Is a 6 mm calculus in the left ureter causing mild hydroureter and hydronephrosis indicated for ureteroscopy, laser lithotripsy, and Double-J (D-J) stent insertion?

Management of 6 mm Left Ureteral Calculus with Hydronephrosis

Ureteroscopy with laser lithotripsy and DJ stent placement is indicated for a 6 mm calculus in the left ureter at L3 level causing upstream hydroureter and hydronephrosis. 1

Rationale for Intervention

• The presence of hydronephrosis indicates obstruction, which requires intervention to prevent renal damage
• The stone size (6 mm) and high density (1568 HU) make spontaneous passage unlikely
• According to the American College of Radiology guidelines, cystoscopic retrograde ureteral decompression with double-J stents prior to definitive ureteroscopic stone extraction should be considered for obstructing stones 1

Treatment Options Analysis

Ureteroscopy with Laser Lithotripsy

• Advantages:
  • High success rates (81-94%) for ureteral stones 1
  • Most patients rendered stone-free in a single procedure
  • Particularly effective for mid-ureteral stones (86% stone-free rate) 1
  • Lower complication rates with modern techniques (ureteral perforation <5%, stricture formation ≤2%) 1

Shock Wave Lithotripsy (SWL)

• Limitations for this case:
  • Less effective for mid-ureteral stones due to overlying bone
  • Lower single-treatment success rates (60.4%) compared to ureteroscopy (87.8%) 2
  • Higher need for auxiliary treatments (42.3%) 2
  • May require multiple sessions to achieve stone clearance

Procedural Considerations

DJ Stent Placement

• Essential component of treatment to:
  • Relieve obstruction and prevent further kidney damage
  • Allow for drainage of stone fragments
  • Reduce risk of steinstrasse (stone street) formation
  • Facilitate healing of the ureter after instrumentation

Technical Aspects

• Ureteroscopy allows direct visualization of the stone
• Holmium laser is highly effective for fragmenting ureteral stones of various compositions
• Stone fragments can be removed with a basket or allowed to pass spontaneously after fragmentation
• DJ stent typically remains in place for 1-2 weeks post-procedure

Post-Procedure Management

• Follow-up imaging (ultrasound or KUB radiography) to confirm stone clearance
• Removal of DJ stent after confirming resolution of obstruction and stone clearance
• Metabolic evaluation to identify underlying causes and prevent recurrence

Potential Complications and Mitigation

• Ureteral injury: Minimized with careful technique and appropriate equipment sizing
• Infection: Perioperative antibiotic prophylaxis recommended
• Stent discomfort: Temporary and manageable with oral analgesics
• Incomplete stone clearance: Follow-up imaging to detect residual fragments

Clinical Pearls

• High-density stones (>1000 HU) like this one (1568 HU) are often resistant to SWL, making ureteroscopy a more appropriate first-line treatment
• The presence of hydronephrosis indicates significant obstruction requiring prompt intervention
• Mid-ureteral stones at L3 level are readily accessible with modern flexible ureteroscopes
• Ureteroscopy has been shown to be safe and effective even in anatomically complex cases 3, 4

Ureteroscopy with laser lithotripsy and DJ stent placement represents the most effective single-procedure approach for this patient's 6 mm ureteral calculus causing hydronephrosis, with high success rates and acceptable morbidity.