What is the best course of treatment for a 27-year-old man with intermittent left abdominal pain due to a left Ureteropelvic Junction (UPJ) stone?

Management of Left UPJ Stone in a 27-Year-Old Man with Intermittent Abdominal Pain

For a 27-year-old man with intermittent left abdominal pain due to a left ureteropelvic junction (UPJ) stone, ureteroscopy (URS) with laser lithotripsy is the recommended first-line treatment approach, as it offers the highest stone-free rates and immediate resolution of the obstruction.

Initial Assessment and Conservative Management

• Evaluate stone size, degree of hydronephrosis, and presence of infection through imaging (CT without contrast is the gold standard) 1
• For small UPJ stones (<10mm) without severe symptoms, infection, or significant obstruction:
  • Consider initial trial of medical expulsive therapy with alpha-blockers
  • Ensure adequate hydration and pain management
  • Close follow-up to monitor for stone passage or complications

Definitive Treatment Options

Ureteroscopy (URS)

• First-line treatment for UPJ stones regardless of stone size 1
• Advantages:
  • High stone-free rates (95% for stones <10mm, 78% for stones >10mm) 2
  • Direct visualization of the stone and ureter
  • Immediate stone clearance
  • Can be performed as outpatient procedure

Technical Considerations for URS

• Safety guidewire placement is essential 1
• Antimicrobial prophylaxis should be administered prior to the procedure 1
• Holmium:YAG or thulium fiber laser lithotripsy for stone fragmentation 2
• Consider ureteral stent placement if:
  • Significant ureteral edema is present
  • Stone impaction has occurred
  • Ureteral injury is noted during the procedure

Shock Wave Lithotripsy (SWL)

• Alternative option for smaller UPJ stones (<10mm) 1
• Less effective than URS for proximal ureteral stones 1
• Consider if patient prefers less invasive approach
• If initial SWL fails, clinicians should offer endoscopic therapy as the next treatment option 1

Percutaneous Nephrolithotomy (PCNL)

• Consider for larger stones (>20mm) or complex cases 1
• Higher morbidity compared to URS but may be more effective for large stones

Special Considerations for UPJ Stones

• UPJ stones may be associated with underlying UPJ obstruction that requires additional evaluation
• If concomitant UPJ obstruction is present, consider:
  • Endopyelotomy during URS
  • Laparoscopic/robotic pyeloplasty with stone extraction for cases requiring reconstruction 1, 3

Post-Procedure Management

• Stone material should be sent for analysis to guide prevention strategies 1
• Follow-up imaging to confirm stone clearance
• Alpha-blockers may be offered to facilitate passage of small residual fragments 1
• If residual fragments are present, clinicians should offer endoscopic procedures to render the patient stone-free 1

Complications to Monitor

• Ureteral injury (3-6% risk)
• Ureteral stricture formation (1-5% risk)
• Urinary tract infection (2-4% risk)
• Spontaneous rupture of the renal pelvis in cases of prolonged obstruction 4

Algorithm for Management Decision

1. If stone is <10mm without infection or severe symptoms:

   • Consider trial of medical expulsive therapy with close follow-up
   • Proceed to URS if no passage within 2-4 weeks

2. If stone is >10mm or associated with infection, severe pain, or obstruction:

   • Proceed directly to URS with laser lithotripsy
   • Consider PCNL for very large stones (>20mm)

3. If URS fails or is contraindicated:

   • Consider SWL for smaller stones
   • Consider PCNL for larger stones

4. If concomitant UPJ obstruction is present:

   • Consider combined endoscopic management or laparoscopic/robotic approach

The evidence strongly supports URS as the most effective approach for this 27-year-old patient with a UPJ stone, offering the highest likelihood of stone clearance with minimal morbidity.