What is the recommended treatment for a 5 x 5.5 mm radio-dense stone impacted in the upper right ureter and two radio-dense stones within the right kidney?

From the Guidelines

The recommended treatment for a 5 x 5.5 mm radio-dense stone impacted in the upper right ureter and two radio-dense stones within the right kidney would be ureteroscopy with laser lithotripsy. This procedure involves inserting a small scope through the urethra and bladder into the ureter to directly visualize and fragment the stone using a laser. For the ureteral stone, this approach has a high success rate for stones of this size. The kidney stones can be addressed during the same procedure if they are accessible. Prior to the procedure, medical expulsive therapy with tamsulosin 0.4 mg daily may be attempted for 2-4 weeks, along with pain management using NSAIDs like ketorolac 10 mg every 6 hours as needed or oral analgesics such as oxycodone/acetaminophen 5/325 mg every 6 hours as needed. Adequate hydration is essential during this period. If the patient experiences severe pain, fever, or signs of infection, immediate medical attention is necessary as these could indicate complications like obstruction or infection. Ureteroscopy is preferred for this case because the 5.5 mm stone is unlikely to pass spontaneously, and its location in the upper ureter makes it amenable to this approach. Extracorporeal shock wave lithotripsy (ESWL) could be an alternative but is generally less effective for upper ureteral stones of this size, as noted in the guidelines 1.

Key Considerations

• The size and location of the stone make ureteroscopy with laser lithotripsy the most effective treatment option.
• Medical expulsive therapy and pain management should be considered before proceeding with the procedure.
• The patient should be closely monitored for signs of complications and receive immediate medical attention if necessary.
• ESWL is a less preferred option due to its lower success rate for upper ureteral stones of this size, as supported by the guidelines 1.

Treatment Approach

• Ureteroscopy with laser lithotripsy is the recommended treatment approach for the ureteral stone and potentially for the kidney stones if accessible.
• The procedure should be performed by an experienced urologist with appropriate equipment and facilities.
• Post-procedure care should include monitoring for complications and managing pain and discomfort as needed, in line with the recommendations from the guidelines 1.

From the Research

Treatment Options for Ureteral Stones

• The recommended treatment for a 5 x 5.5 mm radio-dense stone impacted in the upper right ureter is Extracorporeal Shock Wave Lithotripsy (ESWL) or ureteroscopic pneumatic lithotripsy 2, 3.
• ESWL is an effective and reasonable initial therapy in the management of impacted upper ureteral stones measuring ≤ 2 cm, with a stone-free rate of 88.3% 4.
• Ureteroscopic pneumatic lithotripsy is also an effective treatment option, with a stone-free rate of 91% at 1 month after treatment 3.

Treatment Options for Renal Stones

• For the two radio-dense stones within the right kidney, ESWL is a recommended treatment option, especially for stones between 10 and 20 mm in size 5.
• The size of the stones, 3.5 x 4.5 mm and 2.8 x 3.5 mm, makes ESWL a suitable treatment option, as the stones are within the recommended size range 5.

Considerations for Treatment

• Pre-ESWL ureteral stenting provides no additional benefit over in situ ESWL and is associated with significant patient discomfort and morbidity 4.
• The choice of treatment should be based on the size, location, and composition of the stones, as well as the patient's overall health and anatomy 5.
• Active monitoring may be considered for asymptomatic patients with small residual stones or fragments less than 4 mm 5.