List of Abbreviations
aPTT – activated partial thromboplastin time
UUT – upper urinary tract
IVU – intravenous urography
RIRS – retrograde intrarenal surgery
CI – confidence interval
ESWL – extracorporeal shock wave lithotripsy
UTI – urinary tract infection
MSCT – multislice computed tomography of the kidneys and urinary tract.
UPJ – ureteropelvic junction
mg – milligram
MET – medical expulsive therapy
Micromole – micromole
mm – millimeter
mmol – millimole
Mini-PCNL – mini-percutaneous nephrolithotripsy using a laser
INR – international normalized ratio
IC – urolithiasis (urolithiasis disease)
ICD-10 – International Classification of Diseases 10th Revision
BL – bladder
NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs
PCNL – percutaneous nephrolithotripsy
РКИ – randomized controlled trial
cm – centimeter
ESR – erythrocyte sedimentation rate
US – ultrasound examination
TUL – transurethral ureterolithotripsy
RIRS – retrograde intrarenal surgery
PCN – percutaneous nephrostomy
ECIRS – endoscopic combined intrarenal surgery
AUA – American Urological Association
EAU – European Association of Urology
HU – Hounsfield unit
mSv – millisievert
Terms and Definitions
1. Extracorporeal shock wave lithotripsy (ESWL) is a method of extracorporeal shock wave stone disintegration.
Distal pyelolithotripsy (code A22.28.011);
Distal calicolithotripsy (code A22.28.012);
Distal ureterolithotripsy (code A22.28.001);
Distal nephrolithotripsy (code A22.28.002).
2. Transurethral ureterolithotripsy (TUL) is a method of disintegration and removal of ureteral stones via the natural urinary tract.
Ureteroscopy (code A03.28.003);
Transurethral ureterolithoextraction (code A16.28.054);
Transurethral endoscopic ureterolithotripsy (code A16.28.050);
Transurethral endoscopic laser ureterolithotripsy (code A16.28.050.001).
3. Percutaneous nephrolithotripsy (PCNL) is a method of percutaneous disintegration and removal of kidney stones.
Percutaneous nephrolithotripsy with lithoextraction (nephrolitholapaxy) (code A16.28.049).
4. Antegrade ureterolithotripsy – a method of percutaneous disintegration and removal of ureteral stones.
Antegrade percutaneous ureterolithotripsy (code A16.28.092).
5. Transurethral nephrolithotripsy (TNL) - a method of disintegration and removal of kidney stones via the natural urinary tract.
Transurethral flexible pyelocalicolithotripsy (code A16.28.084.003);
Transurethral endoscopic pyelolithotripsy (code A16.28.084);
Transurethral endoscopic pyelolithotripsy with lithoextraction (code A16.28.084.001);
Transurethral pyelocalicolithotripsy using an access sheath (code A16.28.084.002).
6. Endoscopic combined intrarenal surgery (ECIRS) – a method of disintegration and removal of kidney stones with simultaneous PCNL and TNL;
7. Upper urinary tract drainage - a method of restoring urine outflow from the kidney via the natural urinary tract or percutaneously.
Upper urinary tract catheterization (code A16.28.051);
Percutaneous puncture nephrostomy (code A11.28.011);
Ultrasound-guided percutaneous puncture nephrostomy (code A16.28.001.001)
8. Multislice computed tomography of the kidneys and urinary tract – an imaging method of the urinary tract, including the kidneys, entire ureters, urinary bladder, and urethra, using a computed tomography scanner.
Non-contrast (native): Computed tomography of the abdominopelvic organs and retroperitoneal space (A06.30.005.001) + Spiral computed tomography of the pelvic organs in women / in men (A06.20.002.001 / A06.21.003.001)
Contrast-enhanced: Computed tomography of the kidneys and upper urinary tract with intravenous bolus contrast enhancement (A06.28.009.001) + Spiral computed tomography of the pelvic organs in women / in men with intravenous bolus contrast enhancement (A06.20.002.002 / A06.21.003.002).
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Urolithiasis is a chronic systemic disease resulting from metabolic disorders and/or environmental factors, manifested by the formation of stones in the upper urinary tract.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Currently, formal and causal mechanisms of stone formation are distinguished [1]. The formal mechanism involves urine supersaturation with stone-forming compounds, crystallization (heterogeneous or homogeneous depending on the ionic composition of urine), and crystal aggregation. According to literature data [2], there are 4 main mechanisms of crystal aggregation: 1) stone growth over "white" interstitial hydroxyapatite plaques or Randall's plaques [3]; 2) stone formation over Bellini duct (BD) "plugs" [4]; 3) microlith formation in the collecting ducts of the inner renal medulla [3]; 4) stone formation in a "free" solution within the pelvicalyceal system [5]. Causal genesis, in turn, is nothing other than the influence of exo- and endogenous factors [6]. These include: a) climatic and geographical influences; b) social and living conditions; c) occupational hazards; d) human genetic diseases (enzymopathies and tubulopathies) [7].
1.3 Epidemiology of the Disease or Condition
The incidence of urolithiasis ranges from 1 to 20% [8], is higher in men than in women (a ratio of approximately 3:1), and most commonly manifests at the age of 40–50 years. However, in recent decades this ratio has reversed; according to Stamatelou et al., based on the NHANES (National Health and Nutrition Examination Survey) registry, this proportion was 1.75 to 1 [9]. Recurrence of urolithiasis is observed in 30-50% of patients within 5-10 years after the first episode [10]. The prevalence of urolithiasis varies from 2 to 15% in different regions of the world, with an overall increasing trend.
In 2005, 656,911 cases of urolithiasis were registered in the Russian Federation, and in 2019, 889,891 cases were detected. The increase in urolithiasis incidence from 2005 to 2019 was 35.45%, and this increase was fairly steady. Analysis of urolithiasis incidence per 100,000 population showed that the Magadan Region (1,081.3 cases) and Altai Territory (1,070.2 cases) were the leading regions in urolithiasis prevalence in 2005. The highest rates of urolithiasis incidence per 100,000 population in 2019 were recorded in the Altai Territory (1,345.7 cases), Amur Region (954.5 cases), and Yamalo-Nenets Autonomous Okrug (1,034.4 cases).
Based on data from patients with urolithiasis contained in the "Rochester Epidemiology Project" registry from 1984 to 2003, which included kidney CT data of 2,239 patients, a nomogram for calculating recurrence risk was developed, known as the "ROKS" nomogram [11]. According to this nomogram, symptomatic recurrence after the first stone-forming episode occurs with the following frequency: 11% at 2 years, 20% at 5 years, 31% at 10 years, and 39% at 15 years. Currently in Russia, this nomogram is available in the free smartphone application "StoneMD Urolithiasis" [12].
1.4 Features of Coding the Disease or Condition
Urolithiasis (N20):
N20 – Calculus of kidney and ureter
N20.0 – Calculus of kidney
N20.1 – Calculus of ureter
N20.2 – Calculus of kidney with calculus of ureter
N20.9 – Urinary calculus, unspecified
1.5 Classification of the disease or condition
Stratification of urolithiasis can be performed by etiology, composition, location, size, and radiopacity of the stones. Understanding and assessing the risks of recurrent stone formation are also important [13, 14, 15, 16].
Stratification of urolithiasis by etiology (causes) of stone formation (Appendix A3):
− Metabolic;
− Infectious;
− Genetically determined;
− Drug-induced;
− Idiopathic.
Stratification of urolithiasis by stone chemical composition (Appendix A3).
Stratification of urolithiasis by stone location [17, 18]:
− Upper caliceal stones
− Middle caliceal stones
− Lower caliceal stones
− Renal pelvis stones
− Upper / middle / lower ureteral stones
− Bladder stones (not discussed in this section)
In the Russian and European Associations of Urologists, ureteral stones are subdivided into three zones in accordance with the anatomical classification of the segmental structure of the ureters, where the middle third projects onto the sacrum, whereas the American Urological Association divides them into 2 zones, where the ureter is divided into abdominal and pelvic parts, with the iliac vessels serving as the boundary [19].
Urolithiasis stratification by kidney stone size [20]:
− Large stones: > 2 cm in maximal diameter
− Medium stones: 1 to 2 cm in maximal diameter
− Small stones: < 1 cm in maximal diameter
Urolithiasis stratification by stone radiopacity (Appendix A3):
− Radiopaque;
− Faintly radiopaque;
− Radiolucent
Urolithiasis stratification by recurrence risk group (Appendix A3):
− Low-risk patients: without high-risk factors
− High-risk patients with urolithiasis and any of the following risk factors [21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32]:
1.6 Clinical presentation of the disease or condition
The clinical presentation of urolithiasis depends on the degree and level of urinary tract obstruction by the stone, as well as the presence or absence of urinary tract and kidney inflammation. In cases of kidney and ureteral stones that do not cause upper urinary tract obstruction, the disease may be asymptomatic [33]. The main clinical manifestations of urolithiasis outside of renal colic include: lower back pain on the side of the stone, micro- and macrohematuria, periodic fever with chills, and frequent urination when the stone is located in the lower third of the ureter [34, 35].
2. Diagnostics, medical indications and contraindications for diagnostic methods
2.1 Complaints and Anamnesis
Diagnostic criteria: The diagnosis is established based on medical history, patient complaints, laboratory and instrumental findings. The most reliable diagnostic criterion is stone visualization using computed tomography.
Symptoms of urolithiasis depend on the stone location. The main symptoms of kidney stones are moderate lower back pain and hematuria [34, 35]. An asymptomatic course is also possible [33]. In ureteral stones, the aforementioned symptoms may be accompanied by frequent urination urges, nausea, vomiting, and occasionally fever, although an asymptomatic course is also possible [34, 35]. The diagnosis is established based on medical history, patient complaints, laboratory and instrumental findings. The most reliable diagnostic criterion is stone visualization using contrast-enhanced multislice computed tomography.
It is recommended for initial diagnosis during history-taking in patients with suspected urolithiasis to detail the presence of: a family history of urolithiasis; comorbid conditions and medications contributing to urolithiasis; previous surgeries on either the urinary system or the gastrointestinal tract, including bariatric surgery; inflammatory diseases of the urinary system, gastrointestinal tract, and episodes of spontaneous stone passage in the history [36, 37, 38, 39].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: drugs that crystallize in urine: Allopurinol**, Amoxicillin**, Ceftriaxone**, Fluoroquinolones, Ephedrine, Indinavir, Sulfonamides (J01E: Sulfonamides and trimethoprim), Triamterene (as part of Hydrochlorothiazide + Triamterene), Zonisamide. Drugs that create conditions for stone formation: Acetazolamide**, Allopurinol**, Ascorbic acid**, Calcium supplements, Furosemide**, Laxatives, Ergocalciferol, Topiramate**.
2.2 Physical Examination
It is recommended as part of the physical examination to perform palpation of the lumbar region and abdomen in patients with urolithiasis to identify the localization of pain and perform differential diagnosis with abdominal pathologies [34, 40].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: physical examination may reveal lumbar tenderness characteristic of renal diseases, and also helps perform differential diagnosis with other abdominal conditions [34, 35].
2.3 Laboratory Diagnostics
It is recommended to perform a complete blood count (leukocyte count, leukocyte differential, ESR) in patients with urolithiasis to determine the presence and severity of the inflammatory response [6, 35]1.
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the results of the above tests indicate signs of inflammation (leukocytosis, left shift of the leukocyte differential, elevated ESR) [34].
It is recommended to perform a urinalysis in all patients with urolithiasis to detect indirect signs of urinary tract infection (leukocyturia and bacteriuria) and hematuria [34, 35].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform a blood biochemistry test (blood creatinine level) in patients with urolithiasis to assess renal function [34].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: determination of blood creatinine level makes it possible to assess signs of renal failure [34].
It is recommended to perform a stone mineral composition analysis (code A09.28.018) using a reliable method (X-ray diffraction or infrared spectroscopy) in all patients with urolithiasis during initial diagnosis in case of spontaneous stone passage or after active stone removal, to determine further diagnostic and treatment tactics and select the optimal outpatient metaphylaxis method [34].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: repeat analysis of the urinary stone mineral composition is required in case of true stone recurrence.
It is recommended to perform microbiological (culture) urine tests for bacterial pathogens with antibiotic susceptibility testing in patients with urolithiasis to detect bacteriuria before elective surgery for the prevention and selection of an effective treatment method for intra- and postoperative infectious complications [41, 524, 525].
GPP CLE 4Grading of Recommendations Assessment, Development and Evaluation (GRADE) level C (Level of Evidence – 4)
Comment: Despite the fact that a positive urine culture is a significant risk factor for infectious complications, about 16% of patients with confirmed bacteriuria worldwide undergo surgical treatment for urolithiasis. In routine clinical practice, prior to surgical treatment for urolithiasis, an attempt at medical sterilization of the urine should be made in patients with bacteriuria. For this purpose, patients should be prescribed a course of antibacterial therapy taking into account the susceptibility of the isolated microorganism(s) to antibacterial drugs, followed by a control bacteriological test. In cases of persistent bacteriuria in the follow-up urine culture, as well as in cases of infection stones, to prevent the development of microbial resistance to antibacterial drugs, surgical intervention should be performed under antibacterial prophylaxis considering the susceptibility of the isolated microorganism(s) to antibacterial drugs, having thoroughly informed the patient about the increased risk of infectious complications [41, 524, 525].
It is recommended to perform a coagulogram (screening hemostasis test) (activated partial thromboplastin time (APTT), international normalized ratio (INR), fibrinogen) in patients with urolithiasis when planning surgery to determine bleeding risks and prevent hemorrhagic complications [34] (Related documents p. 1).
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.4 Instrumental Diagnostics
It is recommended to perform non-contrast multislice computed tomography (MSCT) of the kidneys and urinary tract (Computed tomography of the abdominal and retroperitoneal organs (A06.30.005.001) + Spiral computed tomography of the pelvic organs in women / in men (A06.20.002.001 / A06.21.003.001)) in patients with kidney and ureteral stones when planning conservative or surgical treatment, to visualize urinary stones, determine their location, size, density, and number [42, 43, 44, 45, 46, 47, 48, 49, 50].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: the most informative and sensitive method for urolithiasis is native (non-contrast) multislice computed tomography (MSCT)—the method's sensitivity is 96%, specificity up to 100%. It allows determining the number, size, location, structure, and density of the stone, while knowledge of the latter helps predict the efficacy of extracorporeal shock wave lithotripsy. MSCT allows determining the skin-to-stone distance and information about surrounding anatomy, which increases the efficacy of active kidney stone removal and reduces the risk of intraoperative complications [16, 51, 52, 53]. Native MSCT can detect xanthine and uric acid stones, which are invisible on plain urography; the only type of stones not detectable on MSCT is indinavir stones [54]. When diagnosing urinary tract stones, non-contrast MSCT has higher sensitivity and specificity compared to intravenous urography (IVU) and ultrasound [44, 45, 49, 55, 56, 57, 58, 59].
The advantage of unenhanced MSCT lies in the speed of the examination (blood creatinine level determination is not required prior to the procedure), low radiation dose, and the feasibility of performing the study in patients with renal failure. At the same time, it is important to understand that in some cases, to clarify the diagnosis, determine the internal anatomy of the urinary tract, and assess renal function, contrast enhancement is necessary [60].
It is recommended to use low-dose unenhanced MSCT of the kidneys and urinary tract when examining patients with urolithiasis and a body mass index <30 to reduce the radiation exposure [61, 62, 63, 64, 65, 66, 67, 68, 69].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
It is recommended to perform MSCT of the kidneys and urinary tract with intravenous bolus contrast enhancement (A06.28.009.001 Computed tomography of the kidneys and upper urinary tract with intravenous bolus contrast enhancement, A06.20.002.002 Spiral computed tomography of the pelvic organs in women with intravenous bolus contrast enhancement, A06.21.003.002 Spiral computed tomography of the pelvic organs in men with intravenous bolus contrast enhancement) in patients with solitary kidney stones, calyceal diverticulum stones, stones in a previously operated kidney, anomaly-associated kidney stones, suspected renal mass or vascular malformation, hydronephrosis, or ureterohydronephrosis if these conditions are known from the medical history or newly detected during ultrasound or unenhanced MSCT, in order to evaluate the anatomical features of the urinary tract and plan treatment tactics [70, 71, 72, 73].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform renal and urinary tract ultrasound and/or plain urography (radiography of the urinary system) in patients with radiopaque urinary tract stones as a diagnostic monitoring method to assess stone passage or detect residual calculi in the postoperative period [49, 50, 74, 75, 76, 77, 78, 79, 80, 81].
GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)
Comments: when monitoring radiolucent stones, and also considering the fact that in 1/3 of cases ureteral stones may not be accompanied by ureterohydronephrosis, performing low-dose unenhanced MSCT is justified [80, 81].
2.5 Other Procedures
The necessity of performing other diagnostic examinations is determined in each specific clinical situation in accordance with the patient's condition
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
3.1.1 Non-pharmacological treatment
It is recommended to inform patients about the possibility of adding behavioral therapy to the complex of medical expulsive therapy to increase its effectiveness [82-87].
GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)
Comment: historically, vibrating platforms, stair climbing, rope jumping, and other methods were used to enhance the efficacy of medical expulsive therapy [82]. Recently, the expulsive effect of sexual intercourse has been most well-documented in both men and women [83, 84, 85, 86]. The pathogenetic rationale may be the muscle-relaxant effect of nitric oxide [NO] released in the distal ureter and corpora cavernosa during sexual intercourse [87, 88].
3.1.2 Pharmacotherapy
It is recommended to use medical expulsive therapy (MET) with pharmacological agents from the selective $\alpha_1$-adrenergic receptor blocker group (ATC group: Alpha-adrenoreceptor antagonists) in patients with ureteral stones $\le 7$ mm in size with no indications for surgical treatment, in order to accelerate stone passage [89].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: the probability of stone passage from the ureter is determined by its size and location. Thus, the probability of spontaneous ureteral stone passage is 87%, 72%, 47%, and 27% for stone sizes of 1, 4, 7, and 10 mm, respectively. Approximately two-thirds of ureteral stones pass spontaneously within 4 weeks [90, 91, 92, 93].
It is recommended to discontinue MET if there is no positive dynamics in stone migration within 28 days and to employ surgical treatment methods [93, 94, 95, 96].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comments: medical expulsive therapy can be used in informed patients when active stone removal is not indicated. This therapy must be urgently discontinued if complications develop (infection, refractory renal colic, decreased renal function) [34].
The probability of stone passage from the ureter depends on its size and location. #Tamsulosin** is one of the most frequently used selective $\alpha_1$-blockers (ATC group: Alpha-adrenoreceptor antagonists) for MET in the Russian Federation, provided there are no contraindications [98, 99, 100, 101, 102]. However, the results of a clinical study of #tamsulosin**, #terazosin, and #doxazosin** demonstrated their equal efficacy up to 28 days, followed by an evaluation of effectiveness. The efficacy of this drug group is also confirmed by a number of studies demonstrating an increased stone passage rate during administration of #doxazosin** (4 mg daily for up to 28 days, followed by efficacy evaluation) [95, 97, 101], #terazosin (10 mg daily for up to 28 days, followed by efficacy evaluation) [102], #alfuzosin** (10 mg daily for up to 28 days, followed by efficacy evaluation) [103, 104, 105, 106], #silodosin (8 mg daily for up to 28 days, followed by efficacy evaluation) [107, 108], and #tamsulosin** (0.4 mg once daily followed by evaluation of effectiveness). However, despite numerous studies proving the efficacy of medical expulsive therapy, it remains a subject of debate due to the emergence of randomized multicenter trials in which the benefits of such therapy were not proven [109]. The latest Cochrane systematic review proved the efficacy of selective $\alpha_1$-blockers (ATC group: Alpha-adrenoreceptor antagonists) only when the stone size does not exceed 7 mm [89].
It is recommended as a first-line therapy to perform oral chemolysis with citrate mixtures (potassium hydrogen carbonate + citric acid + sodium citrate, and other combinations) or sodium hydrogen carbonate** in patients with stones of any size composed of uric acid, in order to dissolve them [110, 111, 112, 504-508].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: stones composed of uric acid (except for sodium or ammonium urates) can be dissolved by oral medication. Indirect data on the chemical composition of a stone can be obtained by determining its density via MSCT (no more than 600 HU), by radiolucency on plain urography, or by measuring urine hydrogen ion concentration (pH-metry) <5.5. Stone dissolution is performed by urine alkalinization to 6.8-7.2 and is monitored by measuring urine pH at regular intervals three times during the day [111]. Dissolution of a uric acid stone is caused not only by urine alkalinization, but predominantly by the substitution of the hydroxide ion at positions 2 and 6 of the purine ring by potassium and sodium from citrate mixtures, forming highly soluble uric acid salts—potassium and sodium urates. It should be borne in mind that high urine pH values can enhance the crystallization of CaP and $CaOx\cdot\text{H}_2\text{O}$ dihydrate. To correct urine pH, citrate mixtures or sodium hydrogen carbonate** can be used. Therapy with citrate mixtures should be prescribed for one month, followed by control unenhanced MSCT or ultrasound to assess the degree of response to therapy. If a reduction in stone volume is documented, prolongation of therapy for another two months should be considered, followed by control MSCT or ultrasound to assess the response to therapy and, if necessary, extension of therapy for another three months.
It is recommended to perform unenhanced MSCT of the urinary tract or renal ultrasound in patients with nephrolithiasis to monitor stone dissolution after 30 days of treatment [110, 111, 113, 508].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform active ureteral stone removal in patients undergoing oral chemolysis of uric acid stones if there is no positive dynamics in the form of a decrease in stone size after 28 days of therapy [93, 109, 110, 111, 113, 505].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform chemolysis against the background of urinary tract drainage in patients with uric acid stones causing upper urinary tract obstruction, in order to prevent infectious complications and renal colic [112, 114, 505].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
3.1.3 Herbal medicinal products
It is recommended to use herbal medicines as part of complex medical expulsive therapy to increase its effectiveness when it is necessary to provide anti-inflammatory, anti-adhesive, diuretic, antispasmodic, and other effects [115-136].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
Comments: in domestic and foreign literature, numerous studies are dedicated to the isolated and combined use of herbal medicines to increase the effectiveness of medical expulsive therapy. The following combinations of herbal remedies (ATC: G04BX Other urological drugs) are most frequently used in Russia, including:
European centaury herb + Lovage root + Rosemary leaves [115, 116, 117,118,119, 120]
terpenes: pinene, camphene, cineole, fenchone, borneol, anethole, vitamin E [121, 122,123, 124, 125, 509]
other combinations of phytoextracts and vitamins [126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 510]
3.2 Surgical treatment for ureteral stones
Indications for surgical removal of ureteral stones [137, 138, 139]:
low probability of spontaneous stone passage;
recurrent or refractory pain syndrome;
ureteral stone in a solitary kidney;
bilateral ureteral stones;
patient's preference
Contraindications to elective surgery for ureteral stones:
Presence of signs of urinary tract infection
It is recommended to perform upper urinary tract drainage via ureteral catheter placement or percutaneous nephrostomy in patients with hydronephrosis due to stone obstruction of the kidney and ureter, refractory renal colic, and signs of urinary tract infection to prevent the development of sepsis and destructive pyelonephritis [140, 141, 142, 143, 144].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comments: the drainage methods described above have comparable efficacy and safety; therefore, the choice of a particular method should be made taking into account technical feasibility and patient preferences.
It is recommended that in patients with urolithiasis and signs of urinary tract infection due to ureteral stone obstruction, during upper urinary tract drainage, a sample of the renal pelvic urine be collected and microbiologically (culturally) examined for bacterial pathogens, followed by adjustment of antibacterial therapy for the urinary tract infection based on the antimicrobial susceptibility of the bacterial flora to prevent infectious complications [145, 146].
Recommendations Grade CEvidence Level 4Recommendation validity score C (level of evidence – 4)
It is recommended that patients receive systemic antibacterial therapy for acute urinary tract infection after upper urinary tract drainage, with subsequent adjustment of therapy according to the results of microbiological (culture) examination of urine for bacterial pathogens [145, 146, 147, 148, 149, 150, 151, 152, 153, 154].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
It is recommended to perform extracorporeal shock wave lithotripsy (ESWL) and/or transurethral ureterolithotripsy (TUL) (A16.28.050 Transurethral endoscopic ureterolithotripsy) as a first-line treatment method for patients with ureteral stones when indications are present and contraindications are absent [155, 156, 157, 158].
Leads to AEvid 1Level of Evidence A (level of reliability of evidence – 1)
Comments: the patient should be informed about the higher efficacy of TUL compared to ESWL in terms of complete stone clearance within a single session, for the removal of large (>10 mm) stones in the upper third of the ureter, and for stone removal in obese patients [159, 160], as well as in patients with hard stones (>1000 HU) [51, 161, 162, 163]. Patients should also be informed that ESWL is a safer method in terms of complication rates, whereas TUL is a safer method in patients with blood coagulation disorders [164, 165, 166, 167, 168, 169, 170, 171]. The patient's opinion must be taken into account when making the final choice of treatment method.
It is recommended to perform antegrade percutaneous ureterolithotripsy, laparoscopic or open ureterolithotomy as alternative methods to ESWL and TUL in patients with large/medium (>1.5 cm) and/or impacted ureteral stones when indicated and in the absence of contraindications [172, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, 185, 544-547].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: performing antegrade (percutaneous) ureterolithotripsy or laparoscopic ureterolithotomy is recommended for patients with ureteral stones in whom ESWL and TUL have failed, when retrograde access to the ureter is impossible, when TUL is associated with high risks of infectious complications, or when a simultaneous laparoscopic kidney procedure is planned [175, 183, 184]. Open ureterolithotomy is recommended in exceptional cases when ESWL, TUL, antegrade (percutaneous) ureterolithotripsy, or laparoscopic ureterolithotomy is not feasible [185].
3.2.1 Extracorporeal shock wave lithotripsy
It is not recommended (contraindicated) to perform ESWL for ureteral stones in pregnant women [186, 187, 188] and patients with active urinary tract infection [189, 190, 191, 192, 193] due to the high probability of complications.
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is not recommended to perform ESWL for ureteral stones in patients with blood coagulation disorders receiving antiplatelet agents and/or anticoagulators (according to the ATC classification B01A: Antithrombotic agents) [166, 167, 168, 169, 194, 195, 196, 197, 198, 199, 200, 201] and in patients with aneurysms of major arteries [202, 203, 204] due to the high probability of complications.
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is not recommended to routinely place a catheter in the upper urinary tract (ureteral stenting) prior to ESWL in patients with urolithiasis due to the lack of convincing data on improved treatment outcomes [205, 206, 207].
LoR CGoE 1Level of Recommendation C (Level of Evidence – 1)
Comments: pre-stenting does not improve ureteral stone clearance rates, does not reduce the number of additional medical manipulations, and may cause complications associated with stent placement and the occurrence of stent-related symptoms, but it reduces the frequency of "steinstrasse" formation
It is not recommended to routinely administer antibiotic prophylaxis to patients with negative microbiological (culture) urine test results for bacterial pathogens prior to ESWL due to the lack of convincing data on the reduction of infectious complication rates [190, 208, 209, 210, 211].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: antibiotic prophylaxis should be administered to patients with positive urine culture results or with infectious stones according to the antibiogram.
3.2.2 Transurethral ureterolithotripsy.
It is recommended to use "rigid" ureteroscopes $\le$ 8 Fr in size for the removal of ureteral stones in patients with urolithiasis due to their high safety profile. The use of "rigid" ureteroscopes > 8 Fr is possible if ureteral pre-stenting has been performed [137, 222].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: flexible reusable or single-use ureterorenoscopes may be used in special cases for the removal of ureteral stones.
It is recommended that patients with urolithiasis and negative microbiological (culture) urine test results for bacterial pathogens receive a single dose of an antibacterial drug prior to transurethral ureterolithotripsy (TUL) and transurethral nephrolithotripsy (TNL) to reduce the incidence of infectious complications [223, 224, 225, 226, 227, 228, 229, 230, 231].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: despite emerging meta-analysis data indicating that antibiotic prophylaxis prior to TUL does not reduce the incidence of acute urinary tract infection in patients with sterile urine cultures, the working group considers the evidence provided in relevant publications to be insufficient and insists on a single preoperative systemic administration of an antibacterial drug in accordance with pharmacokinetics to reduce the risk of infectious complications. When choosing an antibacterial drug, it is necessary to consider the results of microbiological monitoring of nosocomial infection pathogens and their antibiotic resistance for the period of hospitalization.
It is recommended that patients with urolithiasis and a high risk of infectious complications undergo antibiotic prophylaxis in accordance with the results of microbiological (culture) examination of urine for bacterial pathogens when planning TUL and TNL [229, 230, 231].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: high risk factors for infectious complications include: bacteriuria, infectious stones, history of urinary tract infection episodes, diabetes mellitus, expected operation time > 60 min, stone size > 2 cm, presence of a ureteral stent for more than 30 days, presence of a nephrostomy drainage, ureteral obstruction [231, 232, 233, 234, 235, 236, 237, 238].
It is recommended to use a safety guide wire during TUL in patients with urolithiasis to ensure safety and control of intraoperative complications [239, 240, 241, 242, 243].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to maintain low intrarenal pelvic pressure (<30 cm H2O) during TUL in patients with urolithiasis to ensure safety and prevent infectious complications [244, 245, 246].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comments: exceeding intrarenal pelvic pressure >30 cm H2O may trigger the development of infectious complications.
It is recommended to use anti-reflux devices during transurethral lithotripsy (TUL) in patients with upper ureteral stones who are scheduled for TUL, in order to prevent retrograde stone migration [246].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the use of anti-reflux devices is particularly justified when performing transurethral ureterolithotripsy in the upper third of the ureter.
It is recommended to use laser or pneumatic lithotriptors for stone disintegration in patients with ureteral stones [247, 248, 249, 250, 251, 252, 253, 254, 255].
GCR CLEL 2Grade of Recommendation C (Level of Evidence – 2)
Comments: all indicated methods demonstrate comparable efficacy and safety.
It is not recommended to perform routine pre-stenting of the ureter prior to TUL in patients with ureteral stones due to the lack of compelling evidence of improved treatment outcomes [256, 257, 258, 259].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: if technical difficulties arise during ureteroscopy and contact lithotripsy, it is recommended to conclude the procedure by placing a ureteral stent, with a repeated attempt at stone removal in 5–14 days.
It is not recommended to routinely place a catheter in the upper urinary tract after uncomplicated TUL in patients with urolithiasis due to the lack of compelling evidence of improved treatment outcomes [260, 261, 262, 263, 264].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: placement of a ureteral stent after TUL is indicated:
in patients with a solitary kidney;
in patients who have undergone reconstructive surgery on the ureter;
upon removal of large impacted stones;
in case of intraoperative ureteral injury;
in case of technical difficulties during ureteroscopy;
in the presence of ureteral anomalies;
in the presence of ureteral stricture or deviation;
if there is uncertainty regarding the complete removal of the stone.
3.3 Surgical treatment for kidney stones
Indications for surgical removal of kidney stones:
growth of stones when sized > 5 mm;
patients at high risk of stone formation (Appendix A3);
upper urinary tract obstruction caused by a stone;
chronic recurrent infection caused by a stone;
symptomatic stones (pain, hematuria);
patient preference;
social indications.
Contraindications to surgical removal of kidney stones:
presence of signs of acute urinary tract infection
It is recommended to use SWL (extracorporeal shock wave lithotripsy), PNL (percutaneous nephrolithotripsy with lithoextraction [nephrolitholapaxy]), and RIRS (retrograde intrarenal surgery) as treatment methods for patients with kidney stones <2 cm in size. For stones >2 cm, PNL is recommended [265, 266, 267, 268, 269, 270, 271, 272, 273, 274, 275, 513-516].
GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)
Comments: given the comparable safety of all treatment methods for lower pole kidney stones, the final decision is made jointly with the patient after informing the latter about all the advantages and disadvantages of the methods. For large stones (> 20 mm), treatment should begin with PNL, since SWL in such cases often requires multiple sessions and is associated with the risk of ureteral obstruction (colic, "steinstrasse"), which may require additional interventions.
It is recommended to perform SWL at a frequency of 1-1.5 Hz, starting with the minimum energy level and gradually increasing it, as well as to use contact ultrasound gel to ensure acoustic homogeneity between the acoustic wave generator and the body of a patient with urolithiasis, in order to increase the fragmentation efficiency [212, 213, 217, 219, 511, 512]. Meeting these conditions helps increase fragmentation efficiency and reduce the damaging effect of acoustic waves on tissues. [212, 213, 215, 216, 217, 218, 219, 220, 221, 511, 512].
It is recommended to place a ureteral stent in the upper urinary tract at least 5 days prior to RIRS using an access sheath in patients with kidney stones to achieve passive ureteral dilation, facilitate the procedure, increase the stone-free rate, and reduce the complication rate [258, 259, 276, 277, 278].
Recommendations Grade BEvidence Level 3Recommendation validity score B (level of evidence – 3)
Comments: to reduce the risk of ureteral injury prior to inserting the ureteral access sheath, preliminary placement of a ureteral stent in the upper urinary tract (stenting) for 5-14 days should be performed. Pre-stenting improves RIRS outcomes.
It is recommended to use reusable and single-use flexible ureterorenoscopes to perform RIRS in patients with kidney stones [279, 280, 281, 282, 283, 284, 285].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
Comments: given the more favorable aseptic characteristics of single-use flexible ureterorenoscopes, their use is preferred in patients infected with HIV, hepatitis C, tuberculosis, as well as in patients at high risk of infectious complications.
It is not recommended to use RIRS as a first-line treatment in patients with kidney stones >2 cm due to the high risk of re-interventions [266].
Leveled of Evidence CLevel of Data Reliability 2Level of evidence C (level of data reliability – 2)
Comments: a number of studies indicate that RIRS can be performed for kidney stone treatment with an efficacy comparable to PNL, although the efficacy of RIRS is significantly lower for stones larger than 3 cm [284, 285, 286, 287, 288]. RIRS can be the first-line treatment for kidney stones if PNL is not feasible. At the same time, it can be performed successfully in centers with extensive experience in this technique [290]. The advantages of RIRS are low invasiveness, a low risk of complications such as bleeding and adjacent organ injury, and a shorter hospital stay [270]. In a recent systematic review evaluating the treatment of kidney stones >2 cm in size, the overall stone-free rate was 91%, with an average of 1.45 procedures per patient [223, 288, 289].
It is recommended to use a "safety" guidewire when performing RIRS in patients with kidney stones to ensure surgical safety [240, 241, 242].
Recommendations Grade CEvidence Level 4Recommendation validity score C (level of evidence – 4)
It is recommended for patients with kidney stones, in the presence of high-risk factors for infectious complications, to perform RIRS (A16.28.084 Transurethral endoscopic pyelolithotripsy, A16.28.084.001 Transurethral endoscopic pyelolithotripsy with lithoextraction, A16.28.084.002 Transurethral pyelocalyceal lithotripsy using a ureteral access sheath, A16.28.084.003 Transurethral fibropyelocalyceal lithotripsy) using a "ureteral access sheath" to ensure surgical safety [291, 292, 293, 294, 295, 296].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
Comment: high-risk factors for infectious complications include:
Bacteriuria
Infectious stones
History of urinary tract infection episodes
Diabetes mellitus
Estimated operative time > 60 min
Presence of a ureteral stent for more than 30 days
Presence of a nephrostomy tube
Comments: to reduce the risk of ureteral injury prior to sheath placement, preliminary stenting for 5-14 days is recommended. The use of a ureteral access sheath provides continuous outflow of irrigation fluid during surgery, which improves visualization and maintains low intrarenal pressure to prevent infectious complications. However, studies demonstrate that the use of a ureteral access sheath does not significantly affect the SFR or operative time, and is associated with the risk of ureteral injury. Therefore, the placement of a ureteral access sheath should be approached with caution and reserved for cases with risk factors for RIRS complications [291, 292, 293, 294, 295, 296, 297].
It is not recommended to routinely place a catheter in the upper urinary tract in patients after uncomplicated RIRS and with complete stone removal, as it does not improve treatment outcomes, except when a ureteral access sheath is used during RIRS [262, 263, 264].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
It is recommended to place a catheter in the upper urinary tract in all patients after complicated RIRS—ureteral injury, residual fragments, bleeding, ureteral wall perforation, UTI—as well as in pregnant patients and patients with a solitary kidney to reduce the risk of postoperative complications [262, 263, 264].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
It is recommended to perform PNL (A16.28.049 Percutaneous nephrolithotripsy with lithoextraction [nephrolitholapaxy]) in patients with kidney stones in either the prone or supine position due to comparable efficacy and safety. The choice of patient positioning on the operating table depends on the surgeon's preference and the patient's somatic status [298-300, 517-521].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: the advantages of performing PCNL in the supine patient position include direct anesthesiologist access to the upper airways, as well as a more comfortable opportunity for the urologist to simultaneously perform retrograde access to the upper urinary tract.
It is recommended to perform pelvicalyceal system puncture under combined ultrasound and fluoroscopic guidance to increase the efficacy of PCNL [301, 302, 522].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comments: in addition to reducing radiation exposure for the patient, the advantages of ultrasound-guided puncture include: shorter puncture time, higher success rate of punctures, lower blood loss and complication rate, including injury to adjacent organs.
It is recommended to perform single-step dilation during percutaneous access creation in patients with kidney stones undergoing PCNL [526, 527].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comment: the results of two meta-analyses indicate a higher efficacy of single-step dilation compared to multi-step dilation in terms of shorter access creation time, fluoroscopy time, and a less pronounced decrease in hemoglobin levels.
It is recommended to use ultrasonic, pneumatic, or laser lithotripters for PCNL in patients with kidney stones [248-255, 303, 523].
GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)
Comments: during standard PCNL, preference should be given to ultrasonic and pneumatic lithotripsy, whereas during mini-PCNL, laser lithotripsy should be preferred.
It is recommended to perform tubeless PCNL (percutaneous nephrolithotripsy with lithoextraction (nephrolitholapaxy)) in patients with kidney stones, provided there are no intraoperative complications and no residual stones, in order to reduce the patient's length of hospital stay [304-306, 528-530].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
It is recommended to use tranexamic acid** in order to reduce the risk of hemorrhagic complications and stop bleeding during the removal of complex staghorn stones by PCNL, when planning multi-access PCNL, and also when performing PCNL in patients at high risk for hemorrhagic complications [497-502].
GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)
Comment: there is currently compelling evidence that the use of tranexamic acid results in a less pronounced drop in hemoglobin levels, a lower blood transfusion rate, shorter operative time, and a reduced hospital stay without increasing the risk of thromboembolic complications [497-502].
It is not recommended to use hemostatic agents during tubeless PCNL in patients with kidney stones, as these drugs show no effect in reducing the transfusion rate and the severity of hemoglobin drop [531, 532].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
It is recommended to perform endoscopic combined intrarenal surgery (ECIRS) in patients with staghorn and complex kidney stones [307, 308].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comments: ECIRS is an effective and safe method for treating staghorn and complex kidney stones, associated with a significantly higher single-stage SFR, lower need for auxiliary procedures, and a lower complication rate compared to PCNL, PCNL with antegrade use of a flexible nephroscope, or multi-access PCNL. At the same time, PCNL with antegrade use of a flexible nephroscope appears to be a safer method than multiple accesses in PCNL [309, 310].
It is recommended to perform PCNL using more than one percutaneous access in patients with staghorn and complex kidney stones when ECIRS is not feasible and achieving a stone-free status from a single access is impossible [311, 312, 533, 534].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comments: Despite its high efficacy, performing PCNL through more than one access is associated with an increased bleeding rate and potential impairment of renal function. When selecting an access sheath for multi-access PCNL, preference should be given to miniaturized options not exceeding 21 Fr [313, 314, 315, 316].
It is recommended to administer antibiotic prophylaxis in patients with kidney stones scheduled for PCNL to reduce the incidence of infectious complications [317, 318, 524, 525, 535, 536].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: following a course of systemic antimicrobial therapy, a repeat microbiological (culture) urine test for bacterial pathogens must be performed [319].
It is recommended to perform PCNL (percutaneous nephrolithotripsy with lithoextraction (nephrolitholapaxy)) with active vacuum aspiration in patients with kidney stones and high risk of infectious complications to reduce the likelihood of their occurrence [537].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comment: High risk factors for infectious complications include:
Bacteriuria
Infectious stones
History of urinary tract infections
Diabetes mellitus
Estimated operative time > 60 min
Indwelling ureteral stent for more than 30 days
Presence of a nephrostomy drainage
It is recommended to obtain an emergency consultation with a relevant surgical specialist in the event of chest or abdominal organ injury during percutaneous nephrolithotomy (PCNL) in patients with kidney stones to determine further management tactics [320, 321].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: determination of further management tactics for a patient with adjacent organ injury is carried out by a surgeon in conjunction with a urologist in a surgical inpatient setting.
It is recommended to perform emergency selective and superselective embolization of renal vessels in patients with hemodynamic instability and acute anemia due to uncontrolled intra- or postoperative bleeding occurring during or after PCNL, with the aim of stopping the hemorrhage [322, 323, 324].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform emergency laparoscopic or radical nephrectomy as a lifesaving procedure when renal vessel embolization is not feasible in patients with hemodynamic instability and acute anemia due to uncontrolled intra- or postoperative bleeding occurring during or after PCNL, with the aim of stopping the hemorrhage [320, 321, 322, 323, 324, 360, 361].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Comments: due to the potential risk of nephrectomy following PCNL, patients with a solitary kidney are advised to undergo PCNL only in medical centers equipped with capabilities for emergency renal vessel embolization and hemodialysis.
It is recommended to perform laparoscopic or open pyelolithotomy in patients with kidney stones when ESWL and endourological procedures are contraindicated [177-180, 325-330, 538-543].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comments: according to meta-analysis results, laparoscopic pyelolithotomy is associated with higher stone-free rates, longer operative time and hospital stay, lower incidence of fever and blood transfusions, and a less pronounced decrease in hemoglobin levels compared to PCNL. Laparoscopic or open surgery for kidney stones is performed in rare cases as an alternative treatment when other less invasive methods (ESWL, PCNL, RIRS, or URS) have proven ineffective, have low chances of success, or are associated with high risks of complications [331]. Laparoscopic pyelolithotomy is also advisable when simultaneous laparoscopic renal procedures are planned, such as partial nephrectomy or pyeloplasty. [538-543]
The literature features a single meta-analysis comparing the outcomes of PCNL for staghorn calculi versus open lithotomy. The results of this meta-analysis demonstrated comparable stone-free rates (SFR), while parameters such as operative time, length of hospital stay, blood loss volume, and transfusion rate were lower in patients undergoing PCNL. [543]
3.4 Treatment of urolithiasis in special patient groups
3.4.1 Patients receiving anticoagulant therapy
It is recommended to consult a cardiologist, transfusionist, and/or hematologist to adjust anticoagulant therapy in patients with coagulation disorders or those requiring antithrombotic therapy prior to surgery for the prevention of intra- and postoperative complications [332].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: high bleeding risk procedures include: ESWL; PCNL; percutaneous nephrostomy; laparoscopic/open surgery. Active surveillance may be offered to patients with a high risk of thrombotic complications and asymptomatic stones [196, 333]. Temporary discontinuation of anticoagulant therapy or bridging longer-acting antithrombotics with short-acting agents prior to a high-bleeding-risk procedure is permissible only in consultation with a cardiologist and/or hematologist.
3.4.2 Stones in pregnant women
It is recommended to perform ultrasound of the kidneys and adrenal glands and ultrasound of the urinary tract in pregnant patients as the first-line diagnostic method for urolithiasis. Magnetic resonance imaging of the kidneys at 1.5 Tesla (HASTE sequence) is recommended as a second-line diagnostic method. Low-dose CT is recommended as a third-line diagnostic method [334, 335].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
Comments: Low-dose MSCT can be used only in the second and third trimesters of pregnancy and only in extreme cases. The use of diagnostic imaging during pregnancy must be decided by a medical board. In pregnant patients, besides stochastic effects, ionizing radiation may have deterministic teratogenic, carcinogenic, and mutagenic effects. Doses below 50 mGy are considered safe regarding teratogenic effects. Carcinogenic effects may develop at doses even down to 10 mGy. Mutagenic effects require high effective doses of 500-1000 mGy [335, 336].
It is not recommended to prescribe selective $\alpha$1-blockers (ATX group Alpha-adrenoreceptor antagonists) to pregnant patients with urolithiasis for medical expulsive therapy due to the lack of sufficient evidence regarding their efficacy and safety [337].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to use paracetamol** in pregnant patients with urolithiasis to relieve pain syndrome [338].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comment: the drug is used in accordance with the instructions in the minimum effective doses for the shortest possible course.
It is recommended to place a catheter in the upper urinary tract or perform ultrasound-guided percutaneous nephrostomy (A16.28.001.001) in a pregnant patient with urolithiasis in the presence of refractory pain syndrome and/or hydronephrosis with signs of systemic infection to prevent acute obstructive pyelonephritis [338, 339, 548, 549].
Level of Recommendations CLevel of Evidence 3Level of Recommendation C (Level of Evidence – 3)
Comments: the ureteral stent or nephrostomy tube must be changed regularly every 4–6 weeks until delivery to prevent encrustation [340].
It is not recommended to perform ESWL in pregnant women due to the high probability of fetal tissue damage [341, 187, 188, 189]. ESWL and PNL in pregnant women should be postponed until the postpartum period [342].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: performing PNL during pregnancy is possible under ultrasound guidance in the second and third trimesters of pregnancy if UNL is not feasible and due to stent/nephrostomy intolerance or rapid encrustation (earlier than 4 weeks). This procedure is recommended to be performed in expert centers with an annual PNL volume of more than 120 cases [343, 344, 345, 346].
It is recommended to perform transurethral ureterolithotripsy (TUL) in pregnant patients with ureteral stones in the absence of signs of systemic infection as an alternative to ureteral stenting or nephrostomy [339, 347, 348].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: the optimal period for TUL is the second trimester of pregnancy to minimize the risk of perinatal complications. In case of poor tolerance of the stent or nephrostomy or their rapid encrustation, TUL may also be performed in the third trimester in agreement with an obstetrician-gynecologist in a perinatal setting [347]. Laser lithotripsy is recommended as the optimal stone fragmentation method [348]. Given emerging data on the potential contamination of reusable ureteroscopes, to minimize the risk of infectious complications in pregnant patients, the working group allows for the use of single-use ureteroscopes despite the lack of exhaustive evidence [281, 349].
Starting from the 22nd week of pregnancy, kidney stone treatment must be carried out within a perinatal center equipped with a neonatal intensive care unit (wards).
3.4.3 Stones in patients with urinary diversion
It is recommended to perform ESWL, PNL, antegrade percutaneous ureterolithotripsy, and transstomal retrograde ureterolithotripsy as treatment methods for patients with urinary diversion and upper urinary tract stones [184, 350, 351].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: if any of the above methods cannot be performed, laparoscopic or open surgical intervention should be planned.
It is recommended to perform antegrade percutaneous ureterolithotripsy as an alternative to TUL in patients with a urostomy and upper urinary tract stones when retrograde access to the kidney is difficult [352, 353].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended to avoid damaging the urinary continence mechanism when performing transstomal manipulations in patients with heterotopic urinary diversion and upper urinary tract stones [354, 355].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended to use percutaneous stone removal in patients with orthotopic urinary diversion to reduce the risk of neobladder neck sclerosis [356].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: before performing percutaneous stone removal in patients with an orthotopic or heterotopic reservoir, we recommend performing MSCT of the kidneys and upper urinary tracts with intravenous bolus contrast enhancement to assess the relationship between the bowel and the reservoir [357].
3.4.4 Patients with stones in a renal transplant
It is recommended to perform immediate drainage of the renal transplant in patients with impaired urine outflow from it to prevent complications [358].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended to perform antegrade percutaneous ureterolithotripsy for large ureteral stones (>1.5 cm) in a renal transplant to achieve stone clearance [359].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Specific rehabilitation of patients with urolithiasis after a renal colic attack or urolithiasis surgery is not applied due to the lack of data on its efficacy [361, 362, 363, 364].
It must be taken into account that after percutaneous procedures, the risk of delayed bleeding associated with the formation of an arteriovenous fistula or pseudoaneurysm is 1.5% during the first month; therefore, strenuous physical activity should be avoided during this postoperative period.
5. Prevention and Dispensary Observation
Metaphylaxis of urolithiasis
Kidney stone formation is the result of metabolic disorders manifested by urinary hyperexcretion of stone-forming substances, shifts in urine pH, low diuresis, failures in hormonal regulation, etc. The systemic nature of the condition is also confirmed by the high risk of urolithiasis recurrence, with up to 50% of patients experiencing recurrent stone formation within 5 years and 75% within 20 years, even after complete stone removal [365]. Depending on the type of lithogenic disorders and the therapy used, metaphylaxis can reduce the risk of stone recurrence by an average of about 50% [366, 367, 368], which entails a 41% decrease in the likelihood of hospitalization and a 23% decrease in the likelihood of surgical intervention for urolithiasis [369].
5.1 Diagnostic methods.
The high-risk group includes patients with at least one risk factor listed in Table 1.
High-risk group for urolithiasis [26, 370, 371, 372, 373, 374, 375, 376, 377, 378, 379, 380, 381, 382, 383, 384]
Table 1. Risk factors for urolithiasis recurrence
General factors |
Early onset of urolithiasis (children, adolescents) |
Family history of urolithiasis |
Recurrent urolithiasis |
Two or more urinary stones |
Solitary kidney |
Chronic kidney disease (CKD) |
By stone type |
Brushite-containing stones (CaHPO4.2H2O) |
Uric acid stones |
Infectious stones |
Stone-related medical conditions |
Hyperparathyroidism |
Metabolic syndrome |
Elevated vitamin D levels |
Bone mineral disorders |
Sarcoidosis |
Nephrocalcinosis |
Polycystic kidney disease (PKD) |
Gastrointestinal disorders (jejunoileal bypass, bowel resection, Crohn's disease, malabsorption, enteric hyperoxaluria following urinary diversion, exocrine pancreatic insufficiency, urinary diversion) and bariatric surgery |
Spinal cord injury, neurogenic bladder |
Genetically determined stone formation |
Cystinuria (types A, B, and AB) |
Primary hyperoxaluria (PH) |
Type I renal tubular acidosis (RTA) |
2,8-dihydroxyadeninuria |
Xanthinuria |
Lesch-Nyhan syndrome |
Cystic fibrosis |
Drug-induced stone formation |
Anatomical abnormalities associated with stone formation |
Medullary sponge kidney (tubular ectasia) |
Ureteropelvic junction obstruction |
Calyceal diverticulum, calyceal cyst |
Ureteral stricture |
Vesicoureteral-renal reflux |
Horseshoe kidney |
Ureterocele |
Environmental and occupational factors |
Chronic lead and cadmium exposure |
Hot climate |
It is recommended to perform an additional evaluation of patients belonging to the high-risk group for urolithiasis recurrence to detect metabolic disorders, including:
blood tests: serum creatinine test, blood urea test, serum total calcium test + serum albumin test or serum ionized calcium test, serum inorganic phosphorus test, serum total magnesium test, serum sodium test, serum potassium test, serum chloride test, serum uric acid test [23], as well as serum 25-OH vitamin D test [371] and serum parathyroid hormone test [378, 379].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: considering the need to assess parathyroid hormone levels, it is recommended to draw blood between 7:00 and 11:00 AM. Approximately 50% of total plasma calcium is bound to plasma albumin, while the remaining calcium is in a physiologically active ionized free state. In cases where plasma albumin levels are low, total plasma calcium levels are often evaluated by adjusting for calcium-protein binding. The following formulas are used to determine the corrected level when albumin changes: Corrected total plasma calcium (mmol/L) = measured plasma calcium level (mmol/L) + 0.02 * (40 - measured plasma albumin level (g/L)). Corrected total plasma calcium (mg/dL) = measured plasma calcium level (mg/dL) + 0.8 * (4 - measured plasma albumin level (g/dL)). A more accurate assessment is provided by direct measurement of ionized calcium concentration.
Changes in potassium concentration, both below and above reference values, may be associated with renal tubular acidosis in the patient. Hyperchloremia may also be observed in patients with chronic metabolic acidosis secondary to renal tubular acidosis [4, 400, 401, 402, 403]. Serial monitoring of potassium, magnesium, chloride, and sodium levels is critically important during thiazide diuretic therapy, the side effects of which may include hypokalemia, hypomagnesemia, hyponatremia, and hypochloremic alkalosis.
24-hour urine biochemistry: urinary calcium excretion test, urinary uric acid excretion test, urinary sodium excretion test, urinary chloride excretion test, urinary potassium excretion test, urinary phosphorus excretion test, and urinary creatinine excretion test with urine volume measurement [380, 381, 382].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: it is recommended to perform a blood test (creatinine, urea, uric acid, sodium, magnesium, potassium, chloride, 25-OH vitamin D, parathyroid hormone, total calcium + albumin or ionized calcium tests) and a 24-hour urine test (calcium, uric acid, sodium, chloride, potassium, phosphorus, and creatinine excretion tests) no earlier than 3–4 weeks after the removal or spontaneous passage of a urinary stone, as well as the removal of urinary tract drainage [380, 381, 382]. A 24-hour urine aliquot is submitted to the laboratory. Two non-consecutive 24-hour urine collections are preferred to increase result reliability. After submitting the urine to the laboratory, it is advisable to perform the blood test on the same day for a more accurate reflection of the metabolic status.
It is recommended to determine urine hydrogen ion concentration (pH) immediately after urination using dry-chemistry test strips or pH meters several times a day for several days [23, 382, 383, 384, 385].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Complete clinical urinalysis (urine specific gravity, urine pH, etc.) [23, 382, 385].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Assessment of nutrient intake profile (diet) in patients with urolithiasis [386].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: assessment of a patient's dietary pattern is possible using prospective methods (food diaries) or dietary frequency questionnaires. These methods allow for a rapid determination of the patient's dietary preferences, enabling the specialist to provide recommendations for dietary correction, including the involvement of nutritionists.
To control the quality of 24-hour urine collection, it is recommended to calculate creatinine excretion (mmol/day or mmol/kg/day) [387].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: if creatinine excretion falls outside reference values in the presence of an adequate glomerular filtration rate, it may indicate that the patient violated the 24-hour urine collection protocol. In this case, the results of the 24-hour urine biochemistry will be uninformative.
To assess the effectiveness of dietary interventions and pharmacotherapy, it is recommended to repeat the blood test (serum creatinine test, blood urea test, serum uric acid test, serum sodium test, serum magnesium test, serum potassium test, serum chloride test, serum 25-OH vitamin D test, serum parathyroid hormone test, serum total calcium test + serum albumin test or serum ionized calcium test) and 24-hour urine test (calcium, uric acid, sodium, chloride, potassium, phosphorus, and creatinine excretion tests) no later than 3–6 months after starting therapy [381, 382, 388, 389].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to take into account the results of the urinary stone mineral composition analysis (code A09.28.018) in order to determine further diagnostic and treatment tactics and select the optimal method for outpatient metaphylaxis [34, 382, 390].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to verify whether the patient is taking medications, dietary supplements, or vitamins that stimulate lithogenesis (Table 2), certain HIV protease inhibitors, lipase inhibitors (according to the ATC classification A08AB: Peripherally acting antiobesity products), triamterene (in combination with hydrochlorothiazide + triamterene), chemotherapeutic agents (L01: Antineoplastic agents), vitamin C (ascorbic acid**), vitamin D (cholecalciferol**), calcium-containing substances, and carbonic anhydrase inhibitors such as topiramate**, acetazolamide**, zonisamide, etc.) [39, 391].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Table 2. Medications associated with stone formation [39, 392, 393]
Substances capable of crystallizing in urine | Substances altering urine composition |
• Allopurinol**/oxypurinol • Amoxicillin**/ampicillin** • Ceftriaxone** • Quinolone antibacterial agents • Ephedrine • Indinavir and other HIV protease inhibitors • Magnesium trisilicate • Sulfonamides • Triamterene | • Acetazolamide** • Allopurinol** • Aluminum hydroxide and magnesium hydroxide • Ascorbic acid** • Calcium • Furosemide** • Laxatives • Losartan • Orlistat • Cholecalciferol • Topiramate** • Zonisamide |
It is recommended to perform a microbiological (culture) urine test in patients with a urine pH above 7.0 to rule out an infectious etiology of stone formation [382, 394].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
If distal renal tubular acidosis is suspected, it is recommended to perform an acid loading test in patients with calcium-phosphate and/or calcium-oxalate urinary stones [395, 396, 399, 400, 401, 402].
GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)
Comments: the primary sign of distal renal tubular acidosis is a persistently high urine pH >5.8 in patients with urolithiasis in the absence of urease-producing flora. Distal renal tubular acidosis may be accompanied by hyperchloremic metabolic acidosis (blood chloride >108 mmol/L, blood bicarbonate <23.0 mmol/L, blood pH <7.32), hypokalemia (blood potassium <3.4 mmol/L), and hypocitraturia (24-hour urine citrate <1.67 mmol/day) [395, 396, 399, 400, 401, 402].
The test protocol is as follows: after waking up until 8:00 AM, the patient fasts; during breakfast at 8:00 AM, the patient takes 40 mg of #furosemide** and 1 mg of #fludrocortisone**. Subsequently, urine is collected every hour, and its acidity (urine hydrogen ion concentration [pH]) is measured using indicator strips or a pH meter for 5 hours after drug administration. Contraindications for the test include liver disease, urinary tract infection caused by urease-producing microflora, and severe metabolic acidosis [399, 400].
The test results are interpreted as follows:
1. if urine pH is <5.4 in any of the five urine measurements, renal tubular acidosis is ruled out in the patient;
2. if urine pH is ≥5.5 in all five measurements, renal tubular acidosis is diagnosed [402].
It is recommended that when hyperoxaluria >1.0 mmol/day is detected, the patient be diagnosed with primary hyperoxaluria [403] based on genetic testing to identify mutations in the AGXT, GRHPR, and HOGA genes [403]. If daily urinary oxalate excretion is elevated >0.5 and <1.0 mmol/day, the patient is diagnosed with enteric hyperoxaluria [404, 405].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comment: to perform a definitive differential diagnosis between types of hyperoxaluria, it is advisable to perform a genetic study to detect mutations in the above-mentioned genes.
5.2 General dietary recommendations.
It is recommended that patients suffering from urolithiasis follow general dietary recommendations:
To reduce the concentration of major lithogenic substances in the urine, maintaining a daily diuresis volume of 2–2.5 liters is recommended [366, 406, 407, 408, 409, 410, 507].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
To reduce the intestinal absorption of dietary oxalates and correct hypercalciuria, a dietary calcium intake in the range of 1000–1200 mg per day is recommended [23, 408, 409, 410, 557].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Restriction of salt intake to 3–5 grams per day [411, 418].
GCR ALEL 2Grade of Recommendation A (Level of Evidence - 2)
All patients with urolithiasis are recommended to increase their intake of vegetables and fruit [413, 414, 415, 416, 558].
GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)
Restriction of protein intake to 0.8–1 g per 1 kg of body weight per day [411, 412, 417, 418].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comments: Patients with obesity (BMI ≥ 30 kg/m2) and underweight (BMI <18 kg/m2) are recommended therapy aimed at weight correction. If there is no effect, the involvement of a dietitian and an endocrinologist is required.
Patients with a BMI up to 30 kg/m2, in order to prevent a high acid load that promotes the activation of stone formation, are recommended to observe the following dietary protein proportions: 20-25% animal non-dairy protein, 30-35% animal dairy protein, 40-50% plant protein [411, 412].
The highest protein content per 100 grams of product is found in meat (17–25 g). 100 ml of milk contains from 1 to 3.5 g, dairy products from 3.7 to 25.8 g, mushrooms, legumes, nuts, and corn from 1.2 to 26.3 g. The lowest protein content is found in vegetables and fruit: from 0.7 to 4.2 g per 100 g of product [417].
When following the fluid intake regimen, emphasize the volume of diuresis, which should be at least 2.5 liters per day for adequate secondary prevention of stone formation. An exception is made for patients with chronic heart failure due to the risk of cardiac complications associated with hyperhydration. Fluid intake should be distributed evenly. If monitoring is feasible, the relative urine density indicating an adequate level of fluid intake should not exceed 1010.
An increase in sodium intake by 2.3 g (100 mmol) leads to an increase in calcium excretion by 1 mmol (40 mg). In studies on healthy individuals, excessive NaCl intake leads not only to enhanced calcium excretion, but also to an increase in the levels of parathyroid hormone, 1,25-dihydroxyvitamin D3, and osteocalcin in the urine [418, 419].
It has been proven that an increase in animal protein intake by 40 g also leads to an increase in urinary calcium excretion by 40 mg (1 mmol) [419]. An important aspect of secondary prevention is the "normalization" of lifestyle — thus, combating obesity or hypertension can reduce the risks of stone formation.
5.3 Recommendations for antircurence therapy.
It is recommended, along with dietary therapy, to use citrate mixtures (potassium hydrogen carbonate + citric acid + sodium citrate; potassium citrate + magnesium citrate + theobromine, and other combinations) or sodium hydrogen carbonate** in patients with calcium oxalate, calcium phosphate (excluding infectious etiology), and uric acid urinary stones in order to correct urinary pH to a target value of 6.2–6.8 [420–433, 550].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: correction of urine pH values is necessary only if the pH level goes beyond the designated target values. Maintaining the urine pH level at target values of 6.2–6.8 is possible through dietary modification (patient consumption of lemon water, prevalence of vegetables and fruit in the diet, etc.), as well as through the use of citrate mixtures or sodium hydrogen carbonate.
Despite assumptions about the development of hypercalciuria with the intake of sodium-containing drugs (sodium hydrogen carbonate**, sodium citrate), an increase in urinary calcium excretion was not recorded [430–433].
During the administration of citrate mixtures, an increase in citrate excretion is noted, primarily due to an increase in urinary pH [434, 435, 436, 550].
It is recommended to correct the level of purine intake in patients with hyperuricemia or hyperuricosuria [23, 437, 438, 439].
GPP CLEL 4Level of Evidence Recommendation C (Level of Evidence – 4)
Comments: hyperuricosuria can be the result of excessive purine intake, endogenous production (enzyme defects), myeloproliferative diseases, chemotherapy, gout, or excessive catabolism. A purine intake of no more than 500 mg per day is recommended [339].
It is recommended to use xanthine oxidase inhibitors (M04AA: Uric acid production inhibitors) in patients with diagnosed hyperuricemia or hyperuricosuria when dietary therapy is ineffective [440, 441, 442, 443].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comments: the first line of therapy for hyperuricemia is the prescription of allopurinol** at a dosage of 100–300 mg per day. If allopurinol** is insufficiently effective or if there are contraindications to its use, febuxostat, a non-purine selective inhibitor of uric acid production with minimal effect on other enzymes involved in purine and pyrimidine metabolism, is prescribed. The initial dose of febuxostat is 80 mg/day [444].
It is recommended for patients with urolithiasis, as a first step, to follow general dietary recommendations and normalize urine pH using alkalizing agents (citrate mixtures; sodium hydrogen carbonate**) to correct hypercalciuria at an excretion level of 5–8 mmol/day [397, 420–433, 550].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: to correct hypercalciuria, patients with urolithiasis are recommended to follow general dietary recommendations. Calcium intake should not be restricted below 1000 mg and should not exceed 1200 mg per day [23, 408–410].
It is recommended to prescribe hydrochlorothiazide** to patients with urolithiasis and hypercalciuria > 8 mmol/day, as well as to patients with hypercalciuria of 5–8 mmol/day when dietary therapy and/or alkalizing agents are ineffective [34, 366, 445, 446, 551, 552].
GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)
Comments: A side effect of thiazide diuretics is an increase in the urinary excretion of potassium, sodium, and chloride ions, resulting in hypokalemia, hyponatremia, and hypochloremia. It is recommended to monitor the levels of these electrolytes by performing a biochemical blood test during continuous administration of hydrochlorothiazide**.[447]
In patients taking hydrochlorothiazide**, regular skin examinations are recommended, as they have an increased risk of developing skin cancer and certain forms of melanoma. In patients with a history of skin cancer, the indications for taking hydrochlorothiazide** should be carefully reassessed [448, 449, 450].
If a patient is confirmed to have cystinuria (excretion greater than 0.125 mmol/day) or cystine urolithiasis, it is recommended to prescribe [451, 452, 453, 454, 455, 456, 460, 461, 462]:
High fluid intake: 3500–4000 ml per day [453].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Maintaining urine pH levels at >7.5–8 using citrate mixtures or sodium hydrogen carbonate [420–433].
Level of Evidence AGrade of Evidence 3Level of Recommendations A (Grade of Evidence – 3)
Long-term use of #captopril (starting dose 25 mg with an increase to 50 mg 3 times a day after one or two weeks of administration)** to reduce the level of cystine excretion when excretion exceeds 3 mmol per day or when other therapy is ineffective [457, 458, 459].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
If a patient is confirmed to have a diagnosis of primary hyperoxaluria [463, 464, 465, 466], it is recommended to prescribe:
High fluid intake: 3500–4000 ml per day [464].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
#Pyridoxine** 5–20 mg/kg/day in cases of primary hyperoxaluria type 1 (AGXT gene mutation) with evaluation of the effect after 3 months of drug administration [463, 465, 466].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: a positive effect is defined as at least a 30% reduction in blood oxalate levels.
Citrate mixtures [466, 467, 468].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
If a patient is confirmed to have a diagnosis of enteric hyperoxaluria, it is recommended [404, 405]:
Restrict the consumption of oxalate-rich foods [404].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Restrict fat intake [404].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Consume 1000–1200 mg of calcium per day [405, 469].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Citrate mixtures with a target urine pH level of 6.2–6.8 [420–433, 366].
Level of Evidence AGrade of Evidence 3Level of Recommendations A (Grade of Evidence – 3)
If a patient is confirmed to have a diagnosis of renal tubular acidosis, it is recommended to prescribe:
Citrate mixtures or sodium bicarbonate** (0.5-1 mmol/kg/day) [420-433,366, 561, 562].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Thiazide diuretics: #hydrochlorothiazide** 25-50 mg once daily for hypercalciuria against the background of acid-base balance normalization [34, 366, 445, 446, 559].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
For infectious lithogenesis (struvite, carbonate-apatite, ammonium urate urinary stones), it is recommended to:
acidify urine to 6.2-6.8 using L-methionine, including as part of combination drugs (L-methionine, phytates, zinc, vitamin A, vitamin C, etc.) [366, 470-479, 553].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
In cases of suspected infectious lithogenesis, complete stone removal as far as possible is recommended [475].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Infectious urinary stones include struvite and ammonium urate calculi; the formation of carbonate-apatite urinary stones may also be associated with urinary tract infections [470, 4738]. One of the main markers of infectious urolithiasis is a persistently high urine pH >7.0 and the presence of urease-producing microflora in urine culture [474, 475]. Urease-producing microflora include the following microorganisms, facultative urease producers: Enterobacter gergoviae, Klebsiella spp., Providencia stuartii, Serratia marcescens, Staphylococcus spp., E. coli; obligate urease producers: Proteus spp., Providencia rettgeri, Morganella morganii, Corynebacterium urealyticum, Ureaplasma urealyticum [475]. Patients with infectious urinary stones (struvite, carbonate-apatite, ammonium urate urinary stones) are recommended to undergo a course of postoperative antibacterial therapy according to the bacteriological analysis of urine, as well as culture of the pelvicalyceal urine portion and the stone, if available. Bacteriological examination of the urinary stone can be performed. It has been proven that microorganisms are detected in the bacteriological examination of stones in 56.4% of urolithiasis patients, and in urine examination in 33.3% of cases. At the same time, a high microbial titer in the urine (>103 CFU/ml), especially of urease-producing microorganisms, indicates a phosphate or struvite stone composition. In the case of cystine, uric acid, and oxalate stones, the urine is frequently minimally infected or sterile.
Postoperative bacteriuria in urolithiasis patients is a factor contributing to the recurrence of kidney stones. Following percutaneous nephrolithotripsy with sterile urine, 83.8% of patients showed no stone recurrence. In the presence of a urinary tract infection, stone recurrence occurred in 54.2% of patients.
If it is necessary to provide anti-adhesive, diuretic, antioxidant effects, suppress pathological crystallization, normalize urine pH levels, etc., herbal remedies can be used as part of complex metaphylaxis to increase its effectiveness [121, 122, 123, 126, 138, 139, 472, 480-492].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
Comments: there are numerous papers in domestic and foreign literature dedicated to the isolated and combined use of herbal remedies to increase the effectiveness of metaphylactic measures.
The most frequently used combinations of phytoextracts and vitamins in Russia include:
European centaury herb + lovage roots + rosemary leaves [121, 122, 123];
phytates, polyphenols, magnesium, zinc, vitamin A [472, 483-492];
terpenes: pinene, camphene, cineol, fenchone, borneol, anethole, vitamin E [121-125];
other combinations of herbal remedies and vitamins [126-137].
5.4 Dispensary follow-up
Dynamic monitoring of fixed kidney stones is possible in the absence of data on upper urinary tract urodynamic impairment, pain syndrome, pronounced changes in urinalysis, and other indications for surgical removal of urinary stones, provided that metaphylaxis is carried out [554-556].
LoR BGoE 3Level of Recommendation B (Grade of Evidence–3)
It is recommended to monitor the effectiveness of dietary interventions and drug therapy at least once every 6 months based on blood tests (blood creatinine level, blood urea level, blood uric acid level, blood sodium level, blood magnesium level, blood potassium level, blood chlorides level, blood 25-OH vitamin D level, blood parathyroid hormone level, blood total calcium level + blood albumin level or blood ionized calcium level) and 24-hour urine tests (urine calcium level, urine uric acid level, urine sodium level, urine chlorides level, urine potassium level, urine phosphorus level, urine creatinine level), general (clinical) urinalysis, microbiological (culture) urine test for bacterial pathogens with antibiotic susceptibility testing, and determination of urine hydrogen ion concentration (urine pH measurement) immediately after urination using dry-chemistry test strips or pH meters (Appendix B) [493,494, 503,560].
GGR CLEL 5Grade of Recommendations C (Level of Evidence – 5)
All urolithiasis patients belonging to the high-risk recurrence group are recommended to be monitored by a urologist for life [495,560].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
All urolithiasis patients with a history of surgery, without residual fragments, and not belonging to the high-risk recurrence group are recommended to be monitored by a urologist for 5 years [495,560].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended that all urolithiasis patients under the supervision of a urologist undergo an annual kidney ultrasound to assess the condition of the upper urinary tract [495,560].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
6. Organization of Medical Care
Indications for elective hospitalization:
1) Kidney stones requiring surgical intervention;
2) Ureteral stones requiring surgical intervention;
3) Patient's social status requiring the removal of asymptomatic urinary tract stones.
Indications for emergency hospitalization:
1) Infectious complications of urolithiasis;
2) Uncontrolled pain syndrome caused by urinary tract stones;
3) Complete obstruction of the upper urinary tract by a stone;
Indications for patient discharge from the hospital:
1) Restoration of urine outflow from the kidney;
2) Absence of signs of systemic inflammation;
3) Absence of risk of urolithiasis complications.
It is necessary to inform urolithiasis patients indicated for surgical treatment in detail about all existing treatment methods and their complications in order to increase awareness and assist in making a decision on the choice of surgical intervention method. GPP Level
Comments: modern clinical practice for treating urolithiasis includes numerous surgical options for ridding patients of urinary tract stones with potentially equivalent final efficacy. However, each surgery differs in the frequency of complication risks, stone-free rates, and the degree of invasiveness. Often, the choice of surgery depends on the physician's preferences, which leads to a lack of patient awareness regarding the pros and cons of a particular surgery and thereby impairs treatment adherence. The working group considers it necessary to inform the patient in detail about all existing urolithiasis treatment methods and their complications.
7. Additional Information
No.
Criteria for Evaluating the Quality of Medical Care
No. | Quality criteria | Performance evaluation |
|---|---|---|
1 | A complete blood count (differential) was performed | Yes/no |
2 | General general-therapeutic blood biochemistry performed (blood creatinine level test) | Yes/no |
3 | Microbiological (cultural) urine test for aerobic and facultatively anaerobic opportunistic microorganisms and determination of microorganism susceptibility to antimicrobial chemotherapeutic drugs performed (if not performed on an outpatient basis within 2 months prior to hospitalization) | Yes/no |
4 | Non-contrast computed tomography of the kidneys and urinary tract performed (Computed tomography of the abdominal cavity and retroperitoneal space (A06.30.005.001) + Spiral computed tomography of the pelvic organs in women / in men (A06.20.002.001 / A06.21.003.001)) | Yes/no |
5 | The patient is recommended to undergo mineral composition analysis of the urinary stone, passed spontaneously or removed during surgical treatment (code A09.28.018) | Yes/no |
6 | Upper urinary tract drainage performed via placement of a ureteral catheter or percutaneous puncture nephrostomy in patients with hydronephrosis with stone obstruction of the kidney and ureter, refractory renal colic, and signs of urinary tract infection | Yes/no |
7 | A safety guidewire was used during transurethral lithotripsy in urolithiasis patients | Yes/no |
8 | Preliminary catheter placement in the upper urinary tract performed for at least 5 days before surgery when planning transurethral nephrolithotripsy using a ureteral access sheath | Yes/no |
9 | Transurethral nephrolithotripsy performed using a "ureteral access sheath" in the presence of high-risk factors for infectious complications (bacteriuria, infectious stones, history of urinary tract infection episodes, diabetes mellitus, estimated operation time > 60 min, presence of a ureteral stent for more than 30 days, presence of a nephrostomy drainage) | Yes/no |
10 | Prevention of infectious complications performed with antibacterial drugs during surgical intervention | Yes/no |
11 | As a result of conservative (lithokinetic therapy) or surgical treatment (ESWL, TUL, antegrade percutaneous ureterolithotripsy, laparoscopic or open ureterolithotomy), upper urinary tract obstruction by the stone was resolved. | Yes/no |
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Gao ZM, Gao S, Qu HC, Li K, Li N, Liu CL, Zhu XW, Liu YL, Wang P, Zheng XH. Minimally invasive percutaneous nephrolithotomy improves stone-free rates for impacted proximal ureteral stones: A systematic review and meta-analysis. PLoS One. 2017 Feb 2;12(2):e0171230. doi: 10.1371/journal.pone.0171230.
Wang Y, Chang X, Li J, Han Z. Efficacy and safety of various surgical treatments for proximal ureteral stone ≥10mm: A systematic review and network meta-analysis. Int Braz J Urol. 2020 Nov-Dec;46(6):902-926. doi: 10.1590/S1677-5538.IBJU.2019.0550.
Lai S, Jiao B, Diao T, Seery S, Hu M, Wang M, Hou H, Wang J, Zhang G, Liu M. Optimal management of large proximal ureteral stones (>10 mm): A systematic review and meta-analysis of 12 randomized controlled trials. Int J Surg. 2020 Aug;80:205-217. doi: 10.1016/j.ijsu.2020.06.025. Epub 2020 Jul 1.
Sharma G, Pareek T, Tyagi S, Kaundal P, Yadav AK, Thummala Y, Devana SK. Comparison of efficacy and safety of various management options for large upper ureteric stones a systematic review and network meta-analysis. Sci Rep. 2021 Jun 3;11(1):11811. doi: 10.1038/s41598-021-91364-3.
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Lachinov E.L., Zhantlisov D.A., Gorbachev M.V. Urine pH correction as an effective tool for successful metaphylaxis of urolithiasis. Fitoterapiya. Urologiya. 2020; (3): 104-110.
Laerum E, Larsen S. Thiazide prophylaxis of urolithiasis. A double-blind study in general practice. Acta Med Scand. 1984;215(4):383-9. PMID: 6375276.
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Appendix A1. Working Group Composition
Head of the Working Group: Alexey G. Martov – MD, Corresponding Member of the Russian Academy of Sciences, Professor, Head of the Department of Urology and Andrology, MBUIANO FSBI SSC FMBC named after A.I. Burnazyan, Senior Researcher, MROC Lomonosov Moscow State University, Head of the Urology Center, Central Clinical Hospital of Civil Aviation, Moscow.
Secretary of the Working Group: Revaz R. Kharchilava – PhD, Director of the Praxi Medica Medical Practice Training Center, Sechenov First Moscow State Medical University (Sechenov University), Moscow.
Members of the Working Group:
Gagik N. Акоpyan – MD, Professor, Institute of Urology and Human Reproductive Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow;
Gadzhiev Nariman Kazikhanovich - Dr. Sci. (Med.), Professor of the Department of Hospital Surgery, Saint Petersburg State University, Deputy Director for Medical Affairs (Urology) at the Pirogov Clinic of High Medical Technologies, Saint Petersburg State University, Saint Petersburg;
Prosyannikov Mikhail Yuryevich - Dr. Sci. (Med.), Head of the Department of Urolithiasis at the Lopatkin Scientific Research Institute of Urology and Interventional Radiology - Branch of the National Medical Research Centre of Radiology of the Russian Ministry of Health, Professor at the Department of Biomedical Safety, Bauman Moscow State Technical University, Moscow;
Malkhasyan Vigen Andreevich - Dr. Sci. (Med.), Head of Urological Department No. 67 at the Botkin Moscow City Multidisciplinary Clinical Research Center, Professor at the Department of Urology, Russian University of Medicine of the Russian Ministry of Health, Moscow.
Conflict of interest: all members of the Working Group have confirmed that there is no financial support or conflict of interest to declare.
Appendix A2. Methodology for Developing Clinical Guidelines
The target audience for these clinical guidelines includes specialists with higher medical education in the following specialties:
urology
internal medicine
general practice (family medicine)
surgery
anesthesiology and critical care medicine
Table 1 – Scale for assessing the level of reliability of evidence (LRE) for diagnostic interventions
LoE | Hierarchy of clinical study designs in descending order of the level of reliability of evidence from 1 to 5 |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
Table 2 – Scale for determining the level of reliability of evidence (LRE) for therapeutic, rehabilitation, and preventive interventions
LoE | Hierarchy of clinical study designs in descending order of the level of reliability of evidence from 1 to 5 |
|---|---|
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report or case series, case-control study |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3 – Scale for determining the level of reliability of recommendations (LRR) for diagnostic, therapeutic, and rehabilitation interventions
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision – at least once every 3 years, or whenever new information on the management of patients with the given condition becomes available. The decision to update is made by the Russian Ministry of Health based on proposals submitted by professional medical non-profit organizations. The submitted proposals must take into account the results of a comprehensive assessment of drugs and medical devices, as well as the results of clinical approbation.
Appendix A3. Reference Materials
Stratification of urolithiasis by stone formation etiology:
Metabolic | Infectious stones | Genetically determined stones | Drug-induced |
|---|---|---|---|
Calcium oxalate; Calcium phosphate; Uric acid. | Magnesium ammonium phosphate; Carbonate apatite; Ammonium urate. | Cystine; Xanthine; 2,8-Dihydroxyadenine. | Allopurinol**; Ceftriaxone**; Fluoroquinolones; Ephedrine; Indinavir. |
Stratification of urolithiasis by stone chemical composition:
Chemical composition | Mineral name | Frequency of occurrence |
|---|---|---|
Calcium oxalate monohydrate | Whewellite | 60-70% |
Calcium oxalate dihydrate | Weddellite | 10-15% |
Uric acid | Uricite | 10% |
Uric acid dihydrate | Uricite | 2-5% |
Ammonium urate | 0.5-1% | |
Carbonate apatite | Dahllite | 5% |
Calcium hydrogen phosphate | Brushite | 1% |
Magnesium ammonium phosphate | Struvite | 5-10% |
Cystine | Cystine | 0.5% |
Stratification of urolithiasis by stone radiopacity:
Radiopaque | Faintly radiopaque | Non-radiopaque |
|---|---|---|
Calcium oxalate monohydrate | Magnesium ammonium phosphate | Uric acid |
Calcium oxalate dihydrate | Apatite | Ammonium urate |
Calcium phosphate | Cystine | Xanthine |
2,8-Dihydroxyadenine | ||
Drug-induced stones |
Stratification of urolithiasis by recurrence risk group:
General factors |
|---|
Early onset of urolithiasis (children, adolescents) |
Family history of urolithiasis |
Recurrent urolithiasis |
Two or more urinary stones |
Solitary kidney |
Chronic kidney disease (CKD) |
By stone type |
Brushite-containing stones (CaHPO4.2H2O) |
Uric acid stones |
Infectious stones |
Stone-related medical conditions |
Hyperparathyroidism |
Metabolic syndrome |
Elevated vitamin D levels |
Bone mineral disorders |
Sarcoidosis |
Nephrocalcinosis |
Polycystic kidney disease (PKD) |
Gastrointestinal disorders (jejunal and ileal bypass, bowel resection, Crohn's disease, malabsorption, enteric hyperoxaluria following urinary diversion, exocrine pancreatic insufficiency, urinary diversion) and bariatric surgery |
Spinal cord injury, neurogenic bladder |
Genetically determined stone formation |
Cystinuria (types A, B, and AB) |
Primary hyperoxaluria (PH) |
Type I renal tubular acidosis (RTA) |
2,8-dihydroxyadeninuria |
Xanthinuria |
Lesch-Nyhan syndrome |
Cystic fibrosis |
Drug-induced stone formation |
Anatomical abnormalities associated with stone formation |
Medullary sponge kidney (tubular ectasia) |
Ureteropelvic junction obstruction |
Calyceal diverticulum, calyceal cyst |
Ureteral stricture |
Vesicoureteral-renal reflux |
Horseshoe kidney |
Ureterocele |
Environmental and occupational factors |
Chronic lead and cadmium exposure |
Hot climate |
Appendix B. Physician Action Algorithms
Evaluation algorithm for patients with urolithiasis symptoms (excluding renal colic):
Management algorithm for patients with an indication for surgical intervention for kidney stones:
Management algorithm for patients with an indication for surgical intervention for a ureteral stone:
Prevention and metaphylaxis algorithm for urolithiasis:
Metaphylaxis algorithm for urolithiasis in high-risk recurrence patients:
Appendix C. Patient Information
Kidney stones occur in 20% of the population, more commonly in men aged 40 to 50 years. Urinary tract stones form as a result of the crystallization of minerals and salts in the urine. They are hard masses and can have a diverse chemical composition: calcium phosphate, calcium oxalate, uric acid, ammonium urate, struvite, cystine, and others, as well as combinations thereof. The causes of their formation can also vary: metabolic disorders, infections, genetic factors, various diseases of other systems and organs, your lifestyle, and dietary preferences. The size of a kidney stone can reach 8–10 cm and take the shape of the renal collecting system (staghorn calculus). When kidney stones are detected, the diagnosis of urolithiasis is established.
The following factors are associated with a high risk of urolithiasis progression:
− kidney stones diagnosed in childhood or adolescence;
− personal or family history of urolithiasis in first-degree relatives;
− stones containing brushite, uric acid, or urate;
− urinary tract infection;
− genetic predisposition to stone formation;
− ureteral stricture, most commonly at the pelviureteric junction;
− congenital renal anomalies: horseshoe kidney, duplication of the urinary tract, medullary sponge kidney, etc.;
− polycystic kidney disease;
− nephrocalcinosis (excess calcium in the kidneys);
− vesicoureteral reflux (backflow of urine from the bladder into the ureters or kidneys);
− hyperparathyroidism (overproduction of hormone by the parathyroid glands);
− gastrointestinal disorders (jejunal bypass, bowel resection, Crohn's disease);
− sarcoidosis, etc.
In some cases, kidney stones do not cause any discomfort. These are called asymptomatic stones and are incidentally detected during ultrasound and radiological examinations. However, if they pass into the ureter and block the outflow of urine from the kidney, acute, excruciating pain in the lumbar region—renal colic—can develop. Renal colic is caused by a sudden increase in pressure within the urinary tract and the ureteral wall. The pain comes in waves, does not subside with changes in body position, and may be accompanied by nausea, vomiting, hematuria, and fever. Renal colic is an emergency and requires immediate medical attention. Stones that do not block the ureter may cause periodic dull flank pain and also require medical evaluation.
Diagnostic methods:
Ultrasound (US) is the first-line diagnostic modality for kidney and ureteral stones. Ultrasound can determine the location, size, and degree of urinary tract obstruction caused by the stone. However, radiological imaging and computed tomography (CT) are required to determine stone density and exact size, which may be decisive factors in choosing the treatment method. If additional information about the structure of the renal collecting system is needed, especially in the presence of anomalies, computed tomography can be performed with intravenous contrast administration. Blood and urine tests are necessary in the presence of pain and fever, as well as for treatment planning and stone prevention.
If you "catch" a spontaneously passed stone, you should submit it for analysis to accurately determine its composition, which will help the physician prescribe the correct treatment and prevention.
Factors influencing treatment tactics include:
− symptoms;
− stone characteristics (size, location, density);
− medical history;
− treatment modalities available at your hospital and your physician's experience;
− your personal preferences.
Not all kidney stones require active treatment. It all depends on the presence of symptoms and personal preferences. If you have a kidney or ureteral stone that causes no discomfort, you generally will not receive treatment. Your physician will provide a schedule of regular follow-up visits to ensure your condition does not worsen. If your stone is predicted by the physician to pass spontaneously in the urine, you may be prescribed medications to facilitate this process. This is referred to conservative management.
If your stone continues to grow or causes frequent and severe pain, active treatment is indicated.
Conservative therapy.
Depending on the size and location of the stone, it may take some time for the stone to pass in the urine. During this period, renal colic may occur, requiring medical supervision. If you have a very small stone, there is a 95% probability that it will pass spontaneously within 6 weeks. The larger the stone, the lower the probability of its passage. There are two common options for conservative management: metaphylactic/lithokinetic therapy (medical assistance in stone passage through the urinary tract) and litholytic therapy (medical dissolution of stones if they consist of uric acid).
Even when you have no symptoms, you may need treatment if:
− the stone continues to grow;
− you are at high risk of forming another stone;
− a urinary tract infection is present;
− your stone is very large;
− you prefer active treatment.
Surgical treatment.
There are 3 common methods for stone removal: extracorporeal shock wave lithotripsy (ESWL), ureterorenoscopy, and percutaneous nephrolithotomy (PCNL). The choice of surgical treatment option depends on many aspects. The most important factors are the stone characteristics and the symptoms it causes. Depending on whether the stone is located in the kidney or the ureter, the physician may recommend various treatment options. In rare cases, stone removal is possible only via open or laparoscopic access.
Surgical treatment is indicated if:
− the stone is large, which makes spontaneous passage difficult;
− drug therapy is ineffective;
− infectious complications develop due to the stone;
− pain and/or blood in the urine are present;
− solitary kidney;
− renal function begins to deteriorate.
Extracorporeal shock wave lithotripsy (ESWL).
Extracorporeal shock wave lithotripsy is performed using a device capable of breaking up stones in the kidney and ureter. To fragment the stone, focused shock waves (short high-energy wave pulses) are transmitted to the stone through the skin. The stone absorbs the energy of the shock waves and breaks into smaller pieces. The stone fragments then pass in the urine. The procedure takes about 45 minutes. If you have a large stone, you may need multiple sessions to completely break it up.
ESWL is contraindicated in:
− pregnancy;
− risk of severe bleeding;
− presence of uncontrolled infection;
− urinary tract narrowing distal to the stone;
− very hard stones (e.g., cystine stones).
Good to know! ESWL breaks the stone into small pieces. These fragments will pass in the urine for several days or weeks after the procedure. You may have blood in your urine, but this should not last longer than 2 days. Your physician may prescribe medications that promote faster fragment passage and reduce pain. ESWL may be accompanied by both intra- and postoperative complications.
The following may occur during surgery:
− renal injury, bleeding with the formation of a clinically manifest hematoma, sometimes requiring surgical intervention (up to 1%);
− renal injury with the formation of an asymptomatic hematoma (up to 19%);
Postoperative complications may include:
− accumulation of stone fragments in the ureter requiring conservative or surgical treatment (up to 7%);
− infectious complications (up to 20%);
− growth of residual stone fragments left in the kidney (up to 50%);
− renal colic associated with ureteral obstruction by stone fragments (up to 4%).
− aneurysm, arteriovenous fistula;
- internal organ injury (individual clinical cases described).
You must return to the hospital immediately if:
− fever above 38°C appeared;
− severe flank pain occurred;
− blood in the urine persists for more than 2 days after the procedure.
Percutaneous nephrolithotomy (PCNL).
PCNL is most commonly used when kidney stones are large, of high density, or numerous. PCNL is usually performed under general anesthesia. During this procedure, a small tube called a catheter is placed into the urinary bladder. Another catheter is placed into the ureter. Contrast material, or dye, may be injected through this catheter to provide a better view and precise localization of the stone. Once the stone is located, access to the renal collecting system is established using a thin needle and a so-called guidewire. The guidewire ensures safe access for the nephroscope (an instrument for visualizing the interior of the kidney). After visualizing the stone, some stones can be removed using forceps. Larger stones must be fragmented using a special pneumatic, ultrasonic, or laser device—nephrolithotomy. After removing stone fragments from the kidney, a small temporary tube connecting the kidney to the bladder (stent catheter) is usually placed in the ureter, and a tube draining the kidney (nephrostomy tube) is placed in the working channel through which the surgery was performed. After surgery, these tubes are removed in a few days.
Good to know! PCNL may be accompanied by both intraoperative and postoperative complications.
The following may occur during surgery:
− bleeding that may require blood transfusion (up to 20%), renal vessel embolization, or kidney removal (up to 1.5%);
− pleural injury (up to 11.6%);
− internal organ injury (up to 1.7%);
− mortality (up to 0.3%).
Postoperative complications may include:
− fever (up to 32.1%);
− sepsis (up to 1.1%);
− urinoma (accumulation of urine in the perirenal or retroperitoneal tissue surrounded by a fibrous capsule) up to 1%;
− residual stone fragments (up to 19.4%), requiring reintervention in some cases;
− aneurysm, arteriovenous fistula;
You must return to the hospital immediately if:
− body temperature above 38 °C;
− nausea and vomiting;
− chest pain and difficulty breathing;
− large amount of blood in the urine;
− severe pain on the operated side;
− inability to urinate.
Transurethral uretero- and nephrolithotripsy.
Transurethral ureterolithotripsy is the preferred treatment method for small and medium-sized stones located in any part of the urinary tract. The procedure is usually performed under general anesthesia. During this procedure, a ureteroscope (a long, thin instrument with a tiny camera at the end) is inserted through the urethra and bladder into the ureter or kidney. Once the stone is found, it can be extracted using "forceps or a basket," or a laser or pneumatic device is used to break the stone into smaller pieces before they are extracted with the basket. Ureteroscopes can be flexible, like a long thin straw, or more rigid. After stone removal, a small temporary tube called a stent may be placed in the ureter to facilitate the outflow of urine from the kidney to the bladder. The urinary catheter and/or stent are usually removed shortly after the procedure.
Good to know! Transurethral ureterolithotripsy may be accompanied by both intraoperative and postoperative complications, which in rare cases may require conversion to open surgery or reintervention.
The following may occur during surgery:
− stone migration into the kidney (up to 12%);
− infectious complications (up to 6%);
− ureteral injury (up to 2%);
− bleeding that may require blood transfusion (0.1%);
− ureteral avulsion (0.1%);
Postoperative complications may include:
− fever and sepsis (up to 1.1%);
− persistent hematuria (up to 2%);
− renal colic (2.2%);
− ureteral narrowing (stricture) 0.1%;
− vesicoureteral reflux (0.1%);
− internal organ injury (up to 0.05%);
You must return to the hospital immediately if:
− body temperature above 38 °C;
− inability to urinate;
− large amount of blood in the urine;
− you continue to experience severe flank pain.
Even if you have a low risk of forming another stone, you need to make some lifestyle changes. These measures reduce the risk of recurrence and improve your overall health.
General advice:
− drink 2.5 to 3 liters of water evenly throughout the day;
− choose pH-neutral drinks such as water;
− monitor your urine output (should be 2 to 2.5 liters per day);
− monitor the color of your urine: it should be light;
− drink even more if you live in a hot climate or exercise;
− eat a balanced and varied diet;
− avoid excessive intake of vitamin supplements.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
No.