Surgical removal of kidney stones

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.

 

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.

 

 

1. NICE guideline (2019) Renal and ureteric stones: assessment and management [NG118]
2. Harrison S (2018) Urology, GIRFT Programme National Specialty Report. GIRFT

Last revised December 2023

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