From the Guidelines
Ureteroscopic lithotripsy is the recommended treatment for the 5x4 mm vesicoureteric junction stone with a density of 1247 HU, as it offers a higher stone-free rate in a single procedure compared to shock-wave lithotripsy (SWL) 1. This procedure involves inserting a small scope through the urethra and bladder into the ureter to directly visualize and fragment the stone using laser energy. The high density (1247 HU) indicates a hard stone, likely calcium oxalate or calcium phosphate composition, which responds well to laser fragmentation.
Key Considerations
- Prior to the procedure, patients should receive prophylactic antibiotics such as ciprofloxacin 500 mg or levofloxacin 500 mg one hour before surgery.
- The procedure is typically performed under general anesthesia and takes approximately 30-60 minutes.
- A ureteral stent may be placed afterward to ensure proper drainage and healing, usually remaining for 1-2 weeks, but routine stenting should not be performed in patients undergoing URS if certain criteria are met, such as no suspected ureteric injury during URS, no evidence of ureteral stricture or other anatomical impediments to stone fragment clearance, a normal contralateral kidney, no renal functional impairment, and no planned secondary URS procedure 1.
Post-Procedure Care
- Patients can expect mild discomfort, blood in urine, and urinary frequency for several days post-procedure.
- Pain management typically includes NSAIDs like ibuprofen 600 mg every 6 hours and possibly short-term narcotics.
- Patients should increase fluid intake to 2-3 liters daily after surgery to help flush out stone fragments and prevent recurrence.
Evidence-Based Recommendation
The American Urological Association/Endourological Society guideline recommends URS as first-line therapy for patients with mid or distal ureteral stones who require intervention, due to its higher stone-free rates compared to SWL 1.
From the Research
Ureteroscopic Lithotripsy for Vesicoureteric Junction Stones
- The treatment of large proximal ureteral stones, including those at the vesicoureteric junction, can be achieved through various modalities, including ureteroscopic lithotripsy, extracorporeal shock wave lithotripsy, and laparoscopic ureterolithotomy 2.
- Ureteroscopic lithotripsy has been shown to be an effective treatment for ureteral stones, with successful treatment independent of stone size, composition, and location in the upper urinary tract 3.
- For vesicoureteric junction stones, ureteroscopic lithotripsy can be a viable treatment option, especially for stones that are causing symptoms or obstruction 4, 5.
Considerations for Ureteroscopic Lithotripsy
- The size and location of the stone, as well as the patient's anatomy, can affect the success of ureteroscopic lithotripsy 6.
- In cases where the stone is causing rupture or severe symptoms, urgent surgical intervention may be necessary 4, 5.
- The use of contrast CT scans can be helpful in identifying the anatomy of the kidney and collecting systems, particularly in cases where non-contrast scans may not provide sufficient information 6.
Treatment Outcomes
- Ureteroscopic lithotripsy has been shown to have high success rates for treating ureteral stones, with stone-free rates ranging from 62.5% to 93.3% in some studies 2.
- The treatment of vesicoureteric junction stones with ureteroscopic lithotripsy can result in good outcomes, with many patients achieving stone-free status after a single procedure 5.