Is a 6 mm calculus in the left ureter, causing mild hydroureter and hydronephrosis, indicated for complex ureteroscopy (Ureteroscopy)?

Management of a 6mm Left Ureteral Calculus with Mild Hydroureter and Hydronephrosis

Ureteroscopy (URS) is the recommended treatment for a 6mm calculus in the left ureter at L3 level causing mild hydroureter and hydronephrosis, as it offers higher stone-free rates in a single procedure compared to other treatment modalities. 1

Treatment Options Based on Stone Characteristics

Ureteroscopy (URS) as First-Line Treatment

• For a 6mm ureteral stone at L3 level (proximal ureter), ureteroscopy offers excellent outcomes with stone-free rates of 81-93% in a single procedure 1
• The development of smaller caliber flexible ureteroscopes and improved instrumentation, particularly holmium:YAG laser, has made URS highly effective for stones in all ureteral locations
• Complication rates with modern URS techniques are low:
  • Ureteral perforation rates <5%
  • Long-term complications such as stricture formation ≤2%

Alternative Treatment: Shock Wave Lithotripsy (SWL)

• While historically preferred for proximal ureteral stones, SWL has shown declining stone-free rates compared to earlier analyses 1
• SWL advantages:
  • Can be performed with minimal anesthesia (IV sedation)
  • Less invasive than URS
• SWL disadvantages:
  • Lower stone-free rates for stones >5mm
  • May require multiple sessions

Decision Algorithm for This Case

1. Stone characteristics supporting URS:

   • 6mm size (>5mm)
   • High density (1568 HU) - dense stones respond less favorably to SWL
   • Presence of hydronephrosis indicating obstruction

2. Clinical considerations:

   • Presence of hydroureter and hydronephrosis indicates obstruction that requires prompt intervention
   • Obstruction can lead to progressive renal damage if left untreated 2

3. Procedural considerations:

   • Complex ureteroscopy is appropriate given:
     • Stone location (proximal ureter at L3 level)
     • Stone size (6mm)
     • Evidence of obstruction (hydroureter and hydronephrosis)

Expected Outcomes and Follow-up

• Stone-free rates with ureteroscopy for proximal ureteral stones are approximately 81-93% in a single procedure 1
• Follow-up imaging (ultrasound or KUB radiography) should be performed to confirm stone clearance 3
• Perioperative antibiotic prophylaxis is recommended (single dose before the procedure) 3

Important Considerations and Pitfalls

• Avoid delaying treatment: The presence of hydroureter and hydronephrosis indicates obstruction that can lead to progressive renal damage if left untreated
• Stone density matters: The high density (1568 HU) makes this stone less amenable to SWL
• Stenting considerations: Routine stenting is not necessary for all cases but may be indicated based on operative findings
• Antibiotic prophylaxis: Essential before the procedure to prevent infectious complications

In summary, complex ureteroscopy is the most appropriate treatment for this 6mm proximal ureteral stone causing hydroureter and hydronephrosis, offering the highest likelihood of stone clearance in a single procedure with minimal complications.