What is the management for a 7mm stone in the proximal right ureter at the level of the L3 vertebral body with mild upstream hydroureteronephrosis and a density of 1375 Hounsfield Units (HU), indicated for Extracorporeal Shock Wave Lithotripsy (ESWL)?

From the Guidelines

I strongly recommend proceeding with Extracorporeal Shock Wave Lithotripsy (ESWL) for this 7 mm proximal right ureteral stone at the L3 level, as it offers a non-invasive alternative to ureteroscopy with a high stone-free rate of 82% for proximal ureteral stones 1. The stone's high density (1375 Hounsfield Units) and the presence of mild hydroureteronephrosis indicate ESWL is an appropriate treatment option. Prior to the procedure, ensure adequate hydration and consider pain management with NSAIDs such as ibuprofen (600-800 mg every 6-8 hours) or ketorolac (10 mg every 6 hours). Alpha-blockers like tamsulosin (0.4 mg daily) should be started before ESWL and continued for 2-4 weeks afterward to facilitate stone passage. During recovery, strain all urine to collect stone fragments for analysis, maintain high fluid intake (2-3 liters daily), and continue pain management as needed. ESWL works by using focused shock waves to break the stone into smaller fragments that can pass naturally. This approach is particularly effective for proximal ureteral stones of this size, offering a non-invasive alternative to ureteroscopy while addressing the developing hydronephrosis, which if left untreated could lead to kidney damage. It is also worth noting that clinicians should inform patients that SWL is the procedure with the least morbidity and lowest complication rate, but URS has a greater stone-free rate in a single procedure 1. However, for proximal ureteral stones, ESWL is a recommended treatment option due to its effectiveness and minimal invasiveness. Additionally, routine stenting should not be performed in patients undergoing SWL 1, unless there are specific indications such as suspected ureteric injury or anatomical impediments to stone fragment clearance. Overall, ESWL is a suitable treatment option for this patient, offering a balance between effectiveness and minimal invasiveness.

Some key points to consider:

• ESWL is effective for proximal ureteral stones with a stone-free rate of 82% 1
• Alpha-blockers can facilitate stone passage and should be started before ESWL and continued for 2-4 weeks afterward
• Pain management with NSAIDs and adequate hydration are crucial during recovery
• Strain all urine to collect stone fragments for analysis and maintain high fluid intake (2-3 liters daily)
• SWL has the least morbidity and lowest complication rate compared to URS 1
• Routine stenting is not recommended for patients undergoing SWL unless specific indications are present 1

From the Research

Stone Size and Treatment

• The stone size is approximately 7 mm, which is less than 1 cm [ 2 ].
• For stones less than 1 cm, extracorporeal shockwave lithotripsy (ESWL) is generally the first line treatment [ 2 ].

ESWL as a Treatment Option

• ESWL is a widely used method to treat renal and ureteral stones [ 3 ].
• ESWL fragments stones into smaller pieces that can pass spontaneously down the ureter and into the bladder [ 3 ].
• Alpha-blockers may assist in promoting the passage of stone fragments after ESWL [ 3 ].

Comparison with Ureteroscopy

• Ureteroscopy (URS) can be an option for stones greater than 1 cm, with better results than ESWL [ 2 ].
• For proximal ureteral stones less than 10 mm, both ESWL and URS have similar outcomes [ 4 ].
• URS is preferred over ESWL for larger stones or in patients with contraindications for ESWL [ 4 ].

Specific Considerations

• The presence of mild upstream hydroureteronephrosis may be a consideration in the treatment decision [ 2 ].
• The Hounsfield unit (HU) value of 1375 indicates a dense stone, which may affect treatment outcomes [ 2 ].