What is the treatment for a left ureteral stone?

Treatment for Left Ureteral Stone

For left ureteral stones, ureteroscopy (URS) with laser lithotripsy should be offered as first-line therapy for most patients requiring intervention, while observation with or without medical expulsive therapy (MET) using alpha-blockers is appropriate for uncomplicated stones ≤10mm. 1, 2

Initial Management Approach

Observation vs. Intervention

• Small stones (≤10mm): Initial observation with or without MET is appropriate
  • Spontaneous passage rates: ~62% for stones <5mm, ~35% for stones >5mm 1
  • Alpha-blockers can facilitate stone passage (though off-label) 1
  • Maximum duration for observation: 6 weeks to avoid irreversible kidney injury 1

Indications for Immediate Intervention

• Presence of infection/sepsis with obstruction
• Intractable pain not controlled with analgesics
• Solitary kidney with obstruction
• Bilateral obstruction
• Renal insufficiency due to obstruction

Urgent Decompression

• If infection with obstruction: Urgent decompression of collecting system required via ureteral stent or percutaneous nephrostomy 1, 2
• Definitive stone treatment should be delayed until sepsis resolves 1

Definitive Treatment Options

1. Ureteroscopy (URS) with Laser Lithotripsy

• First-line therapy for most ureteral stones requiring intervention 2
• Advantages:
  • High stone-free rates (85-95%)
  • Immediate resolution of obstruction
  • Can be performed in patients with bleeding disorders or on anticoagulation 1
• Post-procedure stenting:
  • Optional after uncomplicated URS 1
  • Indicated with ureteral injury, stricture, solitary kidney, renal insufficiency, or large residual stone burden 1

2. Shock Wave Lithotripsy (SWL)

• Alternative to URS for stones ≤10mm
• Stone-free rates: ~87% for stones <10mm, ~73% for stones >10mm 1
• Less effective for:
  • Dense stones
  • Obese patients
  • Stones in mid-ureter (poor visualization)
• If initial SWL fails, endoscopic therapy should be offered 1

3. Percutaneous Antegrade Approach

• Indicated for:
  • Large impacted stones in upper ureter
  • Combined with renal stone removal
  • Ureteral stones after urinary diversion
  • Failed retrograde access 1

4. Laparoscopic or Open Surgery

• Reserved for rare cases where SWL, URS, and percutaneous approaches fail or are unlikely to succeed 1
• Laparoscopic ureterolithotomy has largely replaced open surgery with ~88% stone-free rate 1

Special Considerations

Patients with Bleeding Disorders

• URS should be first-line therapy in patients with uncorrected bleeding diatheses or requiring continuous anticoagulation/antiplatelet therapy 1

Pediatric Patients

• Both SWL and URS are effective
• Treatment choice based on child's size and urinary tract anatomy 1
• Stone-free rates in children: SWL (80-85%), URS (~85%) 1
• Complication rates: URS (12.4%-20.5%), SWL (8%-10%) 1

Post-Treatment Care

• Follow-up imaging to confirm stone clearance
• Alpha-blockers may facilitate passage of small residual fragments
• Metabolic evaluation to identify risk factors for recurrence

Common Pitfalls to Avoid

1. Delaying drainage in patients with infected obstructing stones
2. Prolonged observation (>6 weeks) risking kidney damage
3. Failing to obtain cultures before starting antibiotics in suspected infection
4. Routine stenting after uncomplicated URS (associated with lower urinary tract symptoms and pain)

The treatment choice should be guided by stone characteristics (size, location, density), patient factors (anatomy, comorbidities), and available expertise and equipment.