From the Guidelines
The treatment for a ureterovesical junction stone typically involves a combination of medical expulsive therapy and pain management, with alpha-blockers like tamsulosin being the first-line medication to relax the ureter and facilitate stone passage, as recommended by the most recent guidelines 1.
Medical Expulsive Therapy
- Alpha-blockers like tamsulosin (0.4 mg daily) are the preferred agents for medical expulsive therapy, as they have been shown to facilitate ureteral stone passage and reduce the time to stone passage 1.
- The use of alpha-blockers has been demonstrated to be effective in promoting stone passage, with a statistically significant 29% more patients passing their stones with alpha-blocker therapy than with control patients 1.
Pain Management
- Pain control with NSAIDs such as ibuprofen (600-800 mg every 6-8 hours) or ketorolac (30 mg IV or 10 mg orally every 6 hours) is essential, with opioids reserved for severe pain.
- Adequate hydration of 2-3 liters of water daily helps promote stone passage.
Procedural Intervention
- For stones smaller than 10 mm, a conservative approach has a good chance of success, but if the stone doesn't pass within 4 weeks, causes severe symptoms, creates obstruction with infection, or is larger than 10 mm, procedural intervention becomes necessary.
- Options include ureteroscopy with laser lithotripsy, extracorporeal shock wave lithotripsy (ESWL), or in some cases, placement of a ureteral stent to relieve obstruction temporarily.
- These interventions work by either removing or breaking the stone into smaller fragments that can pass naturally through the urinary tract.
Recent Guidelines
- The 2016 American Urological Association guideline recommends offering observation and medical expulsive therapy with alpha-blockers for patients with uncomplicated ureteral stones ≤10 mm, and considering procedural intervention for stones that do not pass within 4 weeks or cause severe symptoms 1.
- The guideline also recommends discussing the relative benefits and risks of different treatment modalities with patients, including stone-free rates, anesthesia requirements, and associated complications.
From the Research
Ureterovesicular Junction Stone Treatment
The treatment for a ureterovesicular junction stone depends on various factors, including the size and location of the stone.
- For stones larger than 20 mm, percutaneous nephrolithotomy (PNL) is currently the first-line recommended treatment, as it has an excellent stone-free rate for large kidney stones 2.
- However, for stones between 20 to 40 mm, staged flexible ureteroscopy (fURS) is a practical option, as it has a minimal blood transfusion risk, short hospitalization, and few restrictions on daily routines 2.
- For patients with a stone burden < 20 mm, ureteroscopy (URS) is a favorable option that promises a high stone-free rate after a single session, either unilaterally or bilaterally 2.
- Medical expulsive therapy (MET) with alpha blockers, such as tamsulosin, can also be effective in facilitating stone passage, especially for distal ureteric stones 3, 4.
- However, the efficacy of tamsulosin in a general emergency department population has not been consistently shown, and its use may not substantially improve outcomes compared to standard therapy alone 5.
Treatment Selection
The selection of treatment for urolithiasis, including ureterovesicular junction stones, depends on various factors, including stone size, composition, and location, as well as patient factors such as habitus and renal anomalies 6.
- Percutaneous nephrolithotomy (PCNL) is indicated for stones larger than 20 mm, staghorn and partial staghorn calculi, and stones in patients with chronic kidney disease 6.
- Flexible ureteroscopy can be an option for lower pole stones between 1.5 and 2 cm in size, and for stones located in the diverticular neck or a diverticulum 6.
- Extracorporeal shock wave lithotripsy (ESWL) is a treatment option for renal stones between 10 and 20 mm in size, excluding lower polar stones, and for proximal ureteral stones 6.