NICE releases 2019 Guidelines for Management of Renal and ureteric stones
NICE has released its 2019 guidelines on assessment and management of Renal and ureteric stones. The guideline covers assessing and managing renal and ureteric stones and aims to improve the detection, clearance and prevention of stones, so reducing pain and anxiety, and improving quality of life.
Following are the major recommendations:
1. Diagnostic imaging
- Offer urgent (within 24 hours of presentation) low-dose non-contrast CT to adults with suspected renal colic. If a woman is pregnant, offer ultrasound instead of CT.
- Offer urgent (within 24 hours of presentation) ultrasound as first-line imaging for children and young people with suspected renal colic.
- If there is still uncertainty about the diagnosis of renal colic after ultrasound for children and young people, consider low-dose non-contrast CT.
2. Pain management
- Offer a non-steroidal anti-inflammatory drug (NSAID) by any route as first-line treatment for adults, children and young people with suspected renal colic.
- Offer intravenous paracetamol to adults, children and young people with suspected renal colic if NSAIDs are contraindicated or are not giving sufficient pain relief.
- Consider opioids for adults, children and young people with suspected renal colic if both NSAIDs and intravenous paracetamol are contraindicated or are not giving sufficient pain relief.
- Do not offer antispasmodics to adults, children and young people with suspected renal colic.
3. Medical expulsive therapy
- Consider alpha blockers for adults, children and young people with distal ureteric stones less than 10 mm.
4. Stenting before shockwave lithotripsy
- Do not offer pre-treatment stenting to adults having shockwave lithotripsy (SWL) for ureteric or renal stones.
- Consider pre-treatment stenting for children and young people having SWL for renal staghorn stones.
5. Surgical treatments (including shockwave lithotripsy)
Renal stones
- Consider watchful waiting for asymptomatic renal stones in adults, children and young people if:
- the stone is less than 5 mm or
- the stone is larger than 5 mm and the person (or their family or carers, as appropriate) agrees to watchful waiting after an informed discussion of the possible risks and benefits.
- Follow the recommendations in table 1 for surgical treatment (including SWL) of renal stones in adults, children and young people.
Table 1 Surgical treatment (including SWL) of renal stones in adults, children and young people
| Stone type and size | Treatment for adults (16 years and over) | Treatment for children and young people (under 16 years) |
| Renal stone less than 10 mm | Offer SWL Consider URS:
Consider PCNL if SWL and URS have failed to treat the current stone or they are not an option | Consider URS or SWL Consider PCNL if:
|
| l stone 10 to 20 mm | Consider URS or SWL Consider PCNL if URS or SWL have failed | Consider URS, SWL or PCNL |
| Renal stone larger than 20 mm, including staghorn stones | Offer PCNL Consider URS if PCNL is not an option | Consider URS, SWL or PCNL |
| Abbreviations: PCNL, percutaneous nephrolithotomy; SWL, shockwave lithotripsy; URS, ureteroscopy. | ||
| Use clinical judgement when considering mini or standard PCNL. Use clinical judgement when considering tubeless, mini or standard PCNL, and supine or prone positions. | ||
Ureteric stones
- Follow the recommendations in table 2 for surgical treatment (including SWL) of ureteric stones in adults, children and young people.
| Stone type and size | Treatment for adults (16 years and over) | Treatment for children and young people (under 16 years) |
| Ureteric stone less than 10 mm | Offer SWL Consider URS if:
| Consider URS or SWL |
| Ureteric stone 10 to 20 mm | Offer URS Consider SWL if local facilities allow stone clearance within 4 weeks Consider PCNL for impacted proximal stones when URS has failed | Consider URS or SWL |
| Abbreviations: PCNL, percutaneous nephrolithotomy; SWL, shockwave lithotripsy; URS, ureteroscopy. | ||
The timing of surgical treatment (including SWL) for adults with ureteric stones and renal colic
- Offer surgical treatment (including SWL) to adults with ureteric stones and renal colic within 48 hours of diagnosis or readmission, if:
- pain is ongoing and not tolerated or
- the stone is unlikely to pass.
Medical expulsive therapy as an adjunct to SWL for adults with ureteric stones less than 10 mm
- Consider alpha blockers as adjunctive therapy for adults having SWL for ureteric stones less than 10 mm.
6. Stenting after ureteroscopy for adults with ureteric stones less than 20 mm
- Do not routinely offer post-treatment stenting to adults who have had ureteroscopy for ureteric stones less than 20 mm.
7. Metabolic testing
- Consider stone analysis for adults with ureteric or renal stones.
- Measure serum calcium for adults with ureteric or renal stones.
- Consider referring children and young people with ureteric or renal stones to a paediatric nephrologist or paediatric urologist with expertise in this area for assessment and metabolic investigations.
8. Preventing recurrence
Dietary and lifestyle advice
- Discuss diet and fluid intake with the person (and their family or carers, as appropriate), and advise:
- adults to drink 2.5 to 3 litres of water per day, and children and young people (depending on their age) 1 to 2 litres
- adding fresh lemon juice to drinking water
- avoiding carbonated drinks
- adults to have a daily salt intake of no more than 6 g, and children and young people (depending on their age) 2 to 6 g
- not restricting daily calcium intake, but maintaining a normal calcium intake of 700 to 1,200 mg for adults, and 350 to 1,000 mg per day for children and young people (depending on their age).
- Follow the recommendations on maintaining a healthy lifestyle in the NICE guideline on preventing excess weight gain.
Potassium citrate
The following recommendations apply alongside the recommendations on dietary and lifestyle advice.
- Consider potassium citrate for adults with a recurrence of stones that are predominantly (more than 50%) calcium oxalate.
- Consider potassium citrate for children and young people with a recurrence of stones that are predominantly (more than 50%) calcium oxalate, and with hypercalciuria or hypocitraturia.
Thiazides
The following recommendation applies alongside the recommendations on dietary and lifestyle advice.
- Consider thiazides for adults with a recurrence of stones that are predominantly (more than 50%) calcium oxalate and hypercalciuria, after restricting their sodium intake to no more than 6 g a day.
For more details click on the link: www.nice.org
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