From the Guidelines
A right-sided vesicoureteric junction stone measuring 6 x 4 mm causing mild hydroureteronephrosis is typically indicated for standard ureteroscopy rather than complex ureteroscopy. According to the 2007 guideline for the management of ureteral calculi 1, ureteroscopy has become a safer and more efficacious modality for the treatment of stones in all locations in the ureter, with high stone-free rates and low complication rates. The location of the stone at the vesicoureteric junction is relatively accessible, and the size of the stone (6 x 4 mm) is considered small, making standard ureteroscopic stone removal with laser lithotripsy the appropriate first-line surgical approach.
The benefits of ureteroscopy for this case include:
- High stone-free rates, with an overall stone-free rate of 94% for distal ureteral stones 1
- Low complication rates, with ureteral perforation rates reduced to less than 5% and long-term complications such as stricture formation occurring with an incidence of 2% or less 1
- The ability to visualize and fragment the stone using laser energy, making it a highly effective procedure for small to medium-sized stones
Alternative approaches, such as observation with medical expulsive therapy for spontaneous passage or extracorporeal shock wave lithotripsy, may be considered depending on the patient's symptoms and stone composition. However, given the mild hydroureteronephrosis and the size and location of the stone, standard ureteroscopy is the most appropriate treatment option. The use of complex ureteroscopy is generally reserved for more challenging cases, such as larger stones, multiple stones, abnormal urinary tract anatomy, or stones in difficult locations, which is not the case here.
From the Research
Indications for Complex Ureteroscopy
- The presence of a 6 x 4 mm vesicoureteric junction stone causing mild right-sided hydroureteronephrosis may be an indication for complex ureteroscopy, considering the stone's size and location 2.
- However, the decision to perform complex ureteroscopy should be based on individual patient circumstances and preferences, as both ureteroscopy and shock-wave lithotripsy are safe and effective options for treating upper ureteral stones 3.
Considerations for Ureteroscopy
- Ureteroscopy is associated with a higher stone-free rate, fewer retreatments, and fewer secondary procedures compared to shock-wave lithotripsy 3.
- However, ureteroscopy is also associated with a higher need for adjunctive procedures, such as the insertion of a JJ stent, and longer hospital stay 3.
- The presence of a decompression tube, such as a JJ stent, does not appear to affect the success rate of shock-wave lithotripsy for ureteral stones 4.
Potential Complications
- Perinephric hematoma is a rare complication that can occur after ureteral stent placement, and its development can be decreased by controlling blood pressure, treating preoperative urinary tract infections, and shortening operating time during ureteroscopy 5.
- Ureteroscopy is associated with a higher complication rate compared to shock-wave lithotripsy, including the risk of perinephric hematoma and other complications 3.