Pearle MS. et al., 2025: Surgical Management of Kidney and Ureteral Stones: AUA Guideline (2026) Part I: Evaluation and Treatment of Patients with Kidney and/or Ureteral Stones.

Margaret S Pearle, Brian R Matlaga, Jodi A Antonelli, Thomas Chi, Ryan S Hsi, Sennett K Kim, Erin Kirkby, Bodo Knudsen, Kevin Koo, Naim M Maalouf, Vernon M Pais Jr, Ann Paris, Kristina L Penniston, Kymora B Scotland, Lesley H Souter, Necole Streeper, Gregory Tasian, Kyle D Wood, Justin B Ziemba
J Urol. 2025 Nov 20:101097JU0000000000004842. doi: 10.1097/JU.0000000000004842

Abstract

Purpose: This Guideline covers the evaluation and treatment of patients with kidney and/or ureteral stones. The summary presented herein represents Part I of the III-part series dedicated to Surgical Management of Kidney and Ureteral Stones. Please refer to Parts II and III for additional information on this topic.

Materials and methods: This systematic review was conducted in 2 planned stages, including a search for systematic reviews followed by a search for primary literature. OVID was used to systematically search MEDLINE and EMBASE databases for articles evaluating surgical management of kidney and ureteral stones. The Panel selected control articles that were deemed relevant and the articles were compared with the literature search strategy output. The methodologist then updated the strategy as necessary to capture all control articles. Databases were searched for studies published from January 2000 through May 2025 (week 20). In addition to the MEDLINE and EMBASE databases searches, reference lists of included systematic reviews and primary literature were scanned for potentially useful studies.

Results: The Panel addressed adult and pediatric patients with kidney and/or ureteral stones for whom surgical intervention may be indicated. Each statement herein addressed a particular patient scenario for which the choice of surgical intervention was reviewed and justified. In addition, the Panel reviewed and analyzed the utility of specific surgical techniques, technologies, or medications aimed at improving patient outcomes.

Conclusions: Selection of optimal treatment modalities for patients with kidney and/or ureteral stones is determined by patient factors, urinary tract anatomy, and stone characteristics and are guided by shared decision-making that additionally takes into account patient goals and preferences, resource availability, and physician expertise. This Guideline serves as a resource for clinicians and patients to provide the best available evidence on which to base discussions with patients in a shared decision-making process to arrive at appropriate treatment decisions.

Comment Hans-Göran Tiselius

Below are selected AUA guidelines 2026 Part I.

1. It is emphasized that for adult and pediatric patients it is important for clinicians to obtain a medical history, carry out physical examination and laboratory studies (urinalysis or urine culture).

1. For adult and pediatric patients, definite surgery should not be carried out in case of untreated bacteriuria /funguria.

1. Differential renal function should be assessed in case of suspected loss of renal function.

1. For adult and pediatric patients with ≤ 10 mm distal ureteral stones, medical expulsive therapy with α-adrenergic blockers should be offered 30 days. The same is recommended for stones in the middle and proximal ureter.

1. For adult patients with ≤ 10 mm distal ureteral stones, URS or SWL may be offered.

1. For proximal ureteral stones <20 mm URS may be offered. If failed SWL, use either second SWL or URS.

1. For stones >20 mm if failed URS/SWL, choose PNL.

1. In case of pain but presence of non-obstructing stones, elective surgical treatment might be an alternative.

1. For ≤ 10 mm lower pole stones, preferred treatment: SWL, URS or PCNL.

1. For <10 mm stone in the lower pole or >20 mm non-lower pole stones, it is recommended NOT to use SWL.

1. Inform patients that for lower pole stones < 10 mm PNL gives higher stone-free rates than SWL or URS.

1. For lower pole stones <20 mm improved results might be obtained by repositioning the stone to a more superior position.

1. For kidney stones <20 mm: recommend PCNL as first line treatment.

1. It is stated that PNL might be performed without discontinuing aspirin.

SUMMARY

Non-LP <10 mm            SWL, URS

LP <10 mm                      SWL,URS or PNL

Non-LP 10 20 mm         Favorable for SWL: SWL URS

                                            Non favorable SWL: URS PNL

LP > 20 mm                     PNL or URS

Hans-Göran Tiselius