What is the best course of treatment for a 6 mm calculus at the right ureterovesical junction (UVJ) with severe right hydroureteronephrosis?

Management of 6 mm Calculus at Right UVJ with Severe Hydroureteronephrosis

This patient requires urgent urological intervention with either retrograde ureteral stenting or percutaneous nephrostomy for immediate decompression, followed by definitive stone removal once any infection is controlled. The presence of severe hydroureteronephrosis indicates significant obstruction that mandates prompt drainage to prevent irreversible renal damage and potential septic complications 1, 2.

Immediate Assessment and Management

Rule Out Infection First

• Obtain urine and blood cultures immediately before starting antibiotics, but do not delay antibiotic administration while awaiting results 1, 2
• If the patient has fever, leukocytosis, or signs of sepsis, initiate broad-spectrum antibiotics immediately (third-generation cephalosporins show superior outcomes compared to fluoroquinolones) 1, 2
• If purulent urine is encountered during any endoscopic intervention, abort the stone removal procedure immediately, establish drainage, and continue antibiotics 3

Urgent Decompression

The severe hydroureteronephrosis requires urgent decompression regardless of infection status:

• Both retrograde ureteral stenting and percutaneous nephrostomy (PCN) are equally effective for decompression 3, 1, 2
• Retrograde ureteral stenting may be preferred as it allows for subsequent ureteroscopic stone removal and has shown decreased hospital stay duration in some cases 1
• PCN may be preferred if the patient is high-risk for anesthesia or if pyonephrosis is suspected (when larger tube decompression is warranted) 3
• Patient survival is significantly higher with decompression (92%) compared to medical therapy alone without decompression (60%) 1

Definitive Stone Management

Timing

• Definitive treatment must be delayed until any sepsis is resolved and infection is cleared following complete antimicrobial therapy 1, 2
• For non-infected cases, definitive treatment can proceed after initial decompression and stabilization

Treatment Options for 6 mm UVJ Stone

Ureteroscopy (URS) is the first-line definitive treatment for this stone:

• A 6 mm stone at the UVJ is ideally suited for ureteroscopic removal 3
• URS can be performed safely and effectively with high stone-free rates for distal ureteral stones 3
• A safety guidewire should be used during the procedure to facilitate rapid re-access if needed and provide access in case of ureteric injury 3
• Complete stone removal is essential to eradicate causative organisms, relieve obstruction, prevent further stone growth, and preserve renal function 1, 2

Alternative Approaches if URS Fails or Is Not Feasible

• Shock wave lithotripsy (SWL) could be considered, though UVJ location may make this less ideal 3
• If initial SWL fails, endoscopic therapy should be offered as the next treatment option 3
• Percutaneous antegrade ureteroscopy is reserved for cases where retrograde access fails 3
• Laparoscopic or open surgery should not be offered as first-line therapy except in rare cases of anatomic abnormalities or when endoscopic approaches have failed 3

Critical Pitfalls to Avoid

• Never perform blind basketing (stone extraction without endoscopic visualization) due to risk of ureteral injury 1
• Do not attempt definitive stone removal if infection/sepsis is present—drainage and antibiotics first 3, 1, 2
• Antimicrobial prophylaxis must be administered within 60 minutes of any stone intervention procedure 3

Follow-Up

• Stone material should be sent for analysis (unless multiple prior stones of documented similar composition) 3
• Follow-up imaging to confirm complete stone removal is essential after definitive treatment 1, 2
• Monitor with periodic imaging to assess resolution of hydroureteronephrosis 1

Clinical Context

The UVJ is the most common location for ureteral stones to lodge at emergency presentation (60.6% of cases), making this a typical presentation 4. The severe hydroureteronephrosis indicates this stone is causing significant obstruction and requires urgent intervention to prevent permanent renal damage.