AUA Guidelines
Should obtain ___ prior to PCNL - answer on-contrast CT
May obtain ___ to decide between URS or SWL – answer Non-contrast CT
May obtain ___ if clinically significant loss of renal function suspected prior to stone
treatment - answerNM renal scan
Required to obtain ____ prior to stone intervention – answer UA; if clinical signs of
infection, then urine culture is indicated
If significant risk of hemorrhage with stone treatment is suspected or patient suspected
of thrombocytopenia, anemia, infection, should obtain: - answerCBC; serum
electrolytes/creatinine if suspected decreased renal function
Surgical management of adult uncomplicated ureteral stone ≤10 mm - answer
Observation (MET if distal); Should obtain re-imaging prior to surgery if passage of
stone is suspected or if stone movement will change management; target ROI and
reduce radiation exposure to uninvolved organs
If MET not successful after 4-6 weeks: - answerClinicians should offer definitive surgical
treatment (or if patient/clinician decide with shared decision-making to intervene sooner)
Should inform adult ureteral stone patients that ___ is procedure of least morbidity and
lowest complication rate, but ___ has greater stone-free rate in a single procedure -
answerSWL; URS
Mid- or distal-ureteral stone that requires intervention (not candidates for or failed MET)
— should offer: - answerURS as first-line therapy; for patients who decline URS, should
offer SWL
____ recommended for patients with suspected cystine or uric acid ureteral stones who
fail MET or desire intervention - answerURS
Routine stenting ___ (should/should not) be performed in patients undergoing SWL -
answerShould not
May omit ureteral stenting in patients who meet all of the following criteria: (5) -
answerNo suspected injury during URS, No ureteral stricture or other anatomical
impediment to stone passage, Normal contralateral kidney, No renal function
impairment, No secondary URS procedure planned
,___ (Need/no need) to routinely place ureteral stent prior to URS - answerNo need
May offer ___ to reduce stent discomfort - answerα-blockers and antimuscarinic therapy
If patients who fail or are unlikely to have success with SWL or URS, clinicians may
offer: - answerPCNL, laparoscopic, open, or robotic assisted stone removal
Should not offer ___ as first-line lithotripsy modality for ureteral stones - answerEHL
(electrohydrolic)
If obstructing stone and suspected infection, clinicians must: - answerUrgently drain
collecting system with ureteral stent or nephrostomy tube and delay stone treatment
Symptomatic patients total non-lower pole stone burden ≤ 2 cm, clinicians may offer: -
answerSWL or URS
Symptomatic patients total stone burden > 2 cm, clinicians should offer: - answerPCNL
as first-line therapy; should not offer SWL as first-line for any patient with total stone
burden > 2 cm
May perform ___ when involved kidney with nephrolithiasis has negligible function in
patients requiring treatment - answerNephrectomy
For symptomatic patients (flank pain) with non-obstructing, caliceal stones without
obvious etiology for pain: - answerClinicians may offer treatment
For asymptomatic patients with non-obstructing, caliceal stones: - answerClinicians may
offer active surveillance
Symptomatic ≤ 10 mm lower-pole renal stone, clinicians should offer: - answerSWL or
URS
Should not offer ___ as first-line therapy for > 10 mm lower pole stone - answerSWL
Should inform patients with > 10 mm lower pole stone that ___ has higher stone free
rate but greater morbidity - answerPCNL
When is nephrostomy tube placement optional after PCNL? - answerIn patients who
undergo uncomplicated PCNL and are presumed stone-free post-op
___ should be a routine part of standard PCNL - answerFlexible nephroscopy
Must use ___ for PCNL and URS - answerNormal saline irrigation
In patients not considered candidates for PCNL, clinicians may offer: - answerStaged
URS
, Clinicians may offer ___ to facilitate passage of stone fragments following SWL -
answerα-blockers
SWL should not be used in patients with: - answerAnatomic or functional obstruction of
collecting system or ureter distal to the stone
Symptomatic caliceal diverticular stones should be managed with: - answerEndoscopic
therapy (URS, PCNL, laparoscopic, robotic)
Staghorn stones should be removed if: - answerAttendant comorbidities do not preclude
treatment
Should offer ___ in uncomplicated pediatric ureteral stones ≤ 10 mm -
answerObservation +/- MET with α-blockers (B)
Should offer ___ for pediatric stones unlikely to pass or failed observation/MET based
on patient-specific anatomy and body habits - answerURS or SWL (B)
Should obtain ___ prior to performing PCNL on pediatric patient - answerLow-dose CT
(C)
___ (Should/Should not) routinely place a stent prior to URS for pediatric ureteral stones
- answerShould not (EO)
May offer ___ as first-line therapy for total renal stone burden ≤ 2 cm in pediatric patient
- answerSWL or URS (C)
Management options for pediatric patients with total renal stone burden > 2 cm: -
answerBoth PCNL and SWL are acceptable treatment options; If SWL is utilized,
clinicians should place internalized ureteral stent or nephrostomy tube (EO)
Clinicians should not routinely perform open/laparoscopic/robotic surgery for upper tract
stones in pediatric patients except in cases of: - answerCoexisting anatomic
abnormalities (EO)
May utilize ___ for asymptomatic and non-obstructing renal stones in pediatric patients -
answerActive surveillance with periodic U/S (EO)
In pregnant patient with ureteral or renal stone(s), clinician should coordinate: -
answerPharmacological and surgical intervention with the obstetrician (CP)
In pregnant patient with ureteral or renal stone(s), clinician should offer: -
answerObservation as first-line therapy for ureteral stones and well-controlled
symptoms (B)
Should obtain ___ prior to PCNL - answer on-contrast CT
May obtain ___ to decide between URS or SWL – answer Non-contrast CT
May obtain ___ if clinically significant loss of renal function suspected prior to stone
treatment - answerNM renal scan
Required to obtain ____ prior to stone intervention – answer UA; if clinical signs of
infection, then urine culture is indicated
If significant risk of hemorrhage with stone treatment is suspected or patient suspected
of thrombocytopenia, anemia, infection, should obtain: - answerCBC; serum
electrolytes/creatinine if suspected decreased renal function
Surgical management of adult uncomplicated ureteral stone ≤10 mm - answer
Observation (MET if distal); Should obtain re-imaging prior to surgery if passage of
stone is suspected or if stone movement will change management; target ROI and
reduce radiation exposure to uninvolved organs
If MET not successful after 4-6 weeks: - answerClinicians should offer definitive surgical
treatment (or if patient/clinician decide with shared decision-making to intervene sooner)
Should inform adult ureteral stone patients that ___ is procedure of least morbidity and
lowest complication rate, but ___ has greater stone-free rate in a single procedure -
answerSWL; URS
Mid- or distal-ureteral stone that requires intervention (not candidates for or failed MET)
— should offer: - answerURS as first-line therapy; for patients who decline URS, should
offer SWL
____ recommended for patients with suspected cystine or uric acid ureteral stones who
fail MET or desire intervention - answerURS
Routine stenting ___ (should/should not) be performed in patients undergoing SWL -
answerShould not
May omit ureteral stenting in patients who meet all of the following criteria: (5) -
answerNo suspected injury during URS, No ureteral stricture or other anatomical
impediment to stone passage, Normal contralateral kidney, No renal function
impairment, No secondary URS procedure planned
,___ (Need/no need) to routinely place ureteral stent prior to URS - answerNo need
May offer ___ to reduce stent discomfort - answerα-blockers and antimuscarinic therapy
If patients who fail or are unlikely to have success with SWL or URS, clinicians may
offer: - answerPCNL, laparoscopic, open, or robotic assisted stone removal
Should not offer ___ as first-line lithotripsy modality for ureteral stones - answerEHL
(electrohydrolic)
If obstructing stone and suspected infection, clinicians must: - answerUrgently drain
collecting system with ureteral stent or nephrostomy tube and delay stone treatment
Symptomatic patients total non-lower pole stone burden ≤ 2 cm, clinicians may offer: -
answerSWL or URS
Symptomatic patients total stone burden > 2 cm, clinicians should offer: - answerPCNL
as first-line therapy; should not offer SWL as first-line for any patient with total stone
burden > 2 cm
May perform ___ when involved kidney with nephrolithiasis has negligible function in
patients requiring treatment - answerNephrectomy
For symptomatic patients (flank pain) with non-obstructing, caliceal stones without
obvious etiology for pain: - answerClinicians may offer treatment
For asymptomatic patients with non-obstructing, caliceal stones: - answerClinicians may
offer active surveillance
Symptomatic ≤ 10 mm lower-pole renal stone, clinicians should offer: - answerSWL or
URS
Should not offer ___ as first-line therapy for > 10 mm lower pole stone - answerSWL
Should inform patients with > 10 mm lower pole stone that ___ has higher stone free
rate but greater morbidity - answerPCNL
When is nephrostomy tube placement optional after PCNL? - answerIn patients who
undergo uncomplicated PCNL and are presumed stone-free post-op
___ should be a routine part of standard PCNL - answerFlexible nephroscopy
Must use ___ for PCNL and URS - answerNormal saline irrigation
In patients not considered candidates for PCNL, clinicians may offer: - answerStaged
URS
, Clinicians may offer ___ to facilitate passage of stone fragments following SWL -
answerα-blockers
SWL should not be used in patients with: - answerAnatomic or functional obstruction of
collecting system or ureter distal to the stone
Symptomatic caliceal diverticular stones should be managed with: - answerEndoscopic
therapy (URS, PCNL, laparoscopic, robotic)
Staghorn stones should be removed if: - answerAttendant comorbidities do not preclude
treatment
Should offer ___ in uncomplicated pediatric ureteral stones ≤ 10 mm -
answerObservation +/- MET with α-blockers (B)
Should offer ___ for pediatric stones unlikely to pass or failed observation/MET based
on patient-specific anatomy and body habits - answerURS or SWL (B)
Should obtain ___ prior to performing PCNL on pediatric patient - answerLow-dose CT
(C)
___ (Should/Should not) routinely place a stent prior to URS for pediatric ureteral stones
- answerShould not (EO)
May offer ___ as first-line therapy for total renal stone burden ≤ 2 cm in pediatric patient
- answerSWL or URS (C)
Management options for pediatric patients with total renal stone burden > 2 cm: -
answerBoth PCNL and SWL are acceptable treatment options; If SWL is utilized,
clinicians should place internalized ureteral stent or nephrostomy tube (EO)
Clinicians should not routinely perform open/laparoscopic/robotic surgery for upper tract
stones in pediatric patients except in cases of: - answerCoexisting anatomic
abnormalities (EO)
May utilize ___ for asymptomatic and non-obstructing renal stones in pediatric patients -
answerActive surveillance with periodic U/S (EO)
In pregnant patient with ureteral or renal stone(s), clinician should coordinate: -
answerPharmacological and surgical intervention with the obstetrician (CP)
In pregnant patient with ureteral or renal stone(s), clinician should offer: -
answerObservation as first-line therapy for ureteral stones and well-controlled
symptoms (B)
