What's the next step in managing a patient with a stone protruding from the ureteral orifice identified during cystoscopy?

Management of a Ureteral Stone Protruding from the Ureteral Orifice

The next step in managing a stone protruding from the ureteral orifice identified during cystoscopy is to perform ureteroscopy with stone extraction under direct visualization. 1, 2

Rationale for Ureteroscopic Stone Extraction

Ureteroscopic stone extraction is the preferred approach for several reasons:

• The patient is already under anesthesia and the stone has been visualized
• Direct visualization during extraction prevents ureteral injury
• The stone is already at the ureteral orifice, making it accessible for extraction
• Ureteroscopy has high success rates for distal ureteral stones (95% for stones <10mm) 2

Procedural Approach

1. Maintain direct visualization: The AUA guideline explicitly states that "blind basketing" (stone extraction without endoscopic visualization) should not be performed due to risk of ureteral injury 1

2. Use appropriate instrumentation:

   • Introduce a safety guidewire first
   • Use a stone basket under direct ureteroscopic vision
   • Consider holmium:YAG or thulium fiber laser lithotripsy if the stone is too large for intact removal

3. Assess for additional stones: Examine the entire ureter to ensure no additional stones are present

4. Consider stent placement: Based on the degree of ureteral manipulation, stone burden, and any evidence of ureteral trauma

Important Considerations

• Stone size assessment: For stones >10mm, fragmentation may be necessary before extraction 1, 2

• Technical precautions:

  • Avoid excessive force during extraction to prevent ureteral injury
  • Maintain irrigation to ensure clear visualization
  • Use appropriately sized instruments to minimize trauma

• Potential complications to monitor:

  • Ureteral injury (occurs in approximately 3% of ureteroscopic procedures) 1, 2
  • Ureteral stricture formation (1-2% risk for distal ureteral stones) 1
  • Urinary tract infection (4% risk) 1

Special Considerations for This Case

• Patient age: The patient is 18 years old, making her a young adult. While pediatric considerations don't strictly apply, gentle technique is important to minimize trauma 3

• Hematuria: The presenting symptom of hematuria has been explained by the stone, but complete examination of the bladder during cystoscopy was important to rule out other causes

• Avoid complications: Cases of retained ureteroscopes due to stone fragment impaction have been reported, particularly with larger stones, highlighting the importance of careful technique 4

Alternative Approaches (Not Recommended as First-Line)

• SWL (Shock Wave Lithotripsy): Not appropriate as first-line when the stone is already at the ureteral orifice and accessible via ureteroscopy 1, 2

• Open or laparoscopic surgery: Reserved only for rare cases where endoscopic approaches fail 1