What is the management for a 26-year-old man with a complete C7 spinal cord injury and a 12 mm obstructing radiolucent ureteropelvic junction (UPJ) stone presenting with abdominal pain, headache, and diaphoresis?

From the Guidelines

The patient is experiencing autonomic dysreflexia due to an obstructing ureteropelvic junction (UPJ) stone and requires immediate management with urgent decompression of the urinary tract via percutaneous nephrostomy or retrograde ureteral stent placement, as recommended by the American Urological Association 1. This is a medical emergency requiring prompt intervention to prevent life-threatening complications. While preparing for decompression, the patient should be placed in an upright position and all tight clothing should be loosened. Blood pressure monitoring is essential, and if systolic pressure exceeds 150 mmHg, antihypertensive medication such as nifedipine 10 mg sublingually or intravenous hydralazine 5-10 mg should be administered. Following acute management, definitive stone treatment with ureteroscopy and laser lithotripsy or percutaneous nephrolithotomy should be planned based on stone characteristics and patient factors, considering the guidelines for surgical management of stones 1. Some key points to consider in the management of this patient include:

• The need for urgent decompression of the urinary tract to prevent life-threatening complications 1
• The importance of blood pressure monitoring and management during the acute phase 1
• The role of ureteroscopy and laser lithotripsy or percutaneous nephrolithotomy in definitive stone treatment 1
• The consideration of patient-specific factors, such as the size and location of the stone, in determining the best approach for definitive stone treatment 1. Autonomic dysreflexia occurs in spinal cord injuries above T6 when noxious stimuli below the level of injury trigger an uncontrolled sympathetic response, causing vasoconstriction, hypertension, and compensatory parasympathetic activation above the injury level, resulting in headache and diaphoresis, as noted in the patient's presentation 1. The obstructing stone is the trigger that must be addressed to resolve this dangerous condition. In patients with obstructing stones and suspected infection, clinicians must urgently drain the collecting system with a stent or other means, as recommended by the American Urological Association 1. The patient's condition requires prompt attention to prevent further complications and to improve their quality of life. The management of this patient should be guided by the principles of minimizing morbidity, mortality, and improving quality of life, with a focus on urgent decompression and definitive stone treatment.

From the Research

Clinical Presentation and Diagnosis

• The patient's symptoms, including vague abdominal pain, severe headache, and diaphoresis, are consistent with a ureteropelvic junction (UPJ) obstruction, as discussed in 2 and 3.
• The presence of a 12 mm obstructing radiolucent UPJ stone, as revealed by imaging, further supports this diagnosis.

Treatment Options

• Minimally invasive techniques, such as laparoscopic and robotic-assisted pyeloplasty, have been shown to be effective in treating UPJ obstruction with concomitant renal stones, as reported in 4.
• These techniques offer excellent surgical solutions with high stone-free rates and UPJ patency, making them a viable option for this patient.
• Open pyeloplasty is also a treatment option, as discussed in 5, but may not be as desirable due to its more invasive nature.

Considerations for Patients with Spinal Cord Injuries

• While the provided studies do not specifically address the treatment of UPJ obstruction in patients with spinal cord injuries, the principles of treatment discussed in 2, 3, and 4 can still be applied.
• The patient's underlying condition may require special consideration when selecting a treatment option, but the goal of relieving the obstruction and removing the stone remains the same.

Surgical Management

• The surgical management of UPJ obstruction, as discussed in 2 and 4, involves relieving the obstruction and removing the stone.
• The choice of surgical technique will depend on the individual patient's circumstances, including the size and location of the stone, as well as the surgeon's experience and preference.