What is the management for a patient with interval descent of right ureterovesical junction lithiasis to the prostatic urethral level?

Management of Stone Descended to Prostatic Urethra

For a stone that has descended from the ureterovesical junction to the prostatic urethral level, endoscopic transurethral removal is the definitive treatment of choice, as stones at this location will not pass spontaneously and require mechanical extraction. 1

Immediate Assessment and Stabilization

• Evaluate for urinary retention or obstruction – A stone lodged in the prostatic urethra can cause acute urinary retention requiring immediate catheterization or suprapubic drainage 2
• Rule out infection/sepsis – Obtain urine culture and assess for fever, leukocytosis, or signs of systemic infection, as infected obstructed systems require urgent decompression 2, 3
• Assess renal function – Check serum creatinine to evaluate for any renal impairment from the preceding obstruction 4

Definitive Treatment: Endoscopic Removal

The stone should be removed via transurethral cystoscopy with mechanical extraction or lithotripsy, as this location represents a bladder/urethral stone rather than a ureteral stone 1

Technical Approach:

• Cystoscopic visualization and extraction – Direct visualization allows grasping and removal of the stone with endoscopic forceps or basket 1
• Lithotripsy options if needed – For larger stones that cannot be extracted intact, use mechanical cystolithotripsy, ultrasonic, pneumatic, electrohydraulic lithotripsy (EHL), Swiss Lithoclast, or holmium:YAG laser fragmentation 1
• Holmium:YAG laser is the gold standard for lithotripsy if fragmentation is required 2

Post-Procedure Management

• Urethral catheterization – Place a Foley catheter for 24-48 hours post-procedure to ensure adequate drainage and allow any urethral edema to resolve 2
• Antibiotic coverage – Continue antibiotics if infection was present, or provide prophylaxis based on urine culture results 2
• Pain management – NSAIDs (diclofenac, ibuprofen) are first-line for post-procedure discomfort 3

Evaluation of Original Obstruction Site

Critical: Assess the ureterovesical junction for fibrosis or stricture formation, as the original stone location may have caused scarring that could lead to future obstruction 4

• Imaging follow-up – Obtain renal ultrasound within 2-4 weeks to assess for persistent hydronephrosis or hydroureter 4
• Consider CT urogram if ultrasound shows persistent dilation, to evaluate for UVJ stricture 4
• Monitor renal function – Repeat serum creatinine to ensure resolution of any obstruction-related impairment 4

Prevention of Recurrence

• Metabolic evaluation – Once acute management is complete, perform metabolic stone workup including 24-hour urine collection to identify risk factors 2
• Medical therapy – Initiate appropriate prophylaxis based on stone composition and metabolic abnormalities 5
• Hydration counseling – Recommend adequate fluid intake to maintain urine output >2L/day 4

Common Pitfalls to Avoid

• Do not attempt ESWL or ureteroscopy – The stone is no longer in the ureter and requires transurethral approach 1
• Do not delay removal – Stones at this location will not pass spontaneously and risk causing urinary retention or infection 1
• Do not ignore the original obstruction site – The UVJ may have developed fibrosis requiring future intervention 4
• Ensure complete stone clearance – Residual fragments in the bladder or urethra can serve as nidus for recurrent stone formation 2