What is the recommended treatment for a 19-year-old patient with a 5.5mm Ureteropelvic Junction (UPJ) stone and moderate hydronephrosis?

Treatment for 19-Year-Old with 5.5mm UPJ Stone and Moderate Hydronephrosis

For a 19-year-old patient with a 5.5mm ureteropelvic junction stone and moderate hydronephrosis, ureteroscopy (URS) is the recommended first-line treatment due to its superior stone-free rate compared to other interventions. 1

Initial Assessment and Considerations

Immediate Evaluation

• Assess for signs of infection (fever, elevated WBC, pyuria)
  • If infection is suspected, urgent drainage via ureteral stent or nephrostomy tube is mandatory before discharge 2
  • Obtain urinalysis and urine culture if infection is suspected 2
• Evaluate pain control and renal function (serum creatinine)
• Confirm stone size and location with appropriate imaging

Treatment Decision Algorithm

1. If no infection and pain is controlled:

   • Consider observation with medical expulsive therapy (MET) using alpha-blockers
   • Stone size (5.5mm) and location (UPJ) make spontaneous passage less likely but possible
   • Stone-free rates with observation alone average 35% for stones >5mm 1

2. If observation/MET is chosen:

   • Limit conservative therapy to maximum of 6 weeks to avoid irreversible kidney damage 1
   • Monitor with periodic imaging to assess stone position and hydronephrosis 2
   • Follow up within 1-2 weeks to confirm stone passage or determine need for intervention 2

3. If intervention is required (recommended in this case):

   • First-line: Ureteroscopy (URS)

     • Offers superior stone-free rate (95%) compared to SWL (87%) for ureteral stones <10mm 1
     • Lower complication rate than PCNL
     • Use of safety guidewire recommended during procedure 1

   • Alternative: Shock Wave Lithotripsy (SWL)

     • Consider if patient declines URS
     • Lower stone-free rate in a single procedure compared to URS 1
     • Lowest morbidity and complication rate among interventional options 1

Important Considerations

Pre-Procedure

• Administer antimicrobial prophylaxis prior to intervention based on local antibiogram 1
• Abort procedure and establish drainage if purulent urine is encountered during intervention 1

Post-Procedure

• Stone material should be sent for analysis to guide prevention strategies 1
• Consider metabolic evaluation to prevent recurrence

Special Considerations for Young Patients

• URS appears to have a high success rate in pediatric/young adult patients (around 85%) 1
• Complication rates may be somewhat higher with URS (12.4%-20.5%) compared to SWL (8%-10%) 1
• The presence of moderate hydronephrosis suggests potential obstruction, which increases the urgency for intervention

Pitfalls to Avoid

• Do not delay intervention beyond 6 weeks if observation is chosen, as this risks irreversible kidney injury 1
• Do not discharge patient without intervention if infection is suspected with obstruction 2
• Avoid routine stenting prior to URS in young patients, as access to the upper tract is usually possible on initial attempt 1
• Do not overlook the possibility of anatomical abnormalities (such as congenital UPJ obstruction) that may complicate stone management 3

The presence of moderate hydronephrosis with a 5.5mm stone at the UPJ warrants intervention, with ureteroscopy being the most effective approach to achieve stone clearance while minimizing complications in this young patient.