What is the best treatment option for a 4 x 3.5 mm left upper ureteric stone with mild hydronephrosis?

From the Guidelines

For a 4 x 3.5 mm left upper ureteric stone with mild hydronephrosis, ureteroscopic lithotripsy (URS) is the recommended treatment option due to its higher stone-free rate in a single procedure compared to shock-wave lithotripsy (SWL). According to the American Urological Association/Endourological Society guideline 1, URS has a greater stone-free rate in a single procedure, with a stone-free rate of 90% for URS versus 72% for SWL.

The patient's stone size and location, as well as the presence of mild hydronephrosis, suggest that URS is a suitable treatment option. The guideline recommends that clinicians 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.

In terms of specific treatment, the guideline suggests that URS is associated with significantly higher stone-free rates in a single procedure compared to SWL, particularly for patients with stones less than 10 mm in size 1. The patient's stone size of 4 x 3.5 mm is well within this range, making URS a suitable treatment option.

It is also important to note that routine stenting should not be performed in patients undergoing URS, unless there is suspected ureteric injury during the procedure, evidence of ureteral stricture or other anatomical impediments to stone fragment clearance, or renal functional impairment 1.

Overall, based on the available evidence, ureteroscopic lithotripsy (URS) is the recommended treatment option for a 4 x 3.5 mm left upper ureteric stone with mild hydronephrosis, due to its higher stone-free rate in a single procedure and lower risk of complications compared to other treatment options.

From the Research

Treatment Options for Left Upper Ureteric Stone

• The left upper ureteric stone measuring 4 x 3.5 mm with mild hydronephrosis can be treated with ureteroscopic lithotripsy (URS) or extracorporeal shock wave lithotripsy (SWL) 2, 3, 4, 5, 6.
• URS is a minimally invasive procedure that involves the use of a small endoscope to visualize the stone and break it up using a laser or other devices 4, 6.
• SWL is a non-invasive procedure that uses shock waves to break up the stone into smaller pieces that can then pass out of the body in the urine 2, 3, 5.

Efficacy of Ureteroscopic Lithotripsy

• Studies have shown that URS has a higher stone-free rate (SFR) compared to SWL, especially for stones larger than 1 cm 3, 5.
• URS also has a lower retreatment rate compared to SWL, regardless of stone size 3, 5.
• However, URS may require a longer hospital stay and more adjunctive procedures, such as the insertion of a JJ stent, compared to SWL 2.

Considerations for Stone Size

• The size of the stone is an important factor in determining the best treatment option 3, 5.
• For stones smaller than 1 cm, SWL may be a suitable option, while for stones larger than 1 cm, URS may be more effective 3.
• In this case, the stone measures 4 x 3.5 mm, which is relatively small, but URS may still be a viable option due to its high SFR and low retreatment rate 3, 5.

Safety and Efficacy of Ureteroscopic Lithotripsy

• URS is a safe and effective procedure for treating ureteral stones, with a high success rate and minimal morbidity 4, 6.
• The procedure can be performed under local anesthesia or sedation, and the patient can usually be discharged on the same day or the next day 6.
• However, as with any surgical procedure, there are potential risks and complications, such as infection, bleeding, and injury to the ureter or surrounding tissues 2, 4.