AUA: Stone Surgery (2016): Difference between revisions
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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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** '''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 == | ||