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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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**# '''<span style="color:#ff0000">Those in whom another ipsilateral URS is planned</span>'''
**# '''<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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*** '''<span style="color:#ff0000">10-20mm: PCNL (first-line) or URS (no SWL)</span>'''
*** '''<span style="color:#ff0000">10-20mm: PCNL (first-line) or URS (no SWL)</span>'''
* '''<span style="color:#ff0000">Symptomatic, total stone burden >20mm: PCNL (first-line) or URS (option) (no SWL)</span>'''
* '''<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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