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Nephrolithiasis

Key sources
The following summarized guidelines for the evaluation and management of nephrolithiasis are prepared by our editorial team based on guidelines from the Canadian Urological Association (CUA 2022), the European Association of Urology (EAU 2021), the American Urological Association (AUA/ES 2016), and the American Urological Association (AUA 2014).
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Guidelines

1.Diagnostic investigations

Clinical evaluation: as per EAU 2021 guidelines, elicit a medical history including stone history (former stone events, family history), dietary habits and medication history in patients with stones of unknown composition.
A
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  • Blood tests

  • Urine tests

  • Diagnostic imaging

  • Bone mineral density testing

2.Diagnostic procedures

Stone analysis
As per CUA 2022 guidelines:
Perform stone analysis when available.
B
Perform stone analysis when stones are collected by patients or removed at the time of surgical intervention.
B

3.Medical management

Observation
As per EAU 2021 guidelines:
Offer initial periodic evaluation in patients with newly diagnosed small ureteral stones, if active removal is not indicated.
A
Offer active surveillance in patients at high risk of thrombotic complications in the presence of an asymptomatic calyceal stone.
B

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  • Medical expulsive therapy

  • Oral chemolysis

  • Management of struvite stones

  • Pain management

4.Nonpharmacologic interventions

Dietary modifications: as per CUA 2022 guidelines, obtain specific dietary assessment with an involvement of a registered dietitian, when possible.
B
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  • Dietary supplements

5.Therapeutic procedures

Indications for stone treatment: as per EAU 2021 guidelines, offer active treatment for renal stones in patients with stone growth, de novo obstruction, associated infection, and acute and/or chronic pain.
B

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  • Choice of procedure (general principles)

  • Choice of procedure (renal stones)

  • Choice of procedure (ureteral stones)

  • Choice of procedure (steinstrasse)

  • Technical considerations (shock wave lithotripsy)

  • Technical considerations (ureterorenoscopy)

  • Technical considerations (percutaneous nephrolithotomy)

  • Urgent decompression

6.Perioperative care

Preoperative evaluation, laboratory tests, EAU
Obtain a urine culture or perform urinary microscopy before any treatment is planned.
A
Exclude or treat UTIs before stone removal.
A

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  • Preoperative evaluation (imaging)

  • Preoperative precautions

  • Preoperative antibiotic prophylaxis

  • Postoperative evaluation

7.Surgical interventions

Surgical stone removal: as per EAU 2021 guidelines, offer laparoscopic or open surgical stone removal in rare cases when shock wave lithotripsy, retrograde or antegrade ureteroscopy and percutaneous nephrolithotomy fail or are unlikely to be successful.
A

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  • Nephrectomy

8.Specific circumstances

Pregnant patients: as per EAU 2021 guidelines, obtain ultrasound as the preferred imaging in pregnant patients.
A
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  • Pediatric patients

  • Patients at high thrombotic risk

  • Patients with transplanted kidneys

9.Preventative measures

Prevention of stone recurrence: as per CUA 2022 guidelines, offer thiazide diuretics and alkali citrates to decrease urinary calcium, increase urinary citrate and reduce stone recurrence in calcium stone forming patients.
B
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10.Follow-up and surveillance

Serial laboratory assessment: obtain 24-hour urine specimen for stone risk factors within 6 months to assess response to dietary and/or medical therapy.
E
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  • Serial imaging assessment