Definitive Treatment

It is reassuring to know that >95% of stones <5 mm spontaneously pass within 40 days [11, 13]. Treatment is therefore geared towards aiding spontaneous stone passage with surgical intervention required when stones are impacted.

Extra corporeal shockwave lithotripsy (ESWL) – Proximal non obstructing calculi are treated by extra corporeal shockwave lithotripsy (ESWL). This cannot be used in pregnancy, coagulopathy, uncontrolled hypertension and febrile UTI [7].

Medical Expulsive therapy – A longitudinal cohort study by Resim in 2005, based on the discovery of α1 receptors in the distal ureter, found that α1-blockers decreased the number of ureteral colic episodes and also intensity of pain during spontaneous passage of lower ureteral calculi during follow up [8]. There were several weaknesses in trial design and no firm conclusions can be drawn. A further Cochrane review published in April 2018 [12] concluded that although α1-blockers increased stone clearance they also increased adverse events.

A recent meta analysis has also demonstrated that use of calcium channel blockers can marginally increase stone expulsion as compared with standard therapy but the rate of adverse effects was significant [9]. It is current recommendation to therefore offer α1-blocker therapy to only assist expulsion of stones <10mm in size.

Ureterorenoscopy (URS) – Retrieval with endoscopy is utilised for large stones, multiple stones or stones causing significant obstruction.

Flexible ureteroscopy has emerged as the main treatment for mid and distal ureteric stones. A Cochrane review of current RCTs has shown that during follow up of ureteroscopic retrieval of stones, hospital stay and complications are increased in comparison to ESWL but stone free rate is increased. However, heterogeneity prevented extrapolation to definitive clinical decision making. Innovative YAG laser technology may in future influence this decision [6].

PCNL – Percutaneous Nephrolithotomy/Nephrolithotripsy
A procedure used for removal of large impacted stones or stones where a trial of ESWL and/or URS have failed.

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