What is the management for a patient with moderately severe right hydroureteronephrosis due to an obstructing stone at the right UVJ (ureterovesical junction)?

Management of Moderately Severe Right Hydroureteronephrosis from UVJ Stone

The primary management approach is urgent urinary decompression via retrograde ureteral stenting as first-line therapy, followed by definitive stone removal once any infection is controlled. 1, 2

Immediate Assessment and Intervention

Evaluate for Infection/Sepsis

• Check for fever, leukocytosis, and obtain urinalysis and urine culture immediately to determine if infection is present, as this dictates urgency of intervention 1, 2
• If signs of infection or sepsis are present, urgent decompression within hours is mandatory to prevent progression to urosepsis and mortality 1, 2

First-Line Decompression Strategy

Retrograde ureteral stenting should be attempted first for the following reasons:

• Associated with decreased hospital stay and ICU admission rates compared to percutaneous nephrostomy (PCN) 1, 2
• Allows for definitive ureteroscopic stone treatment in the same setting once infection clears 1
• Technical success rates are high for distal ureteral stones at the UVJ 1

Alternative Decompression if Retrograde Stenting Fails

Percutaneous nephrostomy (PCN) should be performed if:

• Retrograde stent placement is technically unsuccessful 1, 2
• Patient is at high risk for anesthesia 1
• Pyonephrosis is present requiring larger tube decompression 1
• PCN has technical success rates approaching 100% 2

Critical Management Principles

If Infection/Sepsis is Present

• Abort any definitive stone removal procedure if purulent urine is encountered 1
• Establish drainage immediately (stent or PCN), obtain urine culture, and continue broad-spectrum antibiotics 1, 2
• Delay definitive stone treatment until sepsis is completely resolved 2
• Administer antimicrobial prophylaxis within 60 minutes of any procedure covering gram-positive and gram-negative uropathogens 1

If No Infection is Present

• Medical management with fluids, NSAIDs for pain control, and observation may be considered for smaller stones that could pass spontaneously 2
• However, given moderately severe hydroureteronephrosis, decompression is generally warranted to prevent renal damage 1, 2

Definitive Stone Management

After successful decompression and infection control (if present):

• Ureteroscopy (URS) is the preferred definitive treatment for UVJ stones 1, 2
• Patients initially treated with retrograde stents typically undergo ureteroscopic stone removal 1
• Stone material should be sent for analysis to guide future prevention strategies 1

Important Caveats and Pitfalls

Do Not Delay Decompression

• Even small stones (as small as 3-4 mm) at the UVJ can cause severe obstruction and calyceal rupture due to high intraureteral pressure at this location 3, 4
• The UVJ location creates a particularly high-risk scenario for complications despite moderate stone size 3, 4

Monitor for Complications

• Prolonged manipulation during initial decompression can increase urosepsis risk, so limit manipulation if infection is suspected 1
• Watch for signs of collecting system rupture (perinephric fluid on imaging), which can occur even with small UVJ stones 3, 4

Avoid These Errors

• Do not attempt definitive stone removal in the presence of active infection - this significantly increases morbidity and mortality 1, 2
• Do not use shock wave lithotripsy (SWL) as first-line for UVJ stones - ureteroscopy is more appropriate for this location 2