From the Guidelines
The next step in managing this patient is immediate urological intervention to relieve the obstruction caused by the UPJ stone, specifically with urgent placement of a ureteral stent, as this approach is supported by the American Urological Association/Endourological Society guideline 1. This guideline emphasizes the importance of endoscopic management for the vast majority of stones, and in cases like this, where the patient has a complete C7 spinal cord injury and is experiencing autonomic dysreflexia due to the obstructing stone, urgent relief of the obstruction is crucial to prevent life-threatening complications. The patient's symptoms of vague abdominal pain, severe headache, and diaphoresis are indicative of autonomic dysreflexia, a medical emergency that requires prompt intervention to manage the acute hypertensive crisis and prevent potential complications such as stroke, seizures, or cardiac arrest. Key considerations in the management of this patient include:
- Urgent placement of a ureteral stent to bypass the obstruction and relieve the autonomic dysreflexia
- Administration of intravenous antihypertensive therapy, such as labetalol or nitrates, to manage the acute hypertensive crisis
- Continuous blood pressure monitoring throughout the procedure
- Positioning the patient with the head elevated at 45 degrees to minimize cerebral hypertension Following the acute intervention, definitive stone management can be planned, taking into account the patient's specific factors and stone characteristics, as emphasized by the American Urological Association/Endourological Society guideline 1.
From the Research
Management of Ureteropelvic Junction Stone
The patient in question has a complete C7 spinal cord injury and is experiencing autonomic dysreflexia symptoms due to a 12mm obstructing radiolucent ureteropelvic junction (UPJ) stone. The next step in management should prioritize relieving the obstruction and managing the symptoms.
Considerations for Stone Removal
- The size and location of the stone, as well as the patient's underlying condition, are crucial factors in determining the best approach for stone removal.
- Options for stone removal include extracorporeal shock wave lithotripsy (SWL), percutaneous nephrolithotripsy (PCNL), and ureteroscopic removal.
- According to 2, SWL is an option for patients with UPJ obstruction, especially if the stone can be dislodged or bypassed with a stent.
- However, the patient's symptoms of autonomic dysreflexia, including severe headache and diaphoresis, suggest the need for urgent relief of the obstruction.
Urgent Relief of Obstruction
- Given the patient's symptoms and the size of the stone, urgent relief of the obstruction is necessary to prevent further complications.
- Stent placement (option C) can provide immediate relief of the obstruction and help manage the patient's symptoms.
- According to 3, ureteric wall thickness can be a predictor of failed retrograde ureteric stent placement, but this does not necessarily preclude the use of stent placement in this patient.
- Additionally, 4 highlights the importance of managing autonomic dysreflexia in patients with spinal cord injuries, and relieving the obstruction is a crucial step in this process.
Conclusion Not Applicable - Next Steps
The next step in managing this patient would be to relieve the obstruction and manage the symptoms of autonomic dysreflexia.
- Stent placement (option C) is a viable option for urgent relief of the obstruction.
- Further management of the stone can be planned once the patient's symptoms are under control.
- The patient's underlying condition and the size and location of the stone will guide the choice of definitive treatment for the stone.