October 2026 English edition · Evidence reviewed through October 3, 2026 · David Shusterman, MD

Appendix I: Procedures Compared

A procedure is selected by matching the stone to the patient. Size is important, but so are location, density, anatomy, obstruction, infection, renal function, bleeding risk, body habitus, pregnancy, occupational needs, previous procedures, and patient preference.

Observation — stable patient with a stone considered likely to pass and no urgent indication for drainage. Advantages: avoids anesthesia and instrumentation. Limitations and burdens: requires symptom control, follow-up, and a defined endpoint; passage is not assured.

Medical expulsive therapy — selected ureteral stones, particularly where an alpha-blocker is likely to help. Advantages: nonoperative; may improve passage in selected patients. Limitations and burdens: benefit varies by stone size and location; dizziness and ejaculatory effects may occur.

Ureteral stent — urgent drainage, temporary bypass, or postoperative drainage. Advantages: rapid internal decompression; no external collection bag. Limitations and burdens: urgency, frequency, hematuria, pelvic pressure, flank pain, and removal requirement.

Nephrostomy tube — urgent decompression or percutaneous access. Advantages: direct kidney drainage; useful when retrograde access is difficult. Limitations and burdens: external tube and bag; skin-site care; dislodgment or infection risk.

Shock-wave lithotripsy — selected renal and ureteral stones that can be targeted and fragmented. Advantages: no natural-orifice scope into the ureter; often outpatient. Limitations and burdens: may require repeat treatment; fragments must pass; less effective for dense, large, lower-pole, or poorly targeted stones.

Ureteroscopy — many ureteral and renal stones. Advantages: high stone-free potential in one setting; direct visualization and laser treatment. Limitations and burdens: anesthesia, instrumentation, possible stent, infection or ureteral injury risk.

PCNL — large or complex renal stone burdens. Advantages: highest clearance for many large stones; removes fragments through a tract. Limitations and burdens: more invasive; bleeding and adjacent-organ risks; hospitalization or drainage may be required.

Observation Is an Active Plan

Observation requires confirmed or strongly supported diagnosis, assessment for infection and renal impairment, adequate symptom control, follow-up imaging when indicated, and an agreed point at which continued waiting no longer makes sense. Employment, travel, pregnancy, access to emergency care, and patient tolerance may reasonably favor earlier intervention.

Stent Versus Nephrostomy for Urgent Drainage

Both can decompress an obstructed infected system. The choice depends on anatomy, stone location, operating-room access, interventional radiology availability, coagulopathy, illness severity, and clinician expertise. Drainage treats the emergency; it does not necessarily remove the stone.

SWL Versus Ureteroscopy

SWL avoids ureteroscopic instrumentation but depends on successful fragmentation and spontaneous clearance. Ureteroscopy offers direct treatment and generally higher single-procedure clearance for many stones but requires anesthesia and may involve a stent. Shared decision-making should include retreatment rates, anticipated symptoms, stone-free goals, and the patient’s schedule.

PCNL for Large Burdens

For renal stone burdens above approximately 20 mm, complex branching stones, or situations where other methods are unlikely to clear the kidney efficiently, PCNL is commonly favored. Miniaturized techniques and tubeless pathways may reduce recovery for selected patients, but the operation remains more invasive than SWL or ureteroscopy.

A balanced consultation does not ask which procedure is universally best. It asks which option offers the best tradeoff for this stone, this anatomy, and this patient.