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

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 20:101097JU0000000000004844. doi: 10.1097/JU.0000000000004844

Abstract

Purpose: This Guideline covers the surgical treatment of patients with kidney and/or ureteral stones and is intended for clinicians evaluating and managing patients with these diseases. The summary presented herein represents Part III of the 3-part series dedicated to Surgical Management of Kidney and Ureteral Stones and Future Directions.

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

This publication is one part of the AUA guidelines for evaluation and treatment of patients with kidney and/or ureteral stones. In the comment below I have emphasized points in the guidelines that are of relevance for SWL directly or indirectly.

1. It is recommended for clinicians to prescribe alpha- adrenergic blockers after SWL with the aim of improving stone-free rates.

1. It is emphasized that for adult patients with kidney or ureteral stones who cannot be treated with SWL because of uncorrected bleeding diathesis or who are treated with anticoagulants, URS is the suggested treatment alternative.

1. Patients treated for kidney and/or ureteral stones should be given non-opioid analgesics.

1. It is mentioned of importance to order follow-up imaging after surgical intervention to identify hydronephrosis or other procedure-related complications.

1. For adult and pediatric patients with residual stones clinicians should offer secondary endoscopic removal of residual fragments.

1. Ultrasound should be first line imaging in pregnant patients. If necessary non-contrast magnetic resonance imaging or CT are appropriate alternatives.

1. For pregnant patients pharmacological and surgical intervention should be coordinated with the obstetrician.

1. For pregnant patients with kidney and/or ureteral stones, observation of stones with well controlled symptoms, a trial of stone passage should be offered. If unsuccessful: URS.

Hans-Göran Tiselius