What is the recommended treatment for a 2.5 cm stone at the ureteropelvic junction (UPJ)?

Management of a 2.5 cm Stone at the Ureteropelvic Junction

For a 2.5 cm stone at the ureteropelvic junction (UPJ), percutaneous nephrolithotomy (PCNL) should be offered as first-line therapy due to its superior stone-free rate compared to other interventions for stones >2 cm. 1

Treatment Decision Algorithm

Initial Assessment

• Confirm stone size and location with non-contrast CT scan
• Evaluate for signs of infection (urinalysis, urine culture if indicated)
• Assess renal function (serum creatinine)
• Evaluate degree of hydronephrosis

Treatment Options Based on Stone Size

1. For 2.5 cm UPJ stone (>2 cm):

   • First-line: PCNL

     • Highest stone-free rate (87-94%)
     • Less dependent on stone composition and density
     • Requires single procedure in most cases

   • Second-line options (if PCNL contraindicated):

     • Ureteroscopy (URS)
       • May require staged procedures
       • Lower stone-free rate than PCNL (75% vs 94% for >2 cm stones)
     • Laparoscopic or open surgical approach (rare cases)

   • Not recommended: SWL

     • Stone-free rates significantly reduced for stones >2 cm
     • Success rate drops to approximately 10% for stones >2 cm in lower pole

Procedural Considerations for PCNL

• Preparation:

  • Antimicrobial prophylaxis based on local antibiogram
  • Normal saline irrigation is mandatory (not glycine or other solutions) 1

• Technique:

  • Flexible nephroscopy should be routinely performed as part of PCNL to ensure complete stone clearance 1
  • Tubeless PCNL (without nephrostomy tube) is optional in uncomplicated cases 1

• Post-procedure:

  • Send stone material for analysis to guide prevention strategies 2
  • Consider metabolic evaluation to prevent recurrence

Special Considerations

• If infection is suspected:

  • Urgent decompression of collecting system with percutaneous drainage or ureteral stenting is mandatory before definitive treatment 1

• If PCNL is contraindicated (e.g., anticoagulation that cannot be discontinued, anatomical deformities preventing proper positioning):

  • URS is a viable alternative, though multiple procedures may be needed 1

• For patients with negligible kidney function:

  • Nephrectomy may be considered 1

Complications to Monitor

• Bleeding (more common with PCNL than other approaches)
• Infection/sepsis
• Injury to adjacent organs
• Urine leak
• Residual fragments

Follow-up

• Imaging to confirm stone-free status
• Follow-up within 1-2 weeks post-procedure
• Long-term metabolic evaluation to prevent recurrence

The 2016 American Urological Association guidelines clearly state that for stones >20 mm, PCNL offers the highest stone-free rate and should be the first-line therapy, while SWL should not be offered as first-line therapy for these larger stones 1. The 2.5 cm stone in this case falls well within this recommendation category.