From the Guidelines
For a 2mm calculus at the left ureterovesical junction causing mild left hydroureteronephrosis, the recommended treatment is conservative management with medical expulsive therapy. This approach is based on the most recent and highest quality evidence available, which suggests that small distal ureteral stones have a high spontaneous passage rate, and alpha-blockers like tamsulosin help by relaxing the smooth muscle of the lower ureter 1. The treatment regimen should include:
- Prescribing tamsulosin 0.4mg orally once daily for 4 weeks to relax the ureter and facilitate stone passage
- Providing adequate pain control with ibuprofen 600mg every 6 hours as needed, or if pain is severe, considering short-term narcotic pain medication such as oxycodone 5mg every 6 hours as needed
- Encouraging increased fluid intake of at least 2-3 liters of water daily to promote urination and stone passage
- Instructing the patient to strain their urine to catch the stone for analysis Most stones of this size (2mm) at the ureterovesical junction will pass spontaneously within 1-2 weeks with this regimen. If the patient develops fever, worsening pain, nausea/vomiting, or if the stone hasn't passed within 4 weeks, they should seek immediate medical attention as surgical intervention (ureteroscopy with laser lithotripsy) may be necessary 1. It's worth noting that ureteroscopic stone removal has a higher stone-free rate compared to shock-wave lithotripsy (SWL), but SWL has a lower complication rate and less morbidity 1. However, for a 2mm calculus, conservative management with medical expulsive therapy is the preferred initial approach, given the high likelihood of spontaneous passage and the potential risks and complications associated with more invasive procedures.
From the Research
Treatment Options for Mild Left Hydroureteronephrosis
- The treatment for mild left hydroureteronephrosis secondary to a 2mm calculus at the left ureterovesical junction may involve medical expulsive therapy (MET) or other minimally invasive techniques.
- According to 2, tamsulosin, a medical expulsive therapy, was associated with a significantly higher expulsion rate for distal ureteral stones less than 10 mm.
- A study by 3 compared the effects of tadalafil, tamsulosin, and placebo as a medical expulsive therapy for distal ureteral calculi and found that tamsulosin was more effective for distal ureteric stones with less need for analgesics and less stone expulsion time.
Considerations for Treatment
- The size and location of the stone, as well as the patient's overall health, should be taken into account when determining the best course of treatment.
- As noted in 4, shock wave lithotripsy (SWL) is a non-invasive treatment option for nephrolithiasis, but its effectiveness may depend on various factors, including stone composition and density.
- In some cases, as described in 5, endoscopic laser cystolithotripsy may be a viable treatment option for patients with hydroureteronephrosis secondary to a stone at the ureterovesical junction.
Medical Expulsive Therapy
- Tamsulosin has been shown to be an effective medical expulsive therapy for distal ureteral stones, with a higher expulsion rate and shorter stone expulsion time compared to placebo or other medications 2, 3.
- The use of tamsulosin as a medical expulsive therapy may be associated with a higher incidence of retrograde ejaculation, but it is generally considered safe and effective for patients with distal ureteral stones less than 10 mm 2.