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Recently, the Canadian Urological Association (CUA) updated the guidelines for the treatment of ureteral calculi, including conservative treatment, drug expulsion therapy, shock wave lithotripsy (SWL), and ureteroscopic lithotripsy (URS)
.
Yimaitong has compiled the recommendations of the expert group for your reference! Recommendation 1 for conservative management of ureteral calculi: Because of the high rate of spontaneous excretion, most patients with ureteral calculi can initially undergo non-surgical treatment, especially for patients with smaller stones (<5 mm)
.
In patients receiving conservative treatment, close follow-up is necessary to determine whether the stone is spontaneously dislodged or to decide whether prompt intervention is required (grade 2, strong recommendation)
.
Obstructive pyelonephritis requires early goal-directed therapy, including prompt decompression in an anterograde or retrograde manner, either approach is feasible (grade 2, strong recommendation)
.
Recommendation 2 (imaging): For patients with acute ureteral calculi, ultrasonography (US) and kidney-ureter-bladder (KUB) X-rays are considered as initial options
.
Appropriate use of CT scans (preferably at low doses) will provide useful information for treatment decisions (grade 1, strong recommendation)
.
The use of KUB-X-rays is important for follow-up and decision-making on final treatment options (Level 4, Expert Opinion)
.
Recommendation 3: Whether drug expulsion therapy (MET) promotes spontaneous expulsion remains controversial
.
Current studies suggest that MET may benefit patients with larger (distal) ureteral stones (5-10 mm)
.
The advantages and disadvantages of MET blockers should be discussed with the patient in treatment decisions (Grade 1, strong recommendation)
.
Studies have demonstrated that opioid-free analgesics are effective, and opioid use should be minimized for renal colic; patient education is critical (level 1, strong recommendation)
.
Mandatory IV rehydration for stone removal is not recommended (grade 1, moderate recommendation)
.
Recommendation 4 (renal colic follow-up): Relief of symptoms and patient-reported passage of stones after an episode of renal colic do not always confirm passage of obstructive ureteral stones
.
Imaging is recommended to confirm stone passage (grade 3, strongly recommended)
.
The duration of conservative treatment that doctors recommend varies from person to person and takes into account a number of factors
.
Surgical intervention should be considered in patients who have not expelled obstructive ureteral stones after 4-6 weeks (grade 5, moderate recommendation)
.
Shockwave Lithotripsy (SWL) Recommendation 5 (Clinical Factors Affecting SWL Success): Based on stone size, location, composition, density, and skin-to-stone distance (SSD) can help patients understand SWL success rates
.
URS is best used for uric acid stones, cystine stones, and calcium phosphate stones (grade 4, moderate recommendation)
.
Patients with ureteral stones with a stone density >1000HU or SSD>10cm have a lower stone-free rate (SFR) after shock wave lithotripsy (grade 2, strong recommendation); treatment decisions should be discussed with the patient to balance the advantages and disadvantages of SWL vs URS, Complications and efficacy
.
Recommendation 6 (optimized treatment outcome): Patients with upper ureteral calculi should initially receive low-energy shocks, gradually increasing the voltage to maximum energy (level 2, strong recommendation)
.
If unsuccessful, repeat SWL may be considered, but more than two SWLs for the same ureteral stone will not increase benefit, and URS should be considered in this case (grade 4, moderate recommendation)
.
For patients with upper ureteral calculi >1 cm or opting for retreatment after initial SWL failure, the treatment rate should be <120 pulses/min for best results (grade 1, strong recommendation)
.
Sufficient number of shocks (2000-4000 for most lithotripters) should be given to ensure adequate treatment (grade 4, weak recommendation)
.
More shocks may improve SFR, but limited data preclude it from being a routine recommendation
.
Recommendation 7: After SWL for ureteral stones, an alpha-blocker (eg, tamsulosin) should be prescribed to improve treatment success (grade 1, moderate recommendation)
.
In most patients (stones <2 cm), ureteral stenting after SWL did not improve SFR, nor did it reduce the risk of stone street or infection after treatment (grade 1, moderate recommendation)
.
Ureteroscopic lithotripsy (URS) recommendation 8 (preoperative alpha-blockers): Preoperative alpha-blocker therapy may improve intraoperative and postoperative outcomes with URS
.
However, the optimal duration of preoperative alpha-blocker therapy is unclear (grade 1, moderate recommendation)
.
Recommendation 9 (postoperative imaging): For ureteral calculi, US±KUB X-ray examination can be considered after URS (grade 4, strong recommendation)
.
In complicated cases, enhanced CT can be used for further examination
.
Recommendation 10 (ureteral delivery sheath): The current study shows that the ureteral delivery sheath (UAS) has no significant effect on SFR and intraoperative complications of ureteral stones (grade 2, moderate recommendation), but can improve visualization, reduce intrarenal pressure, promote Debris discharge (level 4, highly recommended)
.
Recommendation 11 (stenting): Pre-URS stenting is not routinely performed, but in patients with larger stones, it may aid UAS insertion and improve patient SFR (Grade 2, weak recommendation)
.
Routine stenting is not required after uncomplicated URS (grade 2, strong recommendation), but is required after UAS (grade 3, weak recommendation)
.
Alpha-blockers and/or anticholinergics improve stent-related symptoms after URS (grade 2, moderate recommendation)
.
If ureteral stones are complex or impossible to enter the ureter, placing a stent and repeating the URS is the safest option (grade 5, strong recommendation)
.
Recommendation 12 (SWL vs URS efficacy): For ureteral stones, SWL and URS have similar stone-clearance rates, but SWL has higher retreatment rates and lower complication rates compared with URS (grade 1, strong recommendation)
.
Although local or regional cost models need to be considered, SWL remains a more cost-effective treatment option for patients with ureteral stones (grade 4, weak recommendation)
.
Treatment Recommendation 13 (Anticoagulation) in Special Clinical Situations: SWL and anterograde URS are contraindicated in patients with untreated coagulopathy
.
Continuing URS while the patient is anticoagulated is an acceptable option when antiplatelet agents or anticoagulants do more harm than good (grade 2, moderate recommendation)
.
Recommendation 14 (antegrade treatment of ureteral stones): Percutaneous antegrade URS should be considered for stone management in patients with urinary diversion, and should be considered for large, incarcerated upper ureteral stones, especially in patients with previous retrograde URS failure ( Level 4, highly recommended)
.
Recommendation 15 (ureteral calculi in children): Ultrasound is the first-line diagnostic option for children with suspected ureteral calculi
.
Can be used in conjunction with KUB X-rays for increased accuracy
.
In some cases, low-dose contrast-enhanced CT may be used (grade 3, strongly recommended)
.
For patients with small stones (<5mm), trial stone expulsion with/without MET is recommended (grade 2, strong recommendation)
.
SWL is a safe and effective treatment option for children with ureteral calculi (grade 2, strong recommendation)
.
If ureteral dilation is required, passive dilation is preferred (grade 4, moderate recommendation)
.
For URS treatment, a ureteroscope of <8Fr is recommended in children (grade 4, moderate recommendation)
.
Recommendation 16 (pregnancy): Ultrasound is the first-line option for the diagnosis of stones in pregnancy, and low-dose contrast-enhanced CT or magnetic resonance imaging (MRI) can also be used (gadolinium-containing contrast agents should not be used in the first trimester) (grade 3, strong recommendation)
.
In the absence of suspected or undiagnosed urinary tract infection, conservative management of ureteral stones in pregnancy is an option (grade 3, moderate recommendation)
.
In pregnant women with symptoms of sepsis, urinary decompression with antibiotics, percutaneous nephrostomy drainage, or ureteral stenting is most important; consultation with an obstetrician is recommended
.
During pregnancy, URS laser lithotripsy is safe; SWL is contraindicated during pregnancy (grade 2, strong recommendation)
.
References: Lee JY, Andonian S, Bhojani N, et al.
Canadian Urological Association guideline: Management of ureteral calculi.
Can Urol Assoc J 2021;15(12):383-93.
http://dx.
doi.
org/ 10.
5489/cuaj.
765 Submission email: tougao@medlive.
cn
.
Yimaitong has compiled the recommendations of the expert group for your reference! Recommendation 1 for conservative management of ureteral calculi: Because of the high rate of spontaneous excretion, most patients with ureteral calculi can initially undergo non-surgical treatment, especially for patients with smaller stones (<5 mm)
.
In patients receiving conservative treatment, close follow-up is necessary to determine whether the stone is spontaneously dislodged or to decide whether prompt intervention is required (grade 2, strong recommendation)
.
Obstructive pyelonephritis requires early goal-directed therapy, including prompt decompression in an anterograde or retrograde manner, either approach is feasible (grade 2, strong recommendation)
.
Recommendation 2 (imaging): For patients with acute ureteral calculi, ultrasonography (US) and kidney-ureter-bladder (KUB) X-rays are considered as initial options
.
Appropriate use of CT scans (preferably at low doses) will provide useful information for treatment decisions (grade 1, strong recommendation)
.
The use of KUB-X-rays is important for follow-up and decision-making on final treatment options (Level 4, Expert Opinion)
.
Recommendation 3: Whether drug expulsion therapy (MET) promotes spontaneous expulsion remains controversial
.
Current studies suggest that MET may benefit patients with larger (distal) ureteral stones (5-10 mm)
.
The advantages and disadvantages of MET blockers should be discussed with the patient in treatment decisions (Grade 1, strong recommendation)
.
Studies have demonstrated that opioid-free analgesics are effective, and opioid use should be minimized for renal colic; patient education is critical (level 1, strong recommendation)
.
Mandatory IV rehydration for stone removal is not recommended (grade 1, moderate recommendation)
.
Recommendation 4 (renal colic follow-up): Relief of symptoms and patient-reported passage of stones after an episode of renal colic do not always confirm passage of obstructive ureteral stones
.
Imaging is recommended to confirm stone passage (grade 3, strongly recommended)
.
The duration of conservative treatment that doctors recommend varies from person to person and takes into account a number of factors
.
Surgical intervention should be considered in patients who have not expelled obstructive ureteral stones after 4-6 weeks (grade 5, moderate recommendation)
.
Shockwave Lithotripsy (SWL) Recommendation 5 (Clinical Factors Affecting SWL Success): Based on stone size, location, composition, density, and skin-to-stone distance (SSD) can help patients understand SWL success rates
.
URS is best used for uric acid stones, cystine stones, and calcium phosphate stones (grade 4, moderate recommendation)
.
Patients with ureteral stones with a stone density >1000HU or SSD>10cm have a lower stone-free rate (SFR) after shock wave lithotripsy (grade 2, strong recommendation); treatment decisions should be discussed with the patient to balance the advantages and disadvantages of SWL vs URS, Complications and efficacy
.
Recommendation 6 (optimized treatment outcome): Patients with upper ureteral calculi should initially receive low-energy shocks, gradually increasing the voltage to maximum energy (level 2, strong recommendation)
.
If unsuccessful, repeat SWL may be considered, but more than two SWLs for the same ureteral stone will not increase benefit, and URS should be considered in this case (grade 4, moderate recommendation)
.
For patients with upper ureteral calculi >1 cm or opting for retreatment after initial SWL failure, the treatment rate should be <120 pulses/min for best results (grade 1, strong recommendation)
.
Sufficient number of shocks (2000-4000 for most lithotripters) should be given to ensure adequate treatment (grade 4, weak recommendation)
.
More shocks may improve SFR, but limited data preclude it from being a routine recommendation
.
Recommendation 7: After SWL for ureteral stones, an alpha-blocker (eg, tamsulosin) should be prescribed to improve treatment success (grade 1, moderate recommendation)
.
In most patients (stones <2 cm), ureteral stenting after SWL did not improve SFR, nor did it reduce the risk of stone street or infection after treatment (grade 1, moderate recommendation)
.
Ureteroscopic lithotripsy (URS) recommendation 8 (preoperative alpha-blockers): Preoperative alpha-blocker therapy may improve intraoperative and postoperative outcomes with URS
.
However, the optimal duration of preoperative alpha-blocker therapy is unclear (grade 1, moderate recommendation)
.
Recommendation 9 (postoperative imaging): For ureteral calculi, US±KUB X-ray examination can be considered after URS (grade 4, strong recommendation)
.
In complicated cases, enhanced CT can be used for further examination
.
Recommendation 10 (ureteral delivery sheath): The current study shows that the ureteral delivery sheath (UAS) has no significant effect on SFR and intraoperative complications of ureteral stones (grade 2, moderate recommendation), but can improve visualization, reduce intrarenal pressure, promote Debris discharge (level 4, highly recommended)
.
Recommendation 11 (stenting): Pre-URS stenting is not routinely performed, but in patients with larger stones, it may aid UAS insertion and improve patient SFR (Grade 2, weak recommendation)
.
Routine stenting is not required after uncomplicated URS (grade 2, strong recommendation), but is required after UAS (grade 3, weak recommendation)
.
Alpha-blockers and/or anticholinergics improve stent-related symptoms after URS (grade 2, moderate recommendation)
.
If ureteral stones are complex or impossible to enter the ureter, placing a stent and repeating the URS is the safest option (grade 5, strong recommendation)
.
Recommendation 12 (SWL vs URS efficacy): For ureteral stones, SWL and URS have similar stone-clearance rates, but SWL has higher retreatment rates and lower complication rates compared with URS (grade 1, strong recommendation)
.
Although local or regional cost models need to be considered, SWL remains a more cost-effective treatment option for patients with ureteral stones (grade 4, weak recommendation)
.
Treatment Recommendation 13 (Anticoagulation) in Special Clinical Situations: SWL and anterograde URS are contraindicated in patients with untreated coagulopathy
.
Continuing URS while the patient is anticoagulated is an acceptable option when antiplatelet agents or anticoagulants do more harm than good (grade 2, moderate recommendation)
.
Recommendation 14 (antegrade treatment of ureteral stones): Percutaneous antegrade URS should be considered for stone management in patients with urinary diversion, and should be considered for large, incarcerated upper ureteral stones, especially in patients with previous retrograde URS failure ( Level 4, highly recommended)
.
Recommendation 15 (ureteral calculi in children): Ultrasound is the first-line diagnostic option for children with suspected ureteral calculi
.
Can be used in conjunction with KUB X-rays for increased accuracy
.
In some cases, low-dose contrast-enhanced CT may be used (grade 3, strongly recommended)
.
For patients with small stones (<5mm), trial stone expulsion with/without MET is recommended (grade 2, strong recommendation)
.
SWL is a safe and effective treatment option for children with ureteral calculi (grade 2, strong recommendation)
.
If ureteral dilation is required, passive dilation is preferred (grade 4, moderate recommendation)
.
For URS treatment, a ureteroscope of <8Fr is recommended in children (grade 4, moderate recommendation)
.
Recommendation 16 (pregnancy): Ultrasound is the first-line option for the diagnosis of stones in pregnancy, and low-dose contrast-enhanced CT or magnetic resonance imaging (MRI) can also be used (gadolinium-containing contrast agents should not be used in the first trimester) (grade 3, strong recommendation)
.
In the absence of suspected or undiagnosed urinary tract infection, conservative management of ureteral stones in pregnancy is an option (grade 3, moderate recommendation)
.
In pregnant women with symptoms of sepsis, urinary decompression with antibiotics, percutaneous nephrostomy drainage, or ureteral stenting is most important; consultation with an obstetrician is recommended
.
During pregnancy, URS laser lithotripsy is safe; SWL is contraindicated during pregnancy (grade 2, strong recommendation)
.
References: Lee JY, Andonian S, Bhojani N, et al.
Canadian Urological Association guideline: Management of ureteral calculi.
Can Urol Assoc J 2021;15(12):383-93.
http://dx.
doi.
org/ 10.
5489/cuaj.
765 Submission email: tougao@medlive.
cn
