What is the next step in managing a 26-year-old man with intermittent left lower abdominal pain and a kidney stone, as shown on the computed tomography (CT) scan?

From the Guidelines

The next step in managing this 26-year-old man with intermittent left lower abdominal pain and a kidney stone is to recommend ureteroscopy (URS) as the first-line therapy, given its higher stone-free rates in a single procedure compared to shock wave lithotripsy (SWL) 1. This approach is based on the American Urological Association/Endourological Society guideline, which suggests that URS is associated with significantly higher stone-free rates in a single procedure compared to SWL, particularly for patients with mid or distal ureteral stones 1. Some key points to consider in the management of this patient include:

• The size and location of the stone, as these factors can influence the treatment approach 1
• The patient's symptoms and overall health status, as these can impact the decision to intervene sooner or later 1
• The potential risks and benefits of each treatment option, including URS and SWL 1
• The importance of close follow-up to monitor for stone passage and complications 1 It is also important to note that routine stenting should not be performed in patients undergoing SWL, and placement of a ureteral stent prior to URS should not be performed routinely 1. Given the most recent and highest quality evidence, ureteroscopy is the recommended treatment approach for this patient 1.

From the Research

Next Steps in Managing Kidney Stones

The next step in managing a 26-year-old man with intermittent left lower abdominal pain and a kidney stone, as shown on the computed tomography (CT) scan, involves several considerations:

• The size and location of the stone
• The severity of symptoms
• The patient's overall health

Treatment Options

Based on the provided studies, the following treatment options are available:

• Ureteroscopy: a minimally invasive procedure to remove the stone, which can be performed under general anesthesia or sedation 2, 3
• Percutaneous nephrolithotomy (PCNL): a surgical procedure to remove large stones, which can be performed under general or spinal anesthesia 4
• Laparoscopic pyelolithotomy: a minimally invasive surgical procedure to remove stones from the kidney, which can be performed under general anesthesia

Anesthesia Considerations

The choice of anesthesia depends on the patient's condition, the surgical team's preference, and the type of procedure:

• General anesthesia: may be preferred for flexible ureterorenoscopy to facilitate early dilatation of ureters and access to the stone 5
• Spinal anesthesia: may be preferred for PCNL to reduce operation time, fluoroscopy time, and length of stay 4
• Sedation: may be used for ureteroscopy, allowing for faster recovery and reduced postoperative complications 2, 3

Procedure Selection

The selection of the procedure depends on the size and location of the stone, as well as the patient's symptoms and overall health:

• Ureteroscopy: may be suitable for smaller stones in the ureter or kidney 2, 3
• PCNL: may be suitable for larger stones in the kidney 4
• Laparoscopic pyelolithotomy: may be suitable for stones in the kidney that cannot be removed by other means 6