skip to main content

Asymptomatic renal pelvic calculus — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

HardNephrolithiasisAsymptomatic renal pelvic calculusMSRA

A 49-year-old woman is reviewed in a stone clinic after an incidental finding on CT performed for unrelated abdominal pain. She has a single 9 mm non-obstructing right renal pelvic calculus. She has had no renal colic, urinary infection or previous stone procedures. Her eGFR is normal, midstream urine culture is negative, and she is not pregnant or taking antithrombotic medication. The stone is radiopaque and confirmed by the lithotripsy service to be targetable with shockwave lithotripsy (SWL). Following an informed discussion of surveillance and intervention, she wishes definitive treatment. What is the most appropriate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Offer definitive SWL without pre-treatment ureteric stenting

Explanation lettering: C = shown as B · B = shown as C · E = shown as D · D = shown as E

The best answer is D. Although watchful waiting is permissible for an asymptomatic renal stone larger than 5 mm after informed discussion, this patient has elected active treatment. For an adult with a renal stone smaller than 10 mm, NICE recommends SWL as first-line treatment. Ureteroscopy is reserved for situations in which SWL is contraindicated, has previously failed, or is unsuitable because of anatomy; none applies here because the stone is targetable and there is no stated contraindication. NICE also specifically advises against pre-treatment ureteric stenting before SWL for either renal or ureteric stones. A is initially attractive because the stone is asymptomatic, but does not respect the patient's informed preference for definitive treatment. B is plausible because ureteroscopy achieves high stone-clearance rates, but it is not the preferred first-line option for a targetable renal stone under 10 mm. C reflects a common procedural instinct to protect against obstruction, but routine pre-SWL stenting offers no demonstrated benefit and can cause stent morbidity. E is disproportionately invasive and is considered only when SWL and ureteroscopy have failed or are not options for renal stones under 10 mm.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Recommendations (Published 2019; updated May 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations NICE NG118: Renal and ureteric stones: assessment and management — Table 1, surgical treatment of renal stones (Published 2019; updated May 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations NICE NG118: Renal and ureteric stones: assessment and management — Recommendation 1.4.1 (Published 2019; updated May 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations