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

'''*****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 ==

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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."

*** '''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'''

* '''Post-intervention'''

** '''Following URS, stent placement is strongly recommended in (5):'''

** '''Following URS, stent placement is strongly recommended in (5):'''

**# '''Ureteric injury during URS'''

**# '''Ureteric injury during URS'''

**# '''Evidence of ureteral stricture or other anatomical impediments to stone fragment clearance, such as ureteral wall edema'''

**# '''Evidence of ureteral stricture or other anatomical impediments to stone fragment clearance, such as ureteral wall edema'''

**# '''Large stone burden (>1.5 cm)'''

**# '''Large stone burden (>1.5 cm)'''

**# '''Anatomically or functionally solitary kidney or renal functional impairment'''

**# '''Anatomically or functionally solitary kidney or renal functional impairment'''

**# '''Those in whom another ipsilateral URS is planned'''

**# '''Those in whom another ipsilateral URS is planned'''

*** '''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'''

** 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.

** 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 ====

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=== UrologySchool.com summary ===

* '''Asymptomatic, non-obstructing caliceal stones: active surveillance'''

* '''Asymptomatic, non-obstructing caliceal stones: active surveillance'''

* '''Symptomatic, total stone burden < 20mm'''

* '''Symptomatic, total stone burden < 20mm'''

** '''Non-lower pole: either SWL or URS''' are preferred over PCNL

** '''Non-lower pole: either SWL or URS''' are preferred over PCNL

** '''Lower pole:'''

** '''Lower pole:'''

*** '''≤10mm: SWL or URS'''

*** '''≤10mm: SWL or URS'''

*** '''10-20mm: PCNL (first-line) or URS (no SWL)'''

*** '''10-20mm: PCNL (first-line) or URS (no SWL)'''

* '''Symptomatic, total stone burden >20mm: PCNL (first-line) or URS (option) (no SWL)'''

* '''Symptomatic, total stone burden >20mm: PCNL (first-line) or URS (option) (no SWL)'''

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

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== PCNL ==

* '''Relative contraindications to PCNL (2):'''

* '''Relative contraindications to PCNL (2):'''

*# '''Use of anti-coagulation or anti-platelet therapy that cannot be discontinued'''

*# '''Use of anti-coagulation or anti-platelet therapy that cannot be discontinued'''

*# '''Anatomic derangements (e.g. contractures, flexion deformities) that may preclude positioning for PCNL'''

*# '''Anatomic derangements (e.g. contractures, flexion deformities) that may preclude positioning for PCNL'''

** '''In patients not considered candidates for PCNL, clinicians may offer staged 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 patients undergoing uncomplicated PCNL who are presumed stone-free, placement of a nephrostomy tube is optional'''

** '''Purpose of the nephrostomy tube following PCNL (4):'''

** '''Purpose of the nephrostomy tube following PCNL (4):'''

**# '''Aid in healing of the nephrostomy tract'''

**# '''Aid in healing of the nephrostomy tract'''

**# '''Promote hemostasis'''

**# '''Promote hemostasis'''

**# '''Prevent extravasation of urine'''

**# '''Prevent extravasation of urine'''

**# '''Allow for re-entry into the collecting system should a secondary procedure be necessary'''

**# '''Allow for re-entry into the collecting system should a secondary procedure be necessary'''

** '''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.'''

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** '''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.'''

== 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.]

@@ Line 8: / Line 8: @@
 * 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 ==
@@ Line 148: / Line 156: @@
 **** 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'''
-* '''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
+***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'''
 ** 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.
-** 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 ====
@@ Line 171: / Line 179: @@
 === 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 ===
@@ Line 232: / Line 241: @@
 == 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'''
 * '''Clinicians must use normal saline irrigation for PCNL and URS'''
@@ Line 244: / Line 253: @@
 ** 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'''
-** '''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.'''
 *** '''“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.'''
@@ Line 324: / Line 333: @@
 ** '''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.'''
+== 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.]