Levels of evidence (Ia-IV), grades of the guideline statements (Standard, Recommendation, Option), and the index patient are defined at the end of the "Major Recommendations" field.
Treatment Guidelines for the Index Patient
For All Index Patients
Standard: Patients with bacteriuria should be treated with appropriate antibiotics. [Based on Panel consensus/Level IV]
Standard: Stone extraction with a basket without endoscopic visualization of the stone (blind basketing) should not be performed. [Based on Panel consensus/Level IV]
For Ureteral Stones <10 mm
Option: In a patient who has a newly diagnosed ureteral stone <10 mm and whose symptoms are controlled, observation with periodic evaluation is an option for initial treatment. Such patients may be offered an appropriate medical therapy to facilitate stone passage during the observation period. [Based on review of the data and panel opinion/Level IA]
Standard: Patients should be counseled on the attendant risks of medical expulsive therapy (MET) including associated drug side effects and should be informed that it is administered for an "off label" use. [Based on Panel consensus/Level IV]
Standard: Patients who elect for an attempt at spontaneous passage or MET should have well-controlled pain, no clinical evidence of sepsis, and adequate renal functional reserve. [Based on Panel consensus/Level IV]
Standard: Patients should be followed with periodic imaging studies to monitor stone position and to assess for hydronephrosis. [Based on Panel consensus/Level IV]
Standard: Stone removal is indicated in the presence of persistent obstruction, failure of stone progression, or in the presence of increasing or unremitting colic. [Based on Panel consensus/Level IV]
For Ureteral Stones >10 mm
For Patients Requiring Stone Removal
Standard: A patient must be informed about the existing active treatment modalities, including the relative benefits and risks associated with each modality. [Based on Panel consensus/Level IV]
Recommendation: For patients requiring stone removal, both shock-wave lithotripsy (SWL) and ureteroscopy (URS) are acceptable first-line treatments. [Based on review of the data and Panel consensus/Level IA-IV]
Recommendation: Routine stenting is not recommended as part of SWL. [Based on Panel consensus/Level III]
Option: Stenting following uncomplicated URS is optional. [Based on Panel consensus/Level IA]
Option: Percutaneous antegrade ureteroscopy is an acceptable first-line treatment in select cases. [Based on Panel consensus/Level III]
Option: Laparoscopic or open surgical stone removal may be considered in rare cases where SWL, URS, and percutaneous URS fail or are unlikely to be successful. [Based on Panel consensus/Level III]
Recommendations for the Pediatric Patient
Option: Both SWL and URS are effective in this population. Treatment choices should be based on the child's size and urinary tract anatomy. The small size of the pediatric ureter and urethra favors the less invasive approach of SWL. [Based on review of data and Panel consensus/Level III]
Recommendations for the Nonindex Patient
Standard: For septic patients with obstructing stones, urgent decompression of the collecting system with either percutaneous drainage or ureteral stenting is indicated. Definitive treatment of the stone should be delayed until sepsis is resolved. [Based on Panel consensus/Level III]
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis of randomized trials
Ib Evidence obtained from at least one randomized trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study
III Evidence obtained from well-designed nonexperimental studies, such as comparative studies, correlation studies, and case reports
IV Evidence obtained from expert committee reports, or opinions, or clinical experience of respected authorities
Grades of Guideline Statements
Standard: A guideline statement is a standard if: (1) the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions, and (2) there is virtual unanimity about which intervention is preferred.
Recommendation: A guideline statement is a recommendation if: (1) the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions, and (2) an appreciable but not unanimous majority agrees on which intervention is preferred.
Option: A guideline statement is an option if: (1) the health outcomes of the interventions are not sufficiently well known to permit meaningful decisions, or (2) preferences are unknown or equivocal.
Index Patient
In constructing these guidelines, an "index patient" was defined to reflect the typical individual with a ureteral stone whom a urologist treats. The following definition was created.
The index patient is a nonpregnant adult with a unilateral noncystine/nonuric acid radiopaque ureteral stone without renal calculi requiring therapy whose contralateral kidney functions normally and whose medical condition, body habitus, and anatomy allow any one of the treatment options to be undertaken.
