What is the management of bilateral renal calculi with bilateral hydronephrosis due to ureteric calculi, with a right ureter stone measuring 18x10mm and a left ureter stone measuring 10mm?

Management of Bilateral Ureteral Calculi with Hydronephrosis

For bilateral ureteral calculi causing hydronephrosis with stones measuring 18×10mm (right) and 10mm (left), urgent decompression of the collecting system with either retrograde ureteral stenting or percutaneous nephrostomy is required, followed by definitive stone removal via ureteroscopy. 1, 2

Initial Assessment and Management

Urgent Decompression

• Indication: Bilateral hydronephrosis indicates significant obstruction which can lead to renal damage and potential renal failure
• Options:
  • Retrograde ureteral stenting - First-line approach for stones <10mm 1
  • Percutaneous nephrostomy (PCN) - Alternative if stenting fails or is contraindicated 1, 2

Pre-intervention Considerations

• Assess for signs of infection (fever, elevated WBC) which would make decompression more urgent
• Check renal function (creatinine, BUN) to evaluate degree of obstruction impact
• Urine culture to guide antibiotic therapy if infection is present

Definitive Stone Management

Right Ureteral Stone (18×10mm)

• Primary recommendation: Ureteroscopy with holmium laser lithotripsy 2
  • Stone size >10mm makes spontaneous passage unlikely
  • Ureteroscopy offers higher single-procedure stone-free rate (94%) 2

Left Ureteral Stone (10mm)

• Options:
  • Ureteroscopy - Preferred for distal ureteral stones 1, 2
  • Shock Wave Lithotripsy (SWL) - Alternative for proximal stones <10mm 1, 2

Timing of Interventions

• Staged approach: Treat the more symptomatic or obstructed side first
• If equally symptomatic, consider treating the side with better renal function first
• Complete treatment of both sides within a reasonable timeframe to prevent further renal damage

Special Considerations

If Infection Present

• Administer appropriate antibiotics before any intervention
• Urgent decompression is mandatory in case of obstructive pyelonephritis 2
• Definitive stone treatment should be delayed until infection is resolved 1

Medical Expulsive Therapy

• Not recommended as primary treatment due to:
  • Stone size (>10mm on right side)
  • Presence of hydronephrosis indicating significant obstruction
  • Bilateral nature of the condition

Follow-up Care

• Imaging (KUB X-ray or ultrasound) within 1-2 weeks post-procedure to confirm stone clearance 2
• Increase fluid intake to >2L/day to prevent recurrence 2
• Consider metabolic evaluation to identify underlying causes of stone formation 2

Potential Complications to Monitor

• Ureteral injury (3-6% with ureteroscopy) 2
• Post-obstructive diuresis after relief of bilateral obstruction
• Infection/sepsis (especially if obstruction persists)
• Residual stone fragments requiring additional procedures

This management approach prioritizes preserving renal function while providing definitive treatment for the bilateral ureteral stones, which is crucial given the significant size of the stones and presence of hydronephrosis.