What is the management for a patient with ureterolithiasis?

Management of Ureterolithiasis

The management of ureterolithiasis should follow a structured approach based on stone size, location, and patient presentation, with medical expulsive therapy (alpha-blockers) being first-line treatment for stones <5mm in the distal ureter, while surgical intervention is recommended for larger stones, proximal stones, or when complications arise. 1

Initial Assessment and Pain Management

• Pain control is the first priority in acute renal colic:

  • NSAIDs are first-line analgesics (if no contraindications) 1, 2, 3
  • NSAIDs reduce inflammation and pressure in the urinary collecting system
  • NSAIDs have fewer side effects compared to opioids (less vomiting, less need for rescue analgesia) 3
  • Opioids should be used as second-choice analgesics when NSAIDs are contraindicated 1

• Imaging is essential for diagnosis and treatment planning:

  • CT scan is the gold standard (97% sensitivity)
  • Ultrasound can be used for monitoring stone position and size
  • KUB radiography can be used for follow-up in radiopaque stones

Emergency Management

• Urgent decompression is strongly recommended in cases of:

  • Sepsis with obstructed kidney
  • Anuria with obstructed kidney 1

• Decompression options:

  • Percutaneous nephrostomy
  • Ureteral stenting 1

• Antibiotic therapy:

  • Obtain urine culture before stone treatment
  • Administer antibiotics immediately in cases of sepsis
  • Adjust antibiotic regimen based on antibiogram findings 1

Medical Management

Medical Expulsive Therapy (MET)

• Alpha-blockers (off-label class effect) are recommended for:
  • Stones amenable to conservative management
  • Greatest benefit for stones >5mm in the distal ureter 1

Chemolysis

• Oral chemolysis is strongly recommended for uric acid stones:
  • Alkalinization with citrate or sodium bicarbonate (pH 7.0-7.2)
  • Success rate of 80.5%, with 15.7% requiring further intervention 1

Surgical Management

Selection of Surgical Approach Based on Stone Size and Location

1. For stones <10mm:

   • Ureteroscopy (URS) or Shock Wave Lithotripsy (SWL) 1
   • URS has higher single-procedure stone-free rates
   • SWL has lower rates of ureteral injury (1-2% vs 3-6% for URS)

2. For stones 10-20mm:

   • URS or SWL, with URS generally preferred 1
   • PCNL (Percutaneous Nephrolithotomy) is another option for stones between 10-20mm 1

3. For stones >20mm:

   • PCNL is the first option regardless of location 1

4. For lower pole stones:

   • <10mm: URS or SWL
   • 10-20mm: URS or PCNL

   • 15mm: URS or PCNL preferred over SWL 1

Perioperative Considerations

• Antibiotic prophylaxis:

  • Recommended for all patients undergoing endourological treatment
  • Single dose of prophylactic antibiotic before ureteroscopy is sufficient 1
  • Obtain urine culture before procedure and treat if positive 1

• Antithrombotic therapy:

  • Patients on antithrombotic therapy should be referred to an internist before stone management
  • Flexible ureteroscopy is recommended when antithrombotic therapy cannot be stopped 1

• Stenting:

  • Routine stenting before SWL is not recommended 1
  • Routine placement of a ureteral stent is not recommended preoperatively or postoperatively 1
  • Alpha-blockers can be prescribed if the ureter is stented after the procedure to reduce stent discomfort 1

Follow-up Care

• Follow-up imaging to confirm stone clearance
• Metabolic evaluation to prevent recurrence
• Increased fluid intake (>2L/day) to prevent recurrent kidney stones

Special Considerations

• Contraindications for ESWL:

  • Pregnancy
  • Bleeding disorders
  • Uncontrolled UTI
  • Severe obesity
  • Skeletal malformations
  • Arterial aneurysm near the stone
  • Anatomic obstructions distal to the stone 1

• Laparoscopic ureterolithotomy:

  • Can be considered for large, impacted stones resistant to first-line treatments
  • Success rate of approximately 90.9%
  • Average hospital stay of 3.3 days 4

The management of ureterolithiasis requires a structured approach based on stone characteristics and patient factors. Medical expulsive therapy with alpha-blockers is effective for smaller distal ureteral stones, while surgical intervention is necessary for larger stones or when complications arise. Pain management with NSAIDs should be prioritized, and appropriate follow-up is essential to ensure stone clearance and prevent recurrence.