From the Guidelines
The next step in managing a ureteral stone protruding from the ureteral orifice during cystoscopy in an 18-year-old woman is to attempt basket extraction. This approach is supported by the most recent and highest quality study, which recommends ureteroscopic management, including basket extraction, for distal ureteral stones 1. The stone's location at the ureteral orifice makes it accessible for direct removal using a stone basket.
Key Considerations
- The stone is already at the distal end of the ureter and visible, making it accessible for direct removal.
- Ureteroscopic management, including basket extraction, has high success rates and low complication rates for distal ureteral stones 1.
- Following extraction, the urologist should inspect the area to ensure complete stone removal and assess for any mucosal injury.
Post-Procedure Care
- Adequate hydration
- Pain management with NSAIDs, such as ibuprofen 400-600mg every 6-8 hours as needed
- Possibly a short course of antibiotics if there are concerns about infection
- The patient should strain her urine for 24-48 hours to catch any additional stone fragments for analysis
Importance of Stone Composition Analysis
Stone composition analysis is important for preventing future stones, as it can help identify underlying causes of stone formation 1.
Avoiding Unnecessary Procedures
This direct removal approach avoids the need for more invasive procedures like ureteroscopy with laser lithotripsy, which would be necessary if the stone were located higher in the ureter or too large for simple extraction 1.
From the Research
Next Steps in Managing Ureteral Stone
The next step in managing a ureteral stone protruding from the ureteral orifice in an 18-year-old woman during cystoscopy involves several considerations based on current medical evidence. The key is to effectively remove the stone while minimizing the risk of complications such as ureteral damage or stone migration.
Options for Stone Removal
- Attempt Basket Extraction: This method involves using a stone retrieval basket to capture and remove the stone. Studies have shown that the use of a stone basket can be effective in preventing stone migration and facilitating extraction 2, 3.
- Laser Lithotripsy: This technique uses a laser to break the stone into smaller pieces that can then be removed. Laser lithotripsy has been shown to be safe and effective for treating ureteral stones, with the Holmium laser being a commonly used option 4, 5.
- Place Ureteral Stent: While not a direct method of stone removal, placing a ureteral stent can help to ensure the ureter remains open and can facilitate the passage of stone fragments after lithotripsy.
Considerations
- The choice between these options may depend on the size and location of the stone, as well as the patient's overall health status.
- The use of a stone basket and laser lithotripsy can be complementary, with the basket helping to prevent stone migration during the lithotripsy procedure 2, 3.
- It's crucial to avoid complications such as ureteral avulsion, which can occur with improper use of stone baskets or ureteroscopes 6.
Decision
Given the stone is protruding from the ureteral orifice and assuming it is of a manageable size, attempting basket extraction or performing laser lithotripsy could be viable next steps. The decision between these options should be based on the specific clinical scenario, the expertise of the practitioner, and the equipment available. Placing a ureteral stent might be considered if there are concerns about ureteral obstruction or if the stone cannot be immediately removed. Stopping the procedure without attempting stone removal is generally not advisable unless there are significant complications or the patient's condition changes. Retrograde pyelogram could be considered if there are concerns about the upper urinary tract, but it is not directly relevant to removing the stone from the ureteral orifice.