Recommendation 1: Manage stones <5mm nonoperatively and follow-up ensuring
passage. Persistent obstruction beyond 4-6 weeks indicates consideration for surgical
intervention. In cases of obstructive pyelonephritis, rapid intervention and early
decompression is critical.
Recommendation 2: Ultrasonography (US) with KUB x-ray should be considered the
initial imaging modality. It allows determination of stone composition and guides
treatment with minimal radiation exposure.
Recommendation 3: Medical expulsive therapy (MET) is better for distal and larger (5-
10mm) stones. Opioid-sparing analgesia is preferred as its efficacious with fewer
adverse events.
Recommendation 4: Forced intravenous (IV) hydration for the sole purpose of stone
expulsion is NOT recommended.
Recommendation 5: Shockwave lithotripsy is recommended first-line as it is equally
efficacious and cheaper than ureteroscopy (URS). Optimal outcomes are governed by
stone location (proximal stones), stone composition (calcium oxalate), stone density
(<1000 HU) and distance below skin (<10cm). Guidelines recommend low-energy
shocks with gradual voltage escalation to an adequate number of shocks. Over two
failed attempts of SWL should prompt consideration for URS.
Recommendation 6: Post- SWL alpha blockers (e.g. tamsulosin) improve treatment
success rates and reduce time to stone passage. Alpha-blockers used pre-URS show
similar benefits.
BONUS! Special populations:
Recommendation 7: Children: US remains the first-line diagnostic modality for
children. This may be coupled with a KUB X-ray or ultra-low dose CT for increased
specificity. For stones <5 mm, a trial of passage is recommended for 2 weeks, and may
be combined with MET. For children requiring surgical intervention, both SWL and URS
are considered first-line, using a size <8 French in URS to minimize complications.
Recommendation 8: Pregnancy: First-line diagnostic testing in pregnancy is US, but
low-dose CT or gadolinium-free MRI can be considered. Obstructing stones can be
managed conservatively, given no underlying urinary infection. Patients with urosepsis
require antibiotics and urinary decompression via nephrostomy insertion or stenting.
URS with laser lithotripsy is safe to perform, while SWL is contraindicated for fetal risk.