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Pulp stones — Clinical Guidelines

Overview

Pulp stones, also known as renal calculi within the renal collecting system, are mineral deposits that can obstruct urine flow and cause significant morbidity. Management strategies vary based on stone size, location, and patient-specific factors.

Diagnosis

Imaging: Non-contrast CT is the gold standard for detecting and characterizing renal stones 1 2 29.

Ultrasound: Useful for initial screening, especially in pregnancy 1 2.

Stone analysis: Essential for identifying composition and guiding treatment 16.

Management

First-line treatments:

- Small stones (<2 cm): Extracorporeal shock wave lithotripsy (ESWL) and retrograde intrarenal surgery (RIRS) are common 18 25. - Large stones or complex cases: Percutaneous nephrolithotomy (PCNL) is preferred 1 11 23.

Adjunctive measures:

- Preoperative video-based education may reduce anxiety levels 5. - Use of ureteral stents may be considered preoperatively to facilitate access 1.

Special Populations

Pediatrics: Flexible ureteroscopy (fURS) generally achieves higher stone-free rates compared to ESWL 4.

Elderly and Comorbidities: RIRS is equally efficient and safe across different American Society of Anesthesia (ASA) physical statuses 13.

Key Recommendations

For small renal stones (<2 cm), consider ESWL or RIRS based on patient preference and stone characteristics (Evidence: Moderate 18 18).

Large or complex renal stones should be managed with PCNL (Evidence: Strong 1 11).

Implement preoperative video-based education to potentially reduce patient anxiety levels (Evidence: Moderate 5).

Preoperative ureteral stenting may be beneficial in selected cases to optimize surgical access (Evidence: Expert opinion 1).

In pediatric patients, prioritize flexible ureteroscopy over ESWL for higher stone-free rates (Evidence: Strong 4).

References

1 Ansari MI, Khan SA, Thakur DK, Agrawal CS. Comparative efficacy of pre-stented versus non-stented retrograde intrarenal surgery: A randomized controlled trial. Medicine 2025. link 2 Wiseman O, Smith D, Starr K, Aucott L, Hernández R, Thomas R et al.. Clinical and cost-effectiveness of percutaneous nephrolithotomy, flexible ureterorenoscopy and extracorporeal shockwave lithotripsy for lower pole stones: the PUrE RCTs. Health technology assessment (Winchester, England) 2025. link 3 Altun I, Garg T, Shaikh J, DePalma AAR, Herren JL, Hubbell GM et al.. Single Specialty-Operated Renal Stone Removal: Initial Experience from 3 Interventional Radiology Centers. Journal of vascular and interventional radiology : JVIR 2024. link 4 Geraghty R, Lombardo R, Yuan C, Davis N, Tzelves L, Petrik A et al.. Outcomes of Flexible Ureteroscopy vs Extracorporeal Shock Wave Lithotripsy for Renal Stones in Pediatric Patients: A European Association of Urology Urolithiasis Guidelines Systematic Review and Meta-Analysis. The Journal of urology 2023. link 5 Karalar M, Demirbas A, Gercek O, Topal K, Keles I. Impact of Preoperative Video-Based Education on Anxiety Levels in Patients with Renal Stones Scheduled for Flexible Ureteroscopic Lithotripsy: A Comparative Study Using APAIS and STAI. Medical science monitor : international medical journal of experimental and clinical research 2023. link 6 Panthier F, Pauchard F, Traxer O. Retrograde intra renal surgery and safety: pressure and temperature. A systematic review. Current opinion in urology 2023. link 7 Taguchi K, Hamamoto S, Okada A, Sugino T, Unno R, Kato T et al.. A Randomized, Single-Blind Clinical Trial Comparing Robotic-Assisted Fluoroscopic-Guided with Ultrasound-Guided Renal Access for Percutaneous Nephrolithotomy. The Journal of urology 2022. link 8 Davis NF, Donaldson JF, Shepherd R, Neisius A, Petrik A, Seitz C et al.. Treatment outcomes of bladder stones in children with intact bladders in developing countries: A systematic review of >1000 cases on behalf of the European Association of Urology Bladder Stones Guideline panel. Journal of pediatric urology 2022. link 9 Zeng G, Zhao Z, Mazzon G, Pearle M, Choong S, Skolarikos A et al.. European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Retrograde Intrarenal Surgery for the Management of Renal Stones. European urology focus 2022. link 10 Tuncer M, Kafkaslı A, Can U, Çoşkun A, Eryıldırım B, Sarica K. What is the optimal frequency in shock wave lithotripsy for pediatric renal stones? A prospective randomized study. Urolithiasis 2021. link 11 Mao T, Wei N, Yu J, Lu Y. Efficacy and safety of laparoscopic pyelolithotomy versus percutaneous nephrolithotomy for treatment of large renal stones: a meta-analysis. The Journal of international medical research 2021. link 12 Donaldson JF, Ruhayel Y, Skolarikos A, MacLennan S, Yuan Y, Shepherd R et al.. Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel. European urology 2019. link 13 Guzel O, Tuncel A, Balci M, Karakoyunlu N, Aslan Y, Erkan A et al.. Retrograde Intrarenal Surgery is equally efficient and safe in patients with different American Society of Anesthesia physical status. Renal failure 2016. link 14 Dauw CA, Simeon L, Alruwaily AF, Sanguedolce F, Hollingsworth JM, Roberts WW et al.. Contemporary Practice Patterns of Flexible Ureteroscopy for Treating Renal Stones: Results of a Worldwide Survey. Journal of endourology 2015. link 15 Gadzhiev N, Brovkin S, Grigoryev V, Tagirov N, Korol V, Petrov S. Sculpturing in urology, or how to make percutaneous nephrolithotomy easier. Journal of endourology 2015. link 16 Haymann JP, Daudon M, Normand M, Hoznek A, Meria P, Traxer O. [First-line screening guidelines for renal stone disease patients: a CLAFU update]. Progres en urologie : journal de l'Association francaise d'urologie et de la Societe francaise d'urologie 2014. link 17 Cai JL, Zhang Y, Sun GF, Li NC, Yuan XL, Na YQ. Proficiency of virtual reality simulator training in flexible retrograde ureteroscopy renal stone management. Chinese medical journal 2013. link 18 Ho CC, Hafidzul J, Praveen S, Goh EH, Bong JJ, Lee BC et al.. Retrograde intrarenal surgery for renal stones smaller than 2 cm. Singapore medical journal 2010. link 19 Safak M, Olgar T, Bor D, Berkmen G, Gogus C. Radiation doses of patients and urologists during percutaneous nephrolithotomy. Journal of radiological protection : official journal of the Society for Radiological Protection 2009. link 20 Istanbulluoglu OM, Ozturk B, Cicek T, Gonen M, Ozkardes H. Case report: bilateral simultaneous tubeless and stentless percutaneous nephrolithotomy. Journal of endourology 2008. link 21 Okeke Z, Lam JS, Gupta M. Use of a ureteral access sheath to facilitate removal of large stone burden during extracorporeal shock wave lithotripsy. Urology 2004. link 22 Jayawardene SA, Goldsmith DJ. Staghorn calculi complicating renal transplantation in patients with persistent post-transplantation hyperparathyroidism. Clinical nephrology 2003. link 23 Bird VG, Fallon B, Winfield HN. Practice patterns in the treatment of large renal stones. Journal of endourology 2003. link 24 Surya BV, Rothberg M, Schwarzman M, Johanson KE. Management of simple renal cysts during percutaneous nephrostolithotomy. Urology 1989. link90134-9) 25 Pemberton J. Extra-corporeal shock wave lithotripsy. Postgraduate medical journal 1987. link 26 Nseyo UO, Rivard DJ, Garlick WB, Bennett AH. Management of bladder stones: should transurethral prostatic resection be performed in combination with cystolitholapaxy?. Urology 1987. link90067-7) 27 Pinto B, Vilanova MA, Ruiz-Marcellan FJ. Kinetic differences of the calcium-binding protein in absorptive hypercalciuric renal stone formers. Urological research 1985. link 28 Riedmiller H, Thüroff J, Alken P, Hohenfellner R. Doppler sonography and B-scanning in renal surgery. Ultrasound in medicine & biology 1983. link 29 Whitfield HN. Percutaneous nephrolithotomy. British journal of urology 1983. link 30 Clorius JH, Huber W, Kjelle-Schweigler M, Schlegel W, Georgi P, Zelt J. Evidence of possible association of nephrolithiasis and nephroptosis. Nephron 1978. link 31 Galka M, Augustyn M. Clinical experience with loop nephrostomy. International urology and nephrology 1976. link

Pulp stones