Surgical removal of kidney stones
Best Practice Guidance
Urinary tract stones are amongst the most common condition dealt with by urologists with an estimated 6,000 patients admitted to hospital per year with the condition. Shockwave lithotripsy (SWL) is a non-surgical technique for treating these stones in the kidney or ureter. The technique uses high energy shockwaves to break the stones into smaller fragments which can then pass spontaneously.
Stones can be observed to see if they pass spontaneously, or treated with shockwave lithotripsy, or surgical techniques such as ureteroscopy (URS) and percutaneous stone surgery (PCNL), both of which may involve placing a stent.
The optimal management depends on the type, size and location of the stone as well as patient factors such as co-morbidity and pregnancy. For appropriate stones SWL is advantageous as it is non-invasive and so has fewer major adverse events than surgery.
This guidance applies to adults aged 19 years and over.
Please refer to NICE Guidance [NG118] (recommendation 1.5) Renal and ureteric stones: assessment and management.
Adult renal stones
<5mm: If asymptomatic consider watchful waiting
5-10mm: If not suitable for watchful waiting offer SWL as first-line treatment (unless contra-indicated or not targetable)
10-20mm: Consider SWL as first-line treatment if treatment can be given in a timely fashion. URS can also be considered if SWL is contraindicated or ineffective
Over 20mm (including staghorn): Offer percutaneous nephrolithotomy (PCNL) as first-line treatment
Adult ureteric stones
<5mm: If asymptomatic consider watchful waiting with medical therapy e.g. Alpha blocker for use with distal ureteric stones
5-10mm: Offer SWL as first-line treatment where it can be given in a timely fashion (unless contra-indicated or not targetable)
10-20mm: Offer URS but consider SWL if local facilities allow stone clearance within 4 weeks.
Rationale for recommendation
ESWL will not always be possible due to lack of access to a lithotripter or appropriately trained staff. As it is often the optimal treatment, hospitals should consider purchasing this equipment or liaising with neighbouring hospitals which do have these facilities.
Adult renal stones
Asymptomatic renal stones less than 5mm may pass spontaneously and so this carries less risk than intervention in the first instance. Watchful waiting for larger stones carries greater risk but in patients with co-morbidities should still be considered as these risks may be less than those of intervention.
For renal stones less than 10mmm SWL has shorter hospital stays, less pain and fewer major adverse events compared to URS, although URS normally needs fewer treatments. Overall as SWL is non-invasive with fewer major adverse events this should be considered first-line treatment. For renal stones between 10mm and 20mm the optimal strategy depends on the stone but would be either SWL or URS. Because SWL is non-invasive with fewer major adverse events this could be considered before URS if treatments can be given in a timely fashion so minimising delay between treatments and SWL is not contraindicated.
Adult ureteric stones
For Ureteric stones less than 10mm SWL showed benefits in terms of readmission and fewer major adverse events although URS had lower retreatment rates. When a stent is used this is often only a temporary measure with additional surgery required to remove the stone. Therefore, SWL should be considered first-line when it is not contra-indicated and the stone is targetable.
For ureteric stones between 10mm and 20mm URS should be offered, though because SWL has been shown to result in shorter hospital stays, less pain and fewer adverse events, it could be considered if stone clearance is possible within four weeks.
There is no specific EBI patient guidance for this intervention.
However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.
Further information on patient involvement in EBI can be found on the EBI for patients section.
WHEN LEFT(der.Spell_Dominant_Procedure,4) in ('M071','M072','M078','M091','M092','M093','M094','M098','M261','M262','M2 63','M268','M271','M272','M273','M278','M284','M285','M288','M289’) AND (der.Spell_Primary_Diagnosis like '%N132%’ OR der.Spell_Primary_Diagnosis like '%N20%’) AND isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120 THEN '2G_kidney_stone_surgery'
Procedure codes (OPCS)
M071 Ureteroscopic laser fragmentation of calculus of kidney
M072 Ureteroscopic extraction of calculus of kidney NEC
M078 Other specified therapeutic ureteroscopic operations on kidney
M091 Endoscopic ultrasound fragmentation of calculus of kidney
M092 Endoscopic electrohydraulic shockwave fragmentation of calculus of kidney
M093 Endoscopic laser fragmentation of calculus of kidney
M094 Endoscopic extraction of calculus of kidney NEC
M098 Other specified therapeutic endoscopic operations on calculus of kidney
M261 Nephroscopic laser fragmentation of calculus of ureter
M262 Nephroscopic fragmentation of calculus of ureter NEC
M263 Nephroscopic extraction of calculus of ureter
M268 Other specified therapeutic nephroscopic operations on ureter
M271 Ureteroscopic laser fragmentation of calculus of ureter
M272 Ureteroscopic fragmentation of calculus of ureter NEC
M273 Ureteroscopic extraction of calculus of ureter
M278 Other specified therapeutic ureteroscopic operations on ureter
M284 Endoscopic catheter drainage of calculus of ureter
M285 Endoscopic drainage of calculus of ureter by dilation of ureter
M288 Other specified other endoscopic removal of calculus from ureter
M289 Unspecified other endoscopic removal of calculus from ureter
Diagnosis codes (ICD)
N132 Hydronephrosis with renal and ureteral calculous obstruction
N200 Calculus of kidney
N201 Calculus of ureter
N202 Calculus of kidney with calculus of ureter
N209 Urinary calculus, unspecified
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and apcs.der_diagnosis_all not like '%D0%' and apcs.der_diagnosis_all not like '%D3%' and apcs.der_diagnosis_all not like '%D4%’
This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
— Private Appointment Exclusion
- NICE guideline (2019) Renal and ureteric stones: assessment and management [NG118]
- Harrison S (2018) Urology, GIRFT Programme National Specialty Report. GIRFT
How up to date is this information?
Last revised December 2023
December 2023 - Coding update. August 2022 - Coding updated