Treatment selection for urolithiasis: percutaneous nephrolithomy, ureteroscopy, shock wave lithotripsy, and active monitoring

Urolithiasis is a significant worldwide source of morbidity, constituting a common urological disease that affects between 10 and 15% of the world population. Recent technological and surgical advances have replaced the need for open surgery with less invasive procedures. The factors which determine the indications for percutaneous nephrolithotomy include stone factors (stone size, stone composition, and stone location), patient factors (habitus and renal anomalies), and failure of other treatment modalities (ESWL and flexible ureteroscopy). The accepted indications for PCNL are stones larger than 20 mm(2), staghorn and partial staghorn calculi, and stones in patients with chronic kidney disease. The contraindications for PCNL include pregnancy, bleeding disorders, and uncontrolled urinary tract infections. Flexible ureteroscopy can be one of the options for lower pole stones between 1.5 and 2 cm in size. This option should be exercised in cases of difficult lower polar anatomy and ESWL-resistant stones. Flexible ureteroscopy can also be an option for stones located in the diverticular neck or a diverticulum. ESWL is the treatment to be discussed as a option in all patient with renal stones (excluding lower polar stones) between size 10 and 20 mm. In addition, in lower polar stones of size between 10 and 20 mm if the anatomy is favourable, ESWL is the option. In proximal ureteral stones, ESWL should be considered as a option with flexible ureteroscopy Active monitoring has a limited role and can be employed in post-intervention (PCNL or ESWL) residual stones, in addition, asymptomatic patients with no evidence of infection and fragments less than 4 mm can be monitored actively.

World journal of urology. 2017 Mar 16 [Epub ahead of print]

Mahesh Desai, Yinghao Sun, Noor Buchholz, Andrew Fuller, Tadashi Matsuda, Brian Matlaga, Nicole Miller, Damien Bolton, Mohammad Alomar, Arvind Ganpule

Muljibhai Patel Urological Hospital, Dr Virendra Desai Road, Nadiad, Gujarat, India. ., Department of Urology, Changhai Hospital the First Affiliated Hospital of the Second Military Medical University (SMMU), Shanghai, China., Sobeh Medical Center, Dubai Health Care City, Dubai, United Arab Emirates., South Terrace Urology, 326 South Terrace, Adelaide, 5000, Australia., Department of Urology and Andrology, Kansai Medical University Hospital, Kansai Medical University, Shin-machi 2-5-1, Hirakata, Osaka, 573-1010, Japan., The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, MD, 21287, USA., Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, 37232-2765, USA., University of Melbourne, Melbourne, Australia., King Saud University, Riyadh, Saudi Arabia., Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India.