Stone disease is common, recurrent (roughly 50% recurrence within 5–10 years without prevention), and often exquisitely painful. Manage the acute episode (pain, obstruction, infection), decide who needs intervention, treat definitively, and then…
28 pathway steps3 pathways4 local-policy stepsTailored for Ohio
Your learning progress0 of 31 chapters complete
Saved privately in this browser and shared across state tabs.
Ohio
Ohio: ureteroscopy is performed in our Columbus ASC. An obstructing stone with infection goes to the hospital, never the ASC.
Didactics
Shared across all locations
Stone disease is
common, recurrent (roughly 50% recurrence within 5–10 years without
prevention), and often exquisitely painful. Manage the acute episode
(pain, obstruction, infection), decide who needs intervention, treat
definitively, and then actually set up prevention so patients do not
keep coming back.
7.1 Acute renal colic
Presentation
— sudden, severe, colicky flank pain that waxes and wanes and may
radiate to the groin, labia, or testis as the stone moves distally.
Nausea and vomiting are common (shared celiac plexus innervation).
The patient is classically restless and cannot find a comfortable
position — a useful discriminator from peritonitis, where patients
lie still. A stone at the ureterovesical junction produces urgency
and frequency that mimics a UTI.
Diagnosis
— non-contrast CT of the abdomen/pelvis is the standard — it
defines stone size, location, density (Hounsfield units, which
predict fragility), skin-to-stone distance, and the degree of
hydronephrosis. Ultrasound (radiation-sparing) is preferred in
pregnancy and reasonable for younger patients and for follow-up.
Plain KUB is useful only for tracking a known radio-opaque stone
(uric acid stones are radiolucent).
Labs —
urinalysis (hematuria is present in ~85% — its ABSENCE does not
exclude a stone), urine culture, CBC, creatinine. Check calcium and
consider PTH later if hypercalcemia.
The stone emergency — never miss it
Fever or signs of infection
with an obstructing stone = obstructive pyelonephritis/urosepsis
→ emergent decompression (stent or nephrostomy) plus
antibiotics (Chapter 2). Antibiotics alone will not save this
patient.
Also escalate: acute kidney
injury, bilateral obstruction, obstruction of a solitary or
transplanted kidney, or intractable pain/vomiting.
The patient who looks “not that sick” with a fever and
an obstructing stone can be in septic shock in three hours. Do
not send them home.
7.2 Acute management
Analgesia:
Use acetaminophen (Tylenol), suzetrigine (Journavx), and
ketorolac 15–30 mg IM in the office if renal function allows. NSAIDs are first-line and
superior to opioids for renal colic if renal function allows —
they reduce ureteral wall edema and prostaglandin-mediated pain.
Opioids are almost always avoided. Patients may already be constipated from
narcotics given in the emergency department; ask when they last had a bowel
movement. Stool burden can amplify renal colic, and restoring bowel function
may help more than giving additional narcotics. Antiemetics for nausea.
Medical
expulsive therapy (MET): an alpha-blocker (tamsulosin 0.4 mg
daily) should be used for any ureteral stone that the patient wants
to try to pass. It relaxes ureteral smooth muscle and can aid stone
passage.
Hydration
and a strainer to capture the stone — send EVERY captured
stone for composition analysis. This is the cheapest, most valuable
test in stone disease and it is skipped constantly.
Expectations:
stones < 6 mm often pass spontaneously; stones ≥ 8 mm
typically require intervention. Distal stones pass more readily than
proximal. Give a reasonable trial of passage
(up to ~4–6 weeks) only if the patient is comfortable, not
infected, and has normal renal function.
7.3 When to intervene, and how — the Advanced
Urology approach
Intervene for
stones unlikely to pass, refractory pain, obstruction with infection
(emergent), AKI, a solitary kidney, or patient preference (many
patients do not want to wait weeks). Central Ohio Urology Group treats the
overwhelming majority of stones — including very large burdens once
considered “percutaneous only” — with ureteroscopy in our
ambulatory surgery centers, reserving PCNL for the largest stones.
Procedure
our practice role
Ureteroscopy (URS) with laser lithotripsy
Our workhorse for ureteral and renal stones — including massive
stones. Done in the ASC with best-in-class thulium fiber lasers,
Dornier single-use digital scopes, and direct-in-line vacuum
aspiration to evacuate fragments (superior clearance, lower
intrarenal pressure). All patients are stented afterward.
Shock wave lithotripsy (SWL)
Non-invasive option for smaller stones in favorable locations;
lower stone-free rate for hard/large stones. Poor for lower-pole
stones, obesity, and dense stones (high Hounsfield units);
contraindicated in pregnancy, uncorrected coagulopathy, and
untreated infection.
Percutaneous nephrolithotomy (PCNL)
Reserved for the largest stones — generally > 4 cm — and
complex/staghorn burdens; highest single-session clearance for
those cases. The added risk of PCNL comes from the ACCESS TRACT —
the working channel we create from the skin, through the flank
muscles, into the kidney's collecting system (see below).
Stent or nephrostomy (decompression)
Temporizing for obstruction/infection before definitive
treatment.
What “the tract” means in PCNL —
and why it is the risk
The tract is the access
channel. Unlike ureteroscopy, which reaches the stone through the
body's own plumbing (urethra → bladder → ureter → kidney),
PCNL requires us to make a NEW route: a needle is passed through
the skin of the flank, through the muscle, through the kidney's
parenchyma, and into a calyx of the collecting system. That
channel is then dilated to about 24–30 Fr — roughly the width
of a pen — so a rigid nephroscope can pass through it to break
up and remove the stone. That channel is the tract.
Why it is dangerous: you are
drilling through a highly vascular organ, and the neighbors are
unforgiving. The complications all flow from creating it:
BLEEDING (the kidney receives ~20% of cardiac output; the tract
can injure a segmental artery and cause significant hemorrhage,
an arteriovenous fistula, or a pseudoaneurysm — occasionally
requiring angioembolization). INJURY TO ADJACENT STRUCTURES: if
the access is placed above the 12th rib (a “supracostal”
puncture, sometimes needed to reach an upper-pole stone), it can
traverse the PLEURA and cause a hydrothorax or pneumothorax; a
poorly placed tract can also injure the COLON, liver, or spleen.
URINE LEAK from the tract, and INFECTION/SEPSIS from irrigating a
stone-bearing, often colonized collecting system under pressure.
Afterward: a nephrostomy
tube is usually left in the tract to drain the kidney and
tamponade bleeding, and it is removed once drainage is clear.
Post-op flank pain, some hematuria, and drainage around the tube
are expected.
The bottom line for counseling: PCNL is more invasive than
ureteroscopy precisely BECAUSE of the tract. That is the trade we
make for the ability to clear a very large stone burden in one
session — and it is exactly why we reserve it for stones over
~4 cm and clear everything else ureteroscopically.
our practice stone philosophy
ASC-based, incision-free
treatment of massive stones: modern thulium-laser dusting plus
vacuum aspiration and premium single-use digital ureteroscopes
let us clear very large stones ureteroscopically in an outpatient
surgery center — so PCNL is reserved for stones over ~4 cm.
All patients are stented
after URS: our standard is to leave a ureteral stent following
every ureteroscopy to protect the ureter, ensure drainage, and
reduce post-op obstruction/pain.
The exception — the infected, obstructed stone: this is
a HOSPITAL case, not an ASC case. That patient needs emergent
decompression plus inpatient sepsis care (and possibly an ICU
bed), and our ASCs are same-day-discharge facilities. Drain them
at the hospital, control the infection, and bring them back to
the ASC weeks later for definitive stone treatment (Chapter 2).
Stent counseling and stent-colic
management
Ureteral stents commonly
cause flank discomfort with voiding (reflux up the stent),
urgency/frequency, and hematuria — this is expected, not
failure. Warn the patient BEFORE surgery or they will think
something went wrong.
Treat stent colic/symptoms
with a urinary analgesic — phenazopyridine (Pyridium) or Uro-MP
— plus mirabegron, which together relieve the bladder spasm and
dysuria better than anything else; this is our go-to for the
symptomatic stent.
For pain, use acetaminophen (Tylenol), suzetrigine
(Journavx), and ketorolac IM in the office if renal function allows. Opioids are
almost always avoided.
Ask about the last bowel movement. Patients with stents are often
constipated from narcotics given in the emergency department or perioperatively,
and constipation can amplify stent colic. Treat the bowel regimen rather than
assuming the answer is more narcotic medication. Persistent or worsening pain
still requires reassessment for obstruction, infection, impaired drainage, or
stent migration.
Emphasize the removal date. A forgotten/retained stent can
encrust, obstruct, and become a serious problem — track it.
This is a classic, entirely preventable disaster.
7.4 Prevention and the metabolic work-up
Prevention is
where most practices fail their stone patients. A recurrent stone
former who never gets a 24-hour urine will simply be back.
Send
every captured stone for composition analysis. It directs
everything downstream.
Universal
advice for all stone formers: fluid intake sufficient to produce
~2.5 L of urine per day (usually ~3 L intake); moderate sodium (<
2,300 mg/day — high sodium drives calcium into the urine); NORMAL
dietary calcium (1,000–1,200 mg/day — do NOT restrict calcium:
dietary calcium binds oxalate in the gut and restricting it
paradoxically INCREASES stone risk); moderate animal protein; and
limit oxalate-rich foods (spinach, nuts, chocolate, tea, beets) for
calcium-oxalate formers.
A 24-hour
urine metabolic panel (volume, calcium, oxalate, citrate, uric
acid, sodium, pH, creatinine) is warranted for recurrent, high-risk,
pediatric, or single-kidney stone formers, and for anyone motivated
to prevent recurrence. Repeat it after any intervention to confirm
the change worked.
Stone type
Key features
Targeted prevention
Calcium oxalate (~70–80%)
Most common; radio-opaque; forms in any pH
Fluids; adequate dietary calcium; limit oxalate and sodium;
thiazide for hypercalciuria; potassium citrate for
hypocitraturia; treat primary hyperparathyroidism if present
Calcium phosphate
Alkaline urine; associated with distal RTA and
hyperparathyroidism
Address the underlying cause; careful with alkalinizing agents
(they can worsen it)
Uric acid (~5–10%)
RADIOLUCENT on plain film (visible on CT); forms in ACIDIC urine
(pH < 5.5); associated with gout, obesity, diabetes, and
metabolic syndrome
Urinary alkalinization with potassium citrate to pH 6.0–6.5 —
this can actually DISSOLVE the stone, which no other stone type
does. Reduce purine intake; allopurinol if hyperuricosuric
Struvite (infection)
Magnesium ammonium phosphate; associated with UREASE-producing
organisms (Proteus, Klebsiella, Ureaplasma); often forms staghorn
calculi
Requires COMPLETE surgical clearance — any residual fragment
harbors bacteria and regrows the stone — plus infection
control. Do not leave fragments behind
Cystine (~1%)
Genetic (autosomal recessive cystinuria); recurrent from
childhood; hexagonal crystals
High fluid intake (goal > 3–4 L/day), urinary
alkalinization, and thiol-binding agents (tiopronin); refer for
genetic counseling
Clinical Pathway
Click any node to expand
Stone disease is common, recurrent (roughly 50% recurrence within 5–10 years without prevention), and often exquisitely painful. Manage the acute episode, decide who needs intervention, treat definitively, and then actually set up prevention so patients do not keep coming back.
Diagnose the stone, screen immediately for the one presentation that cannot wait, then manage pain and passage.
Select a box to open its teaching details.
The discriminator
The patient is classically restless and cannot find a comfortable position — a useful discriminator from peritonitis, where patients lie still.
Also expect
Nausea and vomiting are common — shared celiac plexus innervation
A stone at the ureterovesical junction produces urgency and frequency that mimics a UTI
Ch 7.1 — presentation
Time-critical
Act now
Emergent decompression — stent or nephrostomy — plus antibiotics (Chapter 2)
Antibiotics alone will NOT save this patient
Also escalate for
Acute kidney injury
Bilateral obstruction
Obstruction of a solitary or transplanted kidney
Intractable pain or vomiting
Never miss it
The patient who looks "not that sick" with a fever and an obstructing stone can be in septic shock in three hours. Do not send them home.
Ch 7.1 — the stone emergency
What the CT tells you
Stone size
Location
Density in Hounsfield units — predicts fragility
Skin-to-stone distance
Degree of hydronephrosis
When to use something else
Ultrasound (radiation-sparing) — preferred in pregnancy, reasonable for younger patients and for follow-up
Plain KUB — useful only for tracking a known radio-opaque stone; uric acid stones are radiolucent
Ch 7.1 — diagnosis
Orders
Urinalysis
Urine culture
CBC
Creatinine
Calcium — and consider PTH later if hypercalcemic
Pitfall
A negative urinalysis does not rule out a stone — hematuria is present in only ~85%
Ketorolac 15–30 mg IM in the office — if renal function allows
Why NSAIDs
They reduce ureteral wall edema and prostaglandin-mediated pain.
Our pain strategy
Use Tylenol, Journavx, and ketorolac
Opioids are almost always avoided
Antiemetics for nausea
Do not miss opioid-related constipation
Ask when the patient last had a bowel movement—many received narcotics in the emergency department
Stool burden can amplify renal colic
Restoring bowel function may help more than giving additional narcotics
Persistent or worsening pain still requires reassessment for infected obstruction or impaired drainage
Ch 7.2 — analgesia
Dosing
Tamsulosin 0.4 mg daily
Who gets MET
Use for any ureteral stone that the patient wants to try to pass
Tamsulosin relaxes ureteral smooth muscle and can aid stone passage
Ch 7.2 — MET
Spontaneous passage
< 6 mm — often pass spontaneously
≥ 8 mm — typically require intervention
Distal stones pass more readily than proximal stones
Trial of passage
Give a reasonable trial of passage (up to ~4–6 weeks) ONLY if the patient is comfortable, not infected, and has normal renal function.
Ch 7.2 — expectations
Instruction to the patient
Strain all urine to capture the stone
Send EVERY captured stone for composition analysis
Ch 7.2 — hydration and a strainer
Central Ohio Urology Group treats the overwhelming majority of stones — including very large burdens once considered "percutaneous only" — with ureteroscopy in our ambulatory surgery centers.
Select a box to open its teaching details.
Intervene for
Stones unlikely to pass
Refractory pain
Obstruction with infection — emergent
AKI
A solitary kidney
Patient preference
Ch 7.3
Time-critical
Our rule
That patient needs emergent decompression plus inpatient sepsis care (and possibly an ICU bed). Drain them at the hospital, control the infection, and bring them back to the ASC weeks later for definitive stone treatment (Chapter 2).
Ch 7.3 — our practice stone philosophy
Which procedure?
Local policy
What we use
Best-in-class thulium fiber lasers
Dornier single-use digital scopes
Direct-in-line vacuum aspiration to evacuate fragments — superior clearance, lower intrarenal pressure
Our standard
All patients are stented afterward — to protect the ureter, ensure drainage, and reduce post-op obstruction/pain
Ohio specifics
Columbus ASC — TODO confirm scheduling contact and block days
TODO — stent removal pathway and who owns the tickler in this market
Ch 7.3 — procedures
Poor choice for
Lower-pole stones
Obesity
Dense stones — high Hounsfield units
Contraindicated in
Pregnancy
Uncorrected coagulopathy
Untreated infection
Ch 7.3 — procedures
Where the risk lives
The added risk of PCNL comes from the ACCESS TRACT — the working channel we create from the skin, through the flank muscles, into the kidney's collecting system.
Ch 7.3 — procedures
Time-critical
Role
Temporizing for obstruction/infection before definitive treatment.
Ch 7.3 — procedures
What the tract is
Unlike ureteroscopy, which reaches the stone through the body's own plumbing (urethra → bladder → ureter → kidney), PCNL requires us to make a new route: a needle is passed through the skin of the flank, through the muscle, through the kidney's parenchyma, and into a calyx. That channel is dilated to about 24–30 Fr — roughly the width of a pen — so a rigid nephroscope can pass through it.
Why it is dangerous
Bleeding — the kidney receives ~20% of cardiac output; the tract can injure a segmental artery and cause significant hemorrhage, an AV fistula, or a pseudoaneurysm, occasionally requiring angioembolization
Injury to adjacent structures — a supracostal puncture above the 12th rib can traverse the PLEURA and cause hydrothorax or pneumothorax; a poorly placed tract can injure the COLON, liver, or spleen
Urine leak from the tract
Infection/sepsis from irrigating a stone-bearing, often colonized collecting system under pressure
Afterward
A nephrostomy tube is usually left in the tract to drain the kidney and tamponade bleeding; removed once drainage is clear
Post-op flank pain, some hematuria, and drainage around the tube are expected
The bottom line
PCNL is more invasive than ureteroscopy precisely BECAUSE of the tract. That is the trade we make to clear a very large stone burden in one session — and it is exactly why we reserve it for stones over ~4 cm and clear everything else ureteroscopically.
Ch 7.3 — what "the tract" means in PCNL
Local policy
What to warn about
Flank discomfort with voiding — reflux up the stent
Urgency and frequency
Hematuria
Pitfall
Warn the patient BEFORE surgery or they will think something went wrong.
Ch 7.3 — stent counseling
Local policy
Our regimen
A urinary analgesic — phenazopyridine (Pyridium) or Uro-MP — plus mirabegron
Together they relieve the bladder spasm and dysuria better than anything else
Pain control
Use acetaminophen (Tylenol), suzetrigine (Journavx), and ketorolac IM in the office if renal function allows
Opioids are almost always avoided
Check the bowels
Ask when the patient last had a bowel movement—narcotics from the emergency department or perioperative period commonly cause constipation
Constipation can amplify stent colic; restoring bowel function may help more than additional narcotics
Reassess persistent or worsening pain for obstruction, infection, impaired drainage, or stent migration
Ch 7.3 — stent-colic management
Time-critical
Why
A forgotten/retained stent can encrust, obstruct, and become a serious problem — track it. Emphasize the removal date with the patient.
Ch 7.3 — stent counseling
Local policy
Why this exists
An example of a step that exists in one market only. Delete or rewrite it.
Our process
TODO — who logs it
TODO — where it is logged
TODO — who audits it
Ohio local policy
Prevention is where most practices fail their stone patients. A recurrent stone former who never gets a 24-hour urine will simply be back.
Select a box to open its teaching details.
Why
Send every captured stone for composition analysis. It directs everything downstream — and it is the cheapest, most valuable test in stone disease.
Ch 7.4
The rules
Fluid — enough to produce ~2.5 L of urine per day (usually ~3 L intake)
Sodium — moderate, < 2,300 mg/day; high sodium drives calcium into the urine
Calcium — NORMAL dietary calcium 1,000–1,200 mg/day