What is the recommended treatment for a 15 mm ureterovesical junction (UVJ) stone?

Treatment for 15 mm Ureterovesical Junction (UVJ) Stone

Ureteroscopy (URS) with laser lithotripsy is the recommended first-line treatment for a 15 mm ureterovesical junction stone due to its high stone-free rates and immediate resolution of obstruction. 1, 2

Treatment Algorithm

First-Line Treatment:

• Ureteroscopy (URS) with laser lithotripsy
  • All three major international guidelines (AUA/ES, EAU, SIU/ICUD) recommend URS as first-line treatment for distal ureteral stones >10 mm 1
  • Provides immediate resolution of obstruction with stone-free rates of 85-95% 2
  • Can be performed with semirigid ureteroscope for distal ureteral locations 1, 3

Alternative Options:

• Shock Wave Lithotripsy (SWL)
  • Less effective for stones >10 mm in the distal ureter 1, 2
  • Stone-free rates lower than URS for this size and location 4
  • May require multiple sessions for complete clearance 5

Procedural Considerations

For URS procedure:

• Use of safety wire is recommended (though with low level of evidence) 1
• Laser or pneumatic lithotripsy can be performed with semirigid ureteroscopes 1
• Post-procedure stenting is not routinely recommended but should be considered if:
  • Ureteral injury occurred during procedure
  • Patient has a solitary kidney
  • Renal insufficiency is present
  • Large residual stone burden exists 2
• Alpha-blockers may be prescribed post-procedure if a stent is placed to reduce stent discomfort 1

Expected Outcomes

• Stone-free rates:
  • URS: 94.2% for distal ureteral stones 3
  • Lower success rates with SWL for stones >10 mm 4
• Complications:
  • Low intraoperative complication rates (3.8-7.7%) 3
  • Postoperative complications in 2.5-4.6% of patients 3

Important Considerations

• Maximum observation period: If conservative management is initially chosen, the AUA recommends a maximum duration of 4-6 weeks from initial presentation to avoid irreversible kidney injury 1, 2
• Pre-procedure evaluation: Ensure absence of active infection; if infection with obstruction is present, urgent decompression via stent or nephrostomy is required before definitive treatment 2
• Follow-up imaging: Essential to confirm stone clearance 2

Pitfalls to Avoid

• Prolonged observation: Stones >10 mm in the distal ureter have low spontaneous passage rates and prolonged observation beyond 6 weeks can lead to irreversible kidney damage 1, 2
• Inadequate follow-up: Failure to confirm stone clearance can lead to silent obstruction and kidney damage 2
• Ignoring infection: Treating an obstructing stone in the presence of infection without appropriate antibiotics and drainage can lead to sepsis 2

For a 15 mm UVJ stone, ureteroscopy with laser lithotripsy offers the highest probability of complete stone clearance with minimal morbidity and should be the preferred treatment approach.