:#ff0000">Stone location</span>'''
*** '''<span style="color:#ff0000">Mid or distal ureter:</span>'''
**** '''<span style="color:#ff0000">URS is the recommended first-line therapy</span>'''
**** '''<span style="color:#ff0000">SWL is second-line therapy</span>'''
***** '''For women of child-bearing age with mid or distal ureteral calculi, URS is preferred, as the effects of shock wave energy on the ovary have not been completely elucidated'''
*** '''[Proximal ureter:]'''
**** '''[URS and SWL are options''']
***** '''For proximal ureteric stones < 10mm, stone-free rates with URS are superior than SWL'''
***** '''For proximal ureteric stones >10mm, stone-free rates are equivalanet'''
***** '''Therefore, the recommendation for first-line use of URS was not extended to proximal ureteral stones.'''
*** Alternative treatment options, such as open or laparoscopic ureterolithotomy, or antegrade URS via a percutaneous approach, are not preferred over SWL because of greater invasiveness.
** '''<span style="color:#ff0000">Stone Composition</span>'''
*** '''<span style="color:#ff0000">URS recommended over SWL for suspected cystine or uric acid ureteral stones</span>'''
**** '''Cystine stones are often only faintly radio-opaque and pure uric acid stones are typically radiolucent.''' Therefore, stone targeting with fluoroscopy may be problematic for SWL. Furthermore, cystine stones are typically resistant to SWL fragmentation
** '''In patients who fail or are unlikely to have successful results with SWL and/or URS, clinicians may offer PCNL, laparoscopic, open, or robotic assisted stone removal.'''