Is it safe to discharge a patient with moderate hydronephrosis due to a 2 mm kidney stone in the right ureterovesical junction (UVJ)?

From the Guidelines

It is generally safe to discharge a patient with moderate hydronephrosis due to a 2 mm kidney stone in the right ureterovesical junction (UVJ), provided certain conditions are met, as the stone has a high likelihood of spontaneous passage within 1-2 weeks 1. The patient should have adequate pain control with oral medications such as ibuprofen 600-800 mg every 6-8 hours or naproxen 500 mg twice daily, combined with acetaminophen 650-1000 mg every 6 hours as needed. An alpha-blocker like tamsulosin 0.4 mg daily can be prescribed to facilitate stone passage, as recommended by the American Urological Association 1. Key considerations for discharge include:

• The patient is well-hydrated, afebrile, has normal vital signs, no signs of infection, normal or near-normal renal function, and is able to tolerate oral intake.
• Discharge instructions should include increasing fluid intake to 2-3 liters daily, straining urine to catch the passed stone, and recognizing warning signs that require immediate return to care: fever above 101°F, uncontrolled pain, persistent vomiting, or inability to urinate.
• A follow-up with a urologist should be arranged within 1-2 weeks to ensure stone passage and resolution of hydronephrosis, as the maximum time duration for conservative therapy should not exceed six weeks from initial clinical presentation to avoid irreversible kidney injury 1. If the stone doesn't pass within this timeframe, intervention such as ureteroscopy may be necessary, considering the superior stone-free rates for ureteroscopy over shock-wave lithotripsy (90% for URS versus 72% for SWL) 1.

From the Research

Treatment Plan for Moderate Hydronephrosis

• The treatment plan for a patient with moderate hydronephrosis due to a 2 mm kidney stone in the right ureterovesical junction (UVJ) should be based on the severity of symptoms and the presence of any complications 2, 3.
• The patient should be closely monitored for any signs of worsening symptoms, such as increased pain, nausea, or vomiting 4, 5.
• Imaging studies, such as ultrasound or CT scans, should be used to monitor the size and position of the stone, as well as the degree of hydronephrosis 3, 6.

Safety of Discharge

• The decision to discharge a patient with moderate hydronephrosis due to a 2 mm kidney stone in the right UVJ should be based on the individual patient's condition and the availability of follow-up care 2, 4.
• Patients who are stable and have no signs of complications can be discharged with instructions to follow up with their healthcare provider in a few days to monitor their condition 5, 6.
• However, patients who have severe symptoms, signs of complications, or underlying medical conditions that may affect their ability to recover from the condition should be admitted to the hospital for further treatment and monitoring 2, 3.

Factors to Consider

• The size and location of the stone, as well as the degree of hydronephrosis, should be taken into consideration when determining the treatment plan and deciding whether to discharge the patient 4, 5.
• The patient's overall health and any underlying medical conditions should also be considered when making these decisions 2, 3.
• The availability of follow-up care and the patient's ability to seek medical attention if their condition worsens should also be taken into account 5, 6.