Urinary Stones · Stone Passage vs Lithotripsy/Removal + Approach

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Emergency? + site/size
   Emergency? + stone site and size? (Obstruction with infection is a urological emergency. Surgical indications: failed MET, persistent obstruction/pain, infection, renal impairment, solitary kidney.)
   • Obstruction + infection/sepsis, or solitary kidney/bilateral obstruction/AKI → Obstruction + infection → emergency drainage
   • Ureteric stone ≤10 mm, uncomplicated → ≤10 mm → medical expulsion (MET)
   • Needs surgery: distal ureteric ≤10 mm or proximal <2 cm → Ureteric stone surgery · choose approach
   • Renal stone <2 cm → Renal stone <2 cm → SWL/RIRS
   • Renal stone ≥2 cm (or large lower-pole/staghorn) → Renal stone ≥2 cm → PCNL
2. [End] Obstruction + infection → emergency drainage
   Obstruction + infection/sepsis, or solitary kidney/bilateral obstruction/AKI → emergency decompression (ureteric stent or percutaneous nephrostomy) + antimicrobials + resuscitation; definitive lithotripsy/removal once infection is controlled.
3. [End] ≤10 mm → medical expulsion (MET)
   Ureteric stone ≤10 mm, uncomplicated → conservative expulsion: alpha-blocker (~30 days) + analgesia + hydration; most pass within 4 weeks; failure/progression (pain, infection, renal function) → surgery.
4. [Decision] Ureteric stone surgery · choose approach
   URS or SWL? (When a distal ureteric ≤10 mm or proximal <2 cm stone needs surgery, both are options.)
   • Ureteroscopy URS (lithotripsy/removal, high clearance) → Ureteroscopy URS
   • Extracorporeal shockwave SWL (non-invasive, slightly lower clearance) → Extracorporeal shockwave SWL
5. [End] Ureteroscopy URS
   Ureteroscopic lithotripsy/removal (URS + laser) — high clearance, immediate; suits distal/impacted/hard stones; a double-J stent is usually placed.
6. [End] Extracorporeal shockwave SWL
   Extracorporeal shockwave lithotripsy (SWL) — non-invasive, outpatient; suits <2 cm, non-impacted, fluoroscopically localizable stones; clearance depends on size/density/location.
7. [End] Renal stone <2 cm → SWL/RIRS
   Renal stone <2 cm → SWL or flexible ureteroscopy RIRS (laser); RIRS is better for lower-pole, hard stones or after SWL failure.
8. [End] Renal stone ≥2 cm → PCNL
   Renal stone ≥2 cm (or large lower-pole/staghorn/complex) → percutaneous nephrolithotomy (PCNL, high clearance); preoperative CT to plan the access tract; mini-PCNL reduces complications and bleeding.

Source guidelines & references

• Surgical management of kidney and ureteral stones, AUA guideline 2025; EAU urolithiasis guideline

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways