What is the next step in management for an 18-year-old female with hematuria (blood in urine) who has given consent for a cystoscopy (cysto) and examination under anesthesia, where a stone is seen protruding from the ureteral orifice and the bladder is normal?

From the Guidelines

The next step is to proceed with ureteroscopy to remove the stone protruding from the ureteral orifice. Since the patient is already under anesthesia and has provided consent for examination, extending the procedure to address the obvious cause of her hematuria is appropriate. The urologist should advance a ureteroscope into the ureter, grasp the stone with a basket or forceps, and extract it. If the stone is too large for simple extraction, lithotripsy may be necessary to fragment it before removal. Following stone extraction, the urologist should place a ureteral stent to prevent obstruction from post-procedural edema and to facilitate passage of any remaining stone fragments. The stent would typically remain for 1-2 weeks. This approach directly addresses the cause of the patient's hematuria, as the protruding stone is likely causing mucosal irritation and bleeding. Immediate intervention is justified because the stone is already partially in the bladder, making it accessible, and removing it will prevent potential complications like ongoing bleeding, infection, or complete ureteral obstruction. According to the American Urological Association/Endourological Society guideline 1, advances in ureteroscopy now allow endoscopic management of the vast majority of stones, supporting this approach as the most appropriate next step. Key considerations include:

• The patient's age and overall health, which suggest a low risk for complications from ureteroscopy
• The location and size of the stone, which make it accessible for removal via ureteroscopy
• The potential benefits of immediate intervention, including prevention of ongoing bleeding and potential complications
• The guideline recommendation 1 for endoscopic management of stones, which supports this approach as a strong recommendation with evidence strength of Grade C.

From the Research

Next Steps for 18-year-old Female with Hematuria

• The patient has given consent for cystoscopy and examination under anesthesia, and a stone is seen protruding from the orifice with a normal bladder.
• The next step would be to consider the best treatment option for the stone, taking into account the patient's age, overall health, and the size and location of the stone.
• Possible treatment options include:
  • Extracorporeal shock wave lithotripsy (ESWL) 2, 3
  • Percutaneous nephrolithotomy (PCNL) 2, 3, 4
  • Retrograde intrarenal surgery (RIRS) 2, 3
  • Flexible ureteroscopy 5
• The choice of treatment will depend on the specific characteristics of the stone and the patient's individual needs, and should be made in consultation with a qualified healthcare professional.

Considerations for Treatment

• ESWL may be less effective for lower pole kidney stones than PCNL or RIRS 2, 3
• PCNL may have a higher success rate than ESWL, but may also have a higher risk of complications 2, 3
• Flexible ureteroscopy may be a effective treatment option for renal calculi, with high treatment effectiveness and low complication rates 5
• The patient's overall health and medical history should be taken into account when choosing a treatment option, as certain conditions may increase the risk of complications or affect the success of treatment 6