Indications for active treatment and procedure selection

Technical developments and patient requests for rapid stone removal have led to changes in clinical stone management. Treatment shifted from open to percutaneous surgery, which was then almost replaced by shock wave lithotripsy (SWL). During the last decade, limitations of SWL in some situations became evident, and with the technical improvements of endoscopy and lithotripsy modalities, ureteroscopy (URS) became more than an adjunct to the available procedures. Today, the whole portfolio of minimal-invasive techniques is used, based on an individualized tailored decision tree. Patient-specific parameters such as stone composition or anatomy are important aspects to be considered apart from stone size and localization. The demand for imperative complete stone removal has led to a clear shift toward endourology, even though SWL remains an effective treatment for far the most stone situations. This is underlined by data supporting preventive stone management because of significant rate of symptomatic episodes during surveillance. This chapter discusses indications for active treatment and proposes algorithms for choosing the proper procedure considering all treatment options from SWL, ureterorenoscopy (URS), percutaneous nephrolithotomy (PNL), and open or laparoscopic techniques.