Indications for Active Stone Removal

Introduction to Stone Removal

The European Association of Urology recommends active stone removal for renal stones demonstrating stone growth or in patients at high risk of stone formation, and for ureteral stones when conservative management fails or complications arise 1

The European Association of Urology specifies clear indications for removing renal stones, including stone growth on follow-up imaging 1
The European Association of Urology also recommends removal for patients at high risk of stone formation, such as recurrent stone formers 1
Observation alone is problematic because spontaneous passage occurs in only 3–29% of cases, while symptoms develop in 7–77% of patients 1
Stone growth occurs in 5–66% of cases, and 7–26% ultimately require surgery 1

Active removal of ureteral stones is indicated when conservative management is not appropriate or has failed 1, 3
The European Association of Urology recommends urgent decompression via percutaneous nephrostomy or ureteral stenting for sepsis and/or anuria in an obstructed kidney 3
Intervention is required for urinary tract infection with obstruction 2, intractable pain despite medical management 2, progressive hydronephrosis or declining renal function 2, and solitary kidney or bilateral obstruction 2

The European Association of Urology establishes that conservative management is not appropriate for stones >10 mm, as these have very low spontaneous passage rates 2
The maximum conservative treatment duration is 4–6 weeks to prevent irreversible kidney injury 4
Medical expulsive therapy should be stopped if complications arise 1
Stones <5 mm pass in 75% of cases, compared to only 62% for stones ≥5 mm 1, 5

Once active removal is indicated, the European Association of Urology provides treatment algorithms based on stone location and size 1
For stones 10-20 mm, flexible ureteroscopy and percutaneous nephrolithotomy are generally more effective than shock wave lithotripsy, particularly for lower pole locations 2
For lower pole stones (10 mm), flexible ureteroscopy or percutaneous nephrolithotomy are first-line options, as shock wave lithotripsy has lower stone-free rates 2
For renal pelvis or upper/middle calyx stones (10 mm), flexible ureteroscopy or shock wave lithotripsy are equivalent first-line treatments 2