Synopsis
Choose and explain SWL, ureteroscopy and PCNL using the correct stone location and size framework, procedural feasibility, patient risks and a verified clearance and device outcome.
- Apply separate NICE tables for renal and ureteric stones: adult renal stones above 20 mm, including staghorn stones, are offered PCNL; ureteric stones 10–20 mm are offered ureteroscopy.
- For adult renal stones below 10 mm, NICE offers SWL; for renal 10–20 mm, consider URS or SWL. For ureteric stones below 10 mm, offer SWL with specified reasons to consider URS, including inability to achieve clearance within four weeks.
- SWL fragments externally and often needs subsequent fragment passage or retreatment; URS provides endoscopic access through the urinary tract; PCNL creates a percutaneous tract for larger renal burdens, with a greater bleeding and access-injury burden.
Investigation priorities
Map size, location, density, stone burden and the proposed access route.
Management branches
A forty seven year old woman has recurrent pain and a twenty four-millimetre renal-pelvis stone, with no current infection.
- The team reviews CT, renal function, haemoglobin, urine culture and antithrombotic exposure. CT shows a feasible percutaneous route without interposed bowel, and the urine culture is negative. She is offered PCNL under the NICE greater-than 20 mm renal-stone recommendation, with discussion of bleeding, infection, organ injury, a possible second procedure and the alternative if PCNL becomes unsuitable.
- She chooses PCNL. Procedure-specific antibiotic prophylaxis is given under the hospital culture-based policy, and the surgeon fragments and removes the stone through the planned tract. Renal-pelvis urine and stone material are collected. A temporary nephrostomy is retained because the operative assessment favours drainage and observation of bleeding; its presence is an individual decision, not a requirement for every uncomplicated PCNL.
A stable adult has a ureteric stone for which active treatment has been agreed.