What is the recommended management for patients undergoing ureteroscopy for ureteral stones?

Management of Patients Undergoing Ureteroscopy for Ureteral Stones

Ureteroscopy (URS) is highly effective for treating ureteral stones in all locations with stone-free rates ranging from 81-94% and should be considered first-line therapy for most ureteral stones, particularly those >10mm or in the mid and distal ureter. 1

Stone Location and Treatment Selection

Proximal Ureteral Stones

• Stone-free rate: 81% with ureteroscopy 1
• Flexible ureteroscopy is preferred (87% success) over rigid/semirigid (77% success) 1
• For stones <10mm: Both SWL and URS are appropriate options
• For stones >10mm: URS is preferred due to higher single-procedure success rates 1, 2

Mid-Ureteral Stones

• Stone-free rate: 86% with ureteroscopy 1
• Challenging location for all treatment modalities
• URS is generally preferred over SWL due to difficulties targeting stones over iliac vessels 1

Distal Ureteral Stones

• Stone-free rate: 94% with ureteroscopy 2
• URS is traditionally favored over SWL for this location 1

Procedural Considerations

Equipment Selection

• Semirigid ureteroscopes: Appropriate for most distal and mid-ureteral stones 1
• Flexible ureteroscopes: Preferred for proximal ureteral stones 1
• Lithotripsy devices: Holmium:YAG laser is preferred for most cases 1

Anesthesia Options

• Most cases performed under general anesthesia
• Selected patients may be candidates for local anesthesia with sedation 3
• Advantages of minimal anesthesia should be considered in appropriate patients 1

Stenting Considerations

• Routine stenting after uncomplicated URS is not necessary 1
• Consider stenting in cases of:
  • Ureteral edema/trauma during procedure
  • Large stone burden
  • Incomplete stone removal
  • Anatomical abnormalities
  • Solitary kidney

Complication Management

Common Complications

• Fever: Most common complication (11.7% of cases) 4
• Ureteral perforation: Occurs in approximately 1.2% of cases 4
• Ureteral avulsion: Rare but serious (0.06% of cases) 4
• Stricture formation: Long-term complication in ≤2% of cases 1

Prevention Strategies

• Use appropriate-sized instruments
• Gentle manipulation of ureteroscope
• Avoid forceful advancement of instruments
• Consider access sheath for multiple passages
• Maintain low intrarenal pressures

Special Populations

Pediatric Patients

• Both URS and SWL are effective in children 1
• Use smaller caliber instruments (4.5-6.0 Fr semirigid, 5.3 Fr flexible) 1
• Consider patient size and ureter/urethra dimensions when selecting approach 1

Pregnant Patients

• URS has been successfully performed in pregnant women 1
• Holmium laser is preferred for lithotripsy due to minimal tissue penetration 1
• Fluoroscopy should be minimized or avoided

Patients with Cystinuria

• These patients may have harder stones resistant to fragmentation
• URS with laser lithotripsy is generally effective 1

Post-Procedure Care

• Monitor for fever and signs of infection
• Pain management typically with NSAIDs as first-line
• Follow-up imaging to confirm stone clearance
• Metabolic evaluation to prevent recurrence in appropriate cases

Pitfalls to Avoid

1. Forceful manipulation of instruments leading to ureteral injury
2. Inadequate fragmentation of stones resulting in residual fragments
3. Overlooking infection which can lead to sepsis (most common complication)
4. Inappropriate patient selection for outpatient procedures
5. Neglecting metabolic evaluation in recurrent stone formers

By following these evidence-based recommendations, ureteroscopy can be performed safely with high success rates and minimal complications for patients with ureteral stones.