What is the next step in managing a 22-year-old man with a 3 mm proximal ureteral calculus (kidney stone), perirenal stranding, and contrast extravasation, who has normal white blood cell count (WBC), mildly impaired renal function, and unremarkable urinalysis?

From the Guidelines

The next step in managing this 22-year-old man with a 3 mm proximal ureteral calculus, perirenal stranding, and contrast extravasation is urgent urological intervention, specifically placement of a ureteral stent. Despite his normal WBC count and unremarkable urinalysis, the contrast extravasation indicates urinary tract rupture, which is a urological emergency requiring immediate decompression of the collecting system 1. The patient should be admitted to the hospital, started on intravenous antibiotics, given adequate analgesia, and maintained NPO in preparation for urgent intervention. Intravenous hydration with normal saline should be initiated, with careful monitoring of renal function. While a 3 mm stone would typically have a high likelihood of spontaneous passage, the presence of contrast extravasation changes the management approach entirely. The extravasation indicates that urine is leaking outside the urinary tract, which can lead to urinoma formation, infection, and sepsis if not addressed promptly. The mildly impaired renal function further supports the need for urgent intervention to prevent further deterioration. Following the acute intervention, definitive stone management can be addressed once the urinary tract integrity is restored. Key considerations in this case include:

• Urgent urological intervention to prevent complications such as urinoma formation, infection, and sepsis
• Placement of a ureteral stent as the initial management approach
• Close monitoring of renal function and overall clinical status
• Definitive stone management to be addressed after the acute intervention As per the guidelines, ureteral stenting is recommended in cases of partial ureteral injuries or when urine flow is impaired 1, and the use of ureteral stents is recommended after all surgical repairs to reduce failures and strictures 1. Additionally, a recent study suggests that retrograde ureteral stenting may be preferred over PCN in certain cases, with a higher technical success rate and shorter dwell time 1. However, in this case, the presence of contrast extravasation and mildly impaired renal function necessitates urgent intervention, making ureteral stent placement the most appropriate next step.

From the Research

Management of Ureteral Calculus

The patient in question has a 3 mm proximal ureteral calculus with perirenal stranding and contrast extravasation, indicating potential ureteral obstruction and possible infection. The management of such a condition involves several considerations, including the size and location of the stone, the presence of infection or sepsis, and the patient's overall health status.

Considerations for Ureteral Stenting

• Ureteral stenting is a common procedure for managing ureteral obstruction, but its use is not without complications, including urinary tract infections and stent-related morbidity 2, 3.
• The decision to place a ureteral stent should be based on the individual patient's risk factors and the potential benefits and harms of stenting 4, 5.
• Studies have shown that routine ureteral stenting after uncomplicated ureteroscopy may not be necessary and may even increase the risk of urinary symptoms and pain 4, 5.

Alternative Management Options

• Observation may be an option for patients with small stones and no evidence of infection or sepsis, as the stone may pass spontaneously.
• Antibiotics may be necessary if there is evidence of infection or sepsis, but their use should be guided by culture results and antibiotic susceptibility testing.
• Ureteroscopy and stone removal may be necessary if the stone is large or causing significant obstruction, but this should be done on a case-by-case basis, considering the patient's overall health status and the potential risks and benefits of the procedure.

Next Steps

Based on the patient's presentation and the available evidence, the next steps in management could include:

• Close monitoring of the patient's condition, including serial imaging and laboratory tests to assess for signs of infection or sepsis.
• Consideration of ureteral stenting or other interventions if the patient's condition worsens or if there is evidence of significant obstruction or infection.
• Discussion with the patient about the potential risks and benefits of different management options, including observation, antibiotics, ureteral stenting, and ureteroscopy.