From the Guidelines
For a 6mm vesicoureteral junction (VUJ) stone, I recommend medical expulsive therapy (MET) with a-blockers, such as tamsulosin 0.4mg daily, as first-line management, as suggested by the European Association of Urology (EAU) guidelines 1. This approach is based on the EAU guidelines which consider medical expulsive therapy with a-blockers an option for distal ureteral stones greater than 5 mm. The management plan should also include adequate pain control using NSAIDs like ibuprofen 600mg every 6 hours or ketorolac 10mg every 6 hours as needed, and encourage fluid intake of 2-3 liters daily to promote stone passage. If the stone fails to pass within 4 weeks, if pain becomes uncontrollable, or if complications like infection or obstruction develop, urological intervention is necessary. The most appropriate intervention would be ureteroscopy with laser lithotripsy, which has a high success rate for distal ureteral stones of this size, as supported by the American Urological Association (AUA) and EAU guidelines 1, 2. Extracorporeal shock wave lithotripsy (ESWL) is an alternative but may be less effective for VUJ stones due to their location. Close follow-up with urinalysis to monitor for infection and imaging (typically ultrasound or low-dose CT) at 2-4 weeks is essential to assess stone position and any developing hydronephrosis. It's worth noting that the AUA guidelines suggest a maximal duration of conservative treatment of 4 to 6 weeks from the initial clinical presentation 1. However, the EAU guidelines are more recent and provide a clear recommendation for medical expulsive therapy with a-blockers for distal ureteral stones greater than 5 mm, making them the preferred guideline to follow in this case 1.
From the Research
Management of 6mm Vesicoureteral Junction (VUJ) Stone
- The management of a 6mm VUJ stone can be approached through expectant management, medical expulsive therapy, or surgical intervention 3.
- Expectant management involves monitoring the patient for spontaneous passage of the stone, which is acceptable for distal ureter stones less than 6mm in size, with observation for 2 months 3.
- Medical expulsive therapy using alpha-blockers, such as tamsulosin, can increase the rate of spontaneous stone passage by approximately 50% for small distal stones 4, 5, 6.
- Alpha-blockers are beneficial without lithotripsy for ureteral stones 5 to 10 mm, and can be considered post-lithotripsy for stones 5 to 10 mm, although little benefit may be seen 6.
- The size and location of the ureter stone are important factors for predicting spontaneous passage, with larger stones and more proximal locations having a lower chance of spontaneous passage 3.
Treatment Options
- Acute symptom management of renal colic can be accomplished with a combination of parenteral opioids and NSAIDs, with caution in the elderly due to potential adverse effects 4.
- Medical expulsion therapy with alpha-adrenoceptor antagonists or calcium channel antagonists is efficacious, with alpha-blockers such as tamsulosin being well-tolerated in the elderly 4, 5.
- Corticosteroids and calcium channel antagonists are also effective, but their use in the elderly is not recommended as first-line therapy 4.
Clinical Factors
- The cumulative spontaneous passage rate for ureter stones is 55.3% in 7 days, 73.7% in 14 days, 88.5% in 28 days, and 97.7% in 60 days after the first attack 3.
- The mean time to stone passage is 6.8 days for stones less than 2mm in size, 12.6 days for stones 2-4mm, 14.8 days for stones 4-6mm, and 21.8 days for stones 6-8mm 3.