• The Review Course in Family Medicine

The Top 8 Guideline Updates for Managing Ureteric Calculi

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.