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How to treat an asymptomatic patient with a renal stone 1 to 2 cm in size?
Treatment of the asymptomatic patient with a 1- to 2-cm renal stone is a toss-up. Each expert has an opinion based on the experience of the local medical community. Many asymptomatic stones can be monitored without intervention, other than that noted in question 31. Specifics of stone location, duration, obstruction, and overall patient health are important in the decision. Recurrent, enlarging, or multiple asymptomatic stones or stones with silent obstruction probably should be treated. Urology consultation is essential. Techniques considered by the urologist for stones that do not pass spontaneously include ureteroscopy (URS), percutaneous nephrostomy, ESWL, stent placement, PCNL, open nephrostomy, and robotic-assisted surgery. A combination of these techniques may be necessary for larger stones and depends on stone location. Flexible ureteroscopic lithotripsy with holmium: yttrium–aluminum–garnet (YAG) laser is less invasive and often as effective and safer than PCNL. Other techniques include percutaneous ultrasonic lithotripsy, endoscopic ultrasonic lithotripsy, percutaneous nephrolithotripsy, electrohydraulic lithotripsy, and URS with mechanical crushing, ultrasonography, or laser.
What treatment should be used if the stone is > 3 cm?
If the stone is > 3 cm, lithotripsy alone usually fails. The initial approach to patients with stones of this size includes endoscopic techniques, including PCNL and URS. In certain centers, robotic-assisted surgery is used to treat complex or large-volume renal stones. Open lithotomy is now unusual. Therapy for stones > 2 cm in size depends on the patient’s overall status, wishes, and experiences, and the experiences of the patient’s physician and urologist. A combination of techniques outlined in questions 38 and 39 is sometimes necessary.
