Is unilateral dilatation of the ureter with stent insertion indicated for a patient with mild left hydronephrosis and hydroureter secondary to a 3 mm left ureterovesical junction (UVJ) stone and nonobstructive renal stones?

From the Guidelines

Unilateral dilatation of the ureter with stent insertion is not indicated for a patient with mild left hydronephrosis and hydroureter secondary to a 3 mm left ureterovesical junction (UVJ) stone and nonobstructive renal stones. For a 3 mm UVJ stone, conservative management with medical expulsive therapy is typically the first-line approach, as suggested by the American Urological Association/endourological society guideline, part II 1. This would include alpha-blockers such as tamsulosin 0.4 mg daily for 2-4 weeks to relax the ureter and facilitate stone passage, adequate hydration (2-3 liters of water daily), and pain management with NSAIDs like ibuprofen 600 mg every 6-8 hours as needed. Some key points to consider in the management of this patient include:

• Ureteral stenting is usually reserved for cases with moderate to severe obstruction, intractable pain, urinary tract infection, solitary kidney, or stones larger than 5-6 mm with low likelihood of spontaneous passage.
• The mild hydronephrosis in this case suggests the obstruction is not severe, and most 3 mm UVJ stones have a high probability (approximately 70-80%) of spontaneous passage within 4 weeks, as implied by the principles of stone management 1.
• Nonobstructive renal stones can be monitored if asymptomatic or addressed separately if intervention becomes necessary.
• The patient should be followed with repeat imaging in 2-4 weeks to ensure stone passage or reassess if symptoms persist, in line with recommendations for monitoring and follow-up 1. Given the recent and high-quality evidence from the American Urological Association/endourological society guideline, part II 1, and the principles outlined in the ACR appropriateness criteria for radiologic management of urinary tract obstruction 1, a conservative approach with medical expulsive therapy is the most appropriate initial management strategy for this patient.

From the Research

Indications for Unilateral Dilatation of the Ureter with Stent Insertion

The patient's condition involves mild left hydronephrosis and hydroureter secondary to a 3 mm left ureterovesical junction (UVJ) stone, along with nonobstructive renal stones. The question is whether unilateral dilatation of the ureter with stent insertion is indicated for this condition.

Consideration of Stone Size and Location

• The size of the UVJ stone is 3 mm, which is relatively small.
• The location of the stone is at the ureterovesical junction, which can cause obstruction.
• Nonobstructive renal stones are present on each side, but their size is not specified as being large enough to warrant intervention based on size alone 2.

Review of Relevant Studies

• A study from 1999 compared nephrostomy, JJ stent, and urgent in situ extracorporeal shock wave lithotripsy (ESWL) for obstructing ureteric stones, suggesting that urgent in situ ESWL may be the preferred treatment if facilities are available 3.
• Another study from 2005 discussed the utility of ureteral stents for stone street after ESWL, concluding that ESWL should be performed without a ureteral stent when the stone diameter is below 20 mm 4.
• A case report from 2007 described the successful treatment of an impacted radiolucent stone at the pyeloureteric junction using ESWL and oral dissolution therapy, including the placement of a double-J stent after initial treatment 5.
• A study on stent placement for diagnosing upper tract obstruction found that relief of pain following stent placement can predict a favorable outcome from procedures to relieve the obstruction 6.

Application to the Patient's Condition

• Given the small size of the UVJ stone and the presence of nonobstructive renal stones, the primary concern is the relief of obstruction caused by the UVJ stone.
• The use of a ureteral stent may be considered to relieve the obstruction and prevent further complications, especially if the stone does not pass spontaneously or if there are signs of increasing obstruction.
• However, the decision to insert a stent should be based on the patient's specific symptoms, the degree of obstruction, and the potential risks and benefits of the procedure, as indicated by studies such as 2, 3, 4, 5, 6.