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AUA: Stone Surgery (2016): Difference between revisions

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* This Guideline includes revisions of the previously published AUA Guidelines titled ‘Staghorn Calculi (2005)’ and ‘Ureteral Calculi (2007)’ and is expanded to incorporate the management of patients with non-staghorn renal stones
* This Guideline includes revisions of the previously published AUA Guidelines titled ‘Staghorn Calculi (2005)’ and ‘Ureteral Calculi (2007)’ and is expanded to incorporate the management of patients with non-staghorn renal stones
'''*****All of the information below is contained in the more comprehensive'''
* '''[[Stones: Surgical Modalities for Management of Upper Urinary Tract Calculi|Surgical Modalities for Management of Upper Urinary Tract Calculi Chapter Notes]]'''
* [[Stones: Treatment Selection for Upper Urinary Tract Calculi|'''Treatment Selection for Upper Urinary Tract Calculi Chapter Notes''']]
* [[Stones During Pregnancy|'''Stones During Pregnancy Chapter Notes''']]
* '''NOT included elsewhere is [https://test.urologyschool.com/index.php/AUA:_Stone_Surgery_(2016)#Pediatrics Pediatric Stone Disease] (see below)'''
'''*****'''


== Investigations Prior to Treatment ==
== Investigations Prior to Treatment ==
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==== Conservative treatment ====
==== Conservative treatment ====
* '''Observation'''
* '''Observation'''
** '''Patients with uncomplicated [any location] ureteral stones <10 mm should be offered observation; [different than 2015 CUA Ureteric Calculi guidelines which suggest intervention for stone >5mm]'''
** '''<span style="color:#ff0000">Patients with uncomplicated [any location] ureteral stones <10 mm should be offered observation; </span>[different than 2015 CUA Ureteric Calculi guidelines which suggest intervention for stone >5mm]'''
*** A trial of spontaneous passage is reasonable in patients amenable to conservative therapy with distal ureteral stones <10 mm in whom pain is well controlled and there are no signs of infection or high-grade obstruction.
*** A trial of spontaneous passage is reasonable in patients amenable to conservative therapy with distal ureteral stones <10 mm in whom pain is well controlled and there are no signs of infection or high-grade obstruction.
**** The smaller the stone and the more distally in the ureter the stone is located, the greater the likelihood of spontaneous passage
**** The smaller the stone and the more distally in the ureter the stone is located, the greater the likelihood of spontaneous passage
**** The control arms of RCTs evaluating tamsulosin as MET show that ≈50% of patients with distal ureteral calculi <10 mm in size will spontaneously pass their stones
**** The control arms of RCTs evaluating tamsulosin as MET show that ≈50% of patients with distal ureteral calculi <10 mm in size will spontaneously pass their stones
* '''Medical expulsive therapy'''
* '''Medical expulsive therapy'''
**'''Patients with uncomplicated distal ureteral stones <10mm should be offered medical expulsive therapy (MET) with α-blockers [same as 2015 CUA Ureteric Calculi Guidelines]'''
**'''<span style="color:#ff0000">Patients with uncomplicated distal ureteral stones <10mm should be offered medical expulsive therapy (MET) with α-blockers </span>[same as 2015 CUA Ureteric Calculi Guidelines]'''
***Ureteral contractility is mediated by both α and β adrenoreceptors in the ureteral wall. Stimulation of α1-receptors promotes contraction of ureteral smooth muscle, leading to more vigorous and frequent peristalsis. α1-antagonists have the potential to inhibit ureteral spasm and uncontrolled contraction, theoretically reducing pain and promoting spontaneous stone passage.
***Ureteral contractility is mediated by both α and β adrenoreceptors in the ureteral wall. Stimulation of α1-receptors promotes contraction of ureteral smooth muscle, leading to more vigorous and frequent peristalsis. α1-antagonists have the potential to inhibit ureteral spasm and uncontrolled contraction, theoretically reducing pain and promoting spontaneous stone passage.
****'''In patients with <10 mm distal ureteral stones, spontaneous stone passage rates improves with α-blockers compared to no treatment (ARR: 23%, 77% α-blockers vs. 54% placebo or no treatment)'''
****'''In patients with <10 mm distal ureteral stones, spontaneous stone passage rates improves with α-blockers compared to no treatment (ARR: 23%, 77% α-blockers vs. 54% placebo or no treatment)'''
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****Insufficient supporting data for the utilization of this agent for MET.
****Insufficient supporting data for the utilization of this agent for MET.
***Patients should be informed that '''medications for MET are prescribed off-label'''
***Patients should be informed that '''medications for MET are prescribed off-label'''
**'''MET can be considered an option in patients with an uncomplicated middle or proximal ureteric calculi <10mm; [2015 CUA Ureteric Calculi Guidelines do not explicitly describe role of MET in these locations]'''
**'''<span style="color:#ff0000">MET can be considered an option in patients with an uncomplicated middle or proximal ureteric calculi <10mm; [2015 CUA Ureteric Calculi Guidelines do not explicitly describe role of MET in these locations]'''
*** No benefit of therapy based on the few α-blocker trials that included patients with middle and proximal ureteral calculi; therefore, use of MET for stones in the middle and proximal ureter could not be specifically endorsed. However, because of the low side effect profile of α-blockers and the demonstrated efficacy of α-blockers in patients with <10 mm stones in any location of the ureter, a trial of α-blockers in a patient with middle or proximal ureteric calculi <10mm, can be considered an option, despite the lack of demonstrable benefit
*** No benefit of therapy based on the few α-blocker trials that included patients with middle and proximal ureteral calculi; therefore, use of MET for stones in the middle and proximal ureter could not be specifically endorsed. However, because of the low side effect profile of α-blockers and the demonstrated efficacy of α-blockers in patients with <10 mm stones in any location of the ureter, a trial of α-blockers in a patient with middle or proximal ureteric calculi <10mm, can be considered an option, despite the lack of demonstrable benefit
* '''In most patients, definitive stone treatment should be offered if observation +/- MET is not successful after 4-6 weeks and/or the patient/clinician decide to intervene sooner'''
* '''<span style="color:#ff0000">In most patients, definitive stone treatment should be offered if observation +/- MET is not successful after 4-6 weeks and/or the patient/clinician decide to intervene sooner</span>'''
** '''Indications to proceed with surgical intervention (3):'''
** '''<span style="color:#ff0000">Indications to proceed with surgical intervention (3):</span>'''
**# '''Pain''': recurrent renal colic requiring repeated visits to the emergency department or hospital admission for parenteral analgesia
**# '''<span style="color:#ff0000">Pain</span>''': recurrent renal colic requiring repeated visits to the emergency department or hospital admission for parenteral analgesia
**# '''Worsening renal function'''
**# '''<span style="color:#ff0000">Worsening renal function</span>'''
**# '''Infection:''' evidence of urinary tract sepsis
**# '''<span style="color:#ff0000">Infection:</span>''' evidence of urinary tract sepsis
** A 6-week interval is recommended to reduce the potential for permanent damage. A previous study has also indicated that most stones destined to pass spontaneously will do so within 6 weeks. As such, there seems little benefit in continuing MET beyond this time interval.
** A 6-week interval is recommended to reduce the potential for permanent damage. A previous study has also indicated that most stones destined to pass spontaneously will do so within 6 weeks. As such, there seems little benefit in continuing MET beyond this time interval.


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** '''Other factors that influence the decision to re-image a patient include time interval since prior imaging, pain, and presence of obstruction/hydronephrosis'''
** '''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
** Reimaging should focus on the region of interest and limit radiation exposure to uninvolved regions
* '''Approach: URS vs. SWL for ureteric calculi'''
* '''<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)
** '''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'''
*** '''SWL is the procedure with the least morbidity and lowest complication rate'''
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**** '''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'''
**** '''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'''
*** '''Patients should be informed about the possible need for stent placement after URS, and less commonly, after SWL, because this may influence their decisions'''
** '''Stone location'''
** '''<span style="color:#ff0000">Stone location</span>'''
*** '''Mid or distal ureter:'''
*** '''<span style="color:#ff0000">Mid or distal ureter:</span>'''
**** '''URS is the recommended first-line therapy'''
**** '''<span style="color:#ff0000">URS is the recommended first-line therapy</span>'''
**** '''SWL is second-line therapy'''
**** '''<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'''
***** '''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:]'''
*** '''[Proximal ureter:]'''
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***** '''Therefore, the recommendation for first-line use of URS was not extended to proximal ureteral stones.'''
***** '''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.
*** 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.
** '''Stone Composition'''
** '''<span style="color:#ff0000">Stone Composition</span>'''
*** '''URS recommended over SWL for suspected cystine or uric acid ureteral stones'''
*** '''<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
**** '''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.'''
** '''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.'''
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**** 2019 AUA Update on Pediatric Urolithiasis: "When [SWL]used for renal stones >20 mm, a ureteral stent should be left in place to aid in stone passage and avoid steinstrasse."
**** 2019 AUA Update on Pediatric Urolithiasis: "When [SWL]used for renal stones >20 mm, a ureteral stent should be left in place to aid in stone passage and avoid steinstrasse."
*** '''In URS, stenting prior to treatment may improve stone-free rates and reduce operative times but does not override the added care costs and negative impact on quality of life associated with stents'''
*** '''In URS, stenting prior to treatment may improve stone-free rates and reduce operative times but does not override the added care costs and negative impact on quality of life associated with stents'''
* '''Post-intervention'''
* '''<span style="color:#ff0000">Post-intervention</span>'''
** '''Following URS, stent placement is strongly recommended in (5):'''
** '''<span style="color:#ff0000">Following URS, stent placement is strongly recommended in (5):</span>'''
**# '''Ureteric injury during URS'''
**# '''<span style="color:#ff0000">Ureteric injury during URS</span>'''
**# '''Evidence of ureteral stricture or other anatomical impediments to stone fragment clearance, such as ureteral wall edema'''
**# '''<span style="color:#ff0000">Evidence of ureteral stricture or other anatomical impediments to stone fragment clearance, such as ureteral wall edema</span>'''
**# '''Large stone burden (>1.5 cm)'''
**# '''<span style="color:#ff0000">Large stone burden (>1.5 cm)</span>'''
**# '''Anatomically or functionally solitary kidney or renal functional impairment'''
**# '''<span style="color:#ff0000">Anatomically or functionally solitary kidney or renal functional impairment</span>'''
**# '''Those in whom another ipsilateral URS is planned'''
**# '''<span style="color:#ff0000">Those in whom another ipsilateral URS is planned</span>'''
*** '''Ureteral stenting may be omitted in patients without any of the features above'''; stent placement after uncomplicated URS has also been shown in randomized trials to be unnecessary
*** '''Ureteral stenting may be omitted in patients without any of the features above'''; stent placement after uncomplicated URS has also been shown in randomized trials to be unnecessary
***The duration of ureteral stenting post-operatively should be minimized in order to reduce stent-related morbidity. In general, '''3-7 days of stenting is recommended following routine, uncomplicated ureteroscopic stone intervention'''
* '''α-blockers and anticholinergics therapy may be offered to reduce stent discomfort'''
* '''α-blockers and anticholinergics therapy may be offered to reduce stent discomfort'''
** Patients should be counseled about the possibility of post-operative stent discomfort
** Patients should be counseled about the possibility of post-operative stent discomfort
** Other medications that can be used to alleviate stent discomfort include bladder analgesics for dysuria, non-steroidal anti-inflammatory agents, and narcotic analgesics.
** Other medications that can be used to alleviate stent discomfort include bladder analgesics for dysuria, non-steroidal anti-inflammatory agents, and narcotic analgesics.
** The duration of ureteral stenting post-operatively should be minimized in order to reduce stent-related morbidity. In general, '''3-7 days of stenting is recommended following routine, uncomplicated ureteroscopic stone intervention'''


==== URS for ureteral stones ====
==== URS for ureteral stones ====
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** '''The holmium laser can be activated 0.5 mm from the urothelial surface without risk of injury.'''
** '''The holmium laser can be activated 0.5 mm from the urothelial surface without risk of injury.'''
** Due to a larger working area, EHL can safely be used in the kidney during PCNL, but the risk of perforation using this technology is still higher than other modalities. Therefore, care should be taken to avoid activation of the probe near the urothelial surface.
** Due to a larger working area, EHL can safely be used in the kidney during PCNL, but the risk of perforation using this technology is still higher than other modalities. Therefore, care should be taken to avoid activation of the probe near the urothelial surface.
== Treatment of Renal Stones ==
== Treatment of Renal Stones ==


=== UrologySchool.com summary ===
=== UrologySchool.com summary ===
* '''Asymptomatic, non-obstructing caliceal stones: active surveillance'''
* '''<span style="color:#ff0000">Asymptomatic, non-obstructing caliceal stones: active surveillance</span>'''
* '''Symptomatic, total stone burden < 20mm'''
* '''<span style="color:#ff0000">Symptomatic, total stone burden < 20mm</span>'''
** '''Non-lower pole: either SWL or URS''' are preferred over PCNL
** '''<span style="color:#ff0000">Non-lower pole: either SWL or URS</span>''' are preferred over PCNL
** '''Lower pole:'''
** '''<span style="color:#ff0000">Lower pole:</span>'''
*** '''≤10mm: SWL or URS'''
*** '''<span style="color:#ff0000">≤10mm: SWL or URS</span>'''
*** '''10-20mm: PCNL (first-line) or URS (no SWL)'''
*** '''<span style="color:#ff0000">10-20mm: PCNL (first-line) or URS (no SWL)</span>'''
* '''Symptomatic, total stone burden >20mm: PCNL (first-line) or URS (option) (no SWL)'''
* '''<span style="color:#ff0000">Symptomatic, total stone burden >20mm: PCNL (first-line) or URS (option) (no SWL)</span>'''
[[File:2019auastonesxpathway.jpg|alt=2019 AUA Guideline Algorithm of Selecting Surgical Treatment of Stones|center|thumb|734x734px|2019 AUA Guideline Algorithm of Selecting Surgical Treatment of Stones]]


=== Asymptomatic, non-obstructing caliceal stones ===
=== Asymptomatic, non-obstructing caliceal stones ===
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== PCNL ==
== PCNL ==


* '''Relative contraindications to PCNL (2):'''
* '''<span style="color:#ff0000">Relative contraindications to PCNL (2):</span>'''
*# '''Use of anti-coagulation or anti-platelet therapy that cannot be discontinued'''
*# '''<span style="color:#ff0000">Use of anti-coagulation or anti-platelet therapy that cannot be discontinued</span>'''
*# '''Anatomic derangements (e.g. contractures, flexion deformities) that may preclude positioning for PCNL'''
*# '''<span style="color:#ff0000">Anatomic derangements (e.g. contractures, flexion deformities) that may preclude positioning for PCNL</span>'''
** '''In patients not considered candidates for PCNL, clinicians may offer staged URS'''
** '''In patients not considered candidates for PCNL, clinicians may offer staged URS'''
* '''Clinicians must use normal saline irrigation for PCNL and URS'''
* '''Clinicians must use normal saline irrigation for PCNL and URS'''
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** In an RCT, stone-free rate was higher in patients that underwent concomitant flexible endoscopy with rigid nephroscopy during PCNL, compared to without concomitant flexible nephroscopy, 92.5% vs 70%.
** In an RCT, stone-free rate was higher in patients that underwent concomitant flexible endoscopy with rigid nephroscopy during PCNL, compared to without concomitant flexible nephroscopy, 92.5% vs 70%.
* '''In patients undergoing uncomplicated PCNL who are presumed stone-free, placement of a nephrostomy tube is optional'''
* '''In patients undergoing uncomplicated PCNL who are presumed stone-free, placement of a nephrostomy tube is optional'''
** '''Purpose of the nephrostomy tube following PCNL (4):'''
** '''<span style="color:#ff0000">Purpose of the nephrostomy tube following PCNL (4):</span>'''
**# '''Aid in healing of the nephrostomy tract'''
**# '''<span style="color:#ff0000">Aid in healing of the nephrostomy tract</span>'''
**# '''Promote hemostasis'''
**# '''<span style="color:#ff0000">Promote hemostasis</span>'''
**# '''Prevent extravasation of urine'''
**# '''<span style="color:#ff0000">Prevent extravasation of urine</span>'''
**# '''Allow for re-entry into the collecting system should a secondary procedure be necessary'''
**# '''<span style="color:#ff0000">Allow for re-entry into the collecting system should a secondary procedure be necessary</span>'''
** '''In the appropriately selected patient, "tubeless" PCNL can result in similar stone-free and complication rates as standard PCNL.'''
** '''In the appropriately selected patient, "tubeless" PCNL can result in similar stone-free and complication rates as standard PCNL.'''
*** '''“Tubeless” PCNL is a term used to describe the scenario when no nephrostomy tube is inserted at the end of the procedure. Renal drainage can be established with an indwelling or externalized stent, or the patient can be left without a stent.'''
*** '''“Tubeless” PCNL is a term used to describe the scenario when no nephrostomy tube is inserted at the end of the procedure. Renal drainage can be established with an indwelling or externalized stent, or the patient can be left without a stent.'''
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** '''NSAIDs (e.g., ketorolac) are contraindicated in pregnancy'''
** '''NSAIDs (e.g., ketorolac) are contraindicated in pregnancy'''
* '''URS may be performed in pregnant patients with ureteral stones who fail observation.''' '''Ureteral stent and nephrostomy tube are alternative options with frequent stent or tube changes usually being necessary.'''
* '''URS may be performed in pregnant patients with ureteral stones who fail observation.''' '''Ureteral stent and nephrostomy tube are alternative options with frequent stent or tube changes usually being necessary.'''
== References ==
* [https://pubmed.ncbi.nlm.nih.gov/27238616/ Assimos, Dean, et al. "Surgical management of stones: American urological association/endourological society guideline, PART I." ''The Journal of urology'' 196.4 (2016): 1153-1160.]
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