What is the next step in managing an 18-year-old woman with a stone protruding from the ureteral orifice identified during cystoscopy?

Management of Ureteral Stone Protruding from the Ureteral Orifice

The next step in managing an 18-year-old woman with a stone protruding from the ureteral orifice identified during cystoscopy should be basket extraction of the stone. 1

Rationale for Basket Extraction

Basket extraction is the optimal approach in this scenario for several reasons:

1. Immediate stone removal: The stone is already visible and accessible at the ureteral orifice, making basket extraction the most direct and efficient approach 2, 1

2. Minimizes complications: When a stone is already at the ureteral orifice, basket extraction under direct visualization is safer than more invasive procedures like stenting or lithotripsy 2

3. Prevents further obstruction: Removing the stone immediately eliminates urinary obstruction and associated morbidity 1

4. Avoids unnecessary procedures: More invasive options like laser lithotripsy or stent placement would be excessive when direct extraction is possible 1

Important Technical Considerations

• Direct visualization is mandatory: The American Urological Association guidelines explicitly state that "blind basketing" (basket extraction without endoscopic visualization) should never be performed due to high risk of ureteral injury 2

• Safety technique: The stone should be grasped under direct cystoscopic visualization to minimize the risk of ureteral avulsion or injury 2, 3

• Fragment prevention: Using a specialized basket device like the Dretler stone cone can help prevent proximal stone migration during extraction and facilitate fragment removal 3

Why Other Options Are Less Appropriate

1. Stopping the procedure (Option A) would leave the stone in place, potentially causing continued obstruction, infection risk, and symptoms 1

2. Retrograde pyelogram (Option B) is unnecessary when the stone is already visualized and would add contrast exposure without changing management 1

3. Ureteral stent placement (Option C) is more invasive than needed when direct extraction is possible, and would require a second procedure for stent removal 2

4. Laser lithotripsy (Option E) is unnecessarily invasive for a stone already at the orifice that can be removed intact, and risks creating fragments that may migrate proximally 1, 3

Potential Complications to Consider

• Ureteral injury: Basket extraction carries a 3-6% risk of ureteral damage if not performed carefully 1

• Stone migration: The stone could migrate proximally during manipulation, making retrieval more difficult 3

• Ureteral avulsion: A rare but serious complication of basket extraction, especially with impacted stones or excessive force 4

• Incomplete stone removal: Small fragments may remain, requiring follow-up imaging to confirm complete clearance 1

By performing basket extraction under direct visualization, the urologist can immediately resolve the patient's condition with minimal risk while avoiding unnecessary procedures and their associated complications.