What is the recommended treatment for a 5mm ureterovesical junction (UVJ) stone?

Management of a 5mm Ureterovesical Junction (UVJ) Stone

For a 5mm ureterovesical junction stone, medical expulsive therapy (MET) with alpha-blockers should be offered as first-line treatment, with a high probability of spontaneous passage. 1

Initial Management Approach

• Medical expulsive therapy with alpha-blockers significantly improves stone-free rates for distal ureteral stones <10mm (77.3% vs 54.4% with placebo) and should be the initial approach for a 5mm UVJ stone 1
• Patients should be counseled that alpha-blockers are used "off-label" for this indication and informed about potential side effects 1
• NSAIDs (e.g., diclofenac, ibuprofen) are recommended as first-line analgesics for pain management, with opioids reserved as second-line therapy only if NSAIDs are contraindicated or insufficient 1
• The probability of spontaneous passage is high for a 5mm distal ureteral stone, especially with medical assistance 1, 2

Monitoring Requirements

• Follow-up with periodic imaging studies to monitor stone position and assess for hydronephrosis 1, 3
• Most stones that will pass spontaneously do so within approximately 17 days (range 6-29 days) 3
• The "Rule of 4's" suggests that stones >4mm, located >4mm from the UVJ, or with pain duration >4 days have higher likelihood of requiring intervention 2

Indications for Intervention

• If observation with MET is not successful after 4-6 weeks, definitive stone treatment should be offered 1, 3
• Immediate intervention is warranted if any of these develop:
  • Uncontrolled pain despite adequate analgesia 1, 3
  • Signs of infection or sepsis 1, 4
  • Development of obstruction or significant hydronephrosis 1, 3
  • Rare complications such as calyceal rupture (which can occur even with small stones) 5

Intervention Options

• For patients who fail observation or MET, ureteroscopy (URS) or extracorporeal shock wave lithotripsy (SWL) should be offered 1
• URS generally has higher stone-free rates (approximately 95% for stones <10mm) but slightly higher complication rates compared to SWL 1, 3
• For patients with bleeding disorders or on anticoagulation therapy who require intervention, URS should be considered first-line 1, 4
• Open/laparoscopic/robotic surgery should not be offered as first-line therapy and is reserved for rare cases with anatomic abnormalities or those requiring concomitant reconstruction 6

Procedural Considerations

• Antimicrobial prophylaxis should be administered prior to stone intervention based on prior urine culture results and local antibiogram patterns 6, 4
• A safety guidewire should be used for most endoscopic procedures to facilitate rapid re-access to the collecting system if needed 6
• If purulent urine is encountered during endoscopic intervention, the procedure should be aborted, appropriate drainage established, and antibiotic therapy continued 6, 4
• Stone material should be sent for analysis, especially for first-time stone formers 6, 4

Special Considerations

• About 20% of asymptomatic renal stones ≤5mm require surgical treatment within 5 years, so patients should be informed about potential future interventions even if initial conservative management is successful 7
• Distal ureteral stones, particularly at the UVJ, are the most common location for ureteral stones (46.3% of cases in one study) 8
• Rarely, what appears to be a UVJ stone on imaging may actually be a stone in a bladder diverticulum near the UVJ, which can cause similar symptoms and obstruction 9