What is the recommended initial approach for an elderly patient with a 9.2 mm proximal ureteric calculus obstruction causing right hydrouretero nephrosis?

Management of Elderly Patient with 9.2 mm Proximal Ureteric Calculus and Hydroureteronephrosis

This elderly patient requires urgent ureteroscopy (URS) as the definitive treatment, as the 9.2 mm proximal ureteral stone will not pass spontaneously and medical expulsive therapy is inappropriate for stones of this size. 1, 2

Immediate Assessment and Stabilization

Rule Out Sepsis First

• Assess immediately for clinical signs of sepsis (fever, tachycardia, hypotension, altered mental status), as infected obstructed kidneys constitute a urological emergency requiring urgent decompression before definitive stone treatment 3, 4
• Obtain urine culture and blood cultures if infection is suspected 1, 5
• If sepsis is present, urgent decompression with either percutaneous nephrostomy or retrograde ureteral stenting must be performed immediately, with definitive stone treatment delayed until infection resolves 3, 4

Elderly-Specific Considerations

• Assess frailty, comorbidities, and medication history (particularly anticoagulation) as elderly patients require careful evaluation for surgical risk 3
• Evaluate renal function, as prolonged obstruction may have compromised kidney function 2, 5
• Obtain baseline laboratory tests including serum creatinine to assess for acute kidney injury 3

Why Surgical Intervention is Mandatory

Stone Size Dictates Treatment

• Stones >10 mm require surgical intervention, and this 9.2 mm stone is at the threshold where spontaneous passage is highly unlikely 1, 2, 5
• Medical expulsive therapy with alpha-blockers is only appropriate for stones ≤10 mm, making it unsuitable for this case 1, 5
• The presence of hydroureteronephrosis indicates significant obstruction, and patients with hydronephrosis are poor candidates for bladder-sparing/conservative approaches 3

Location Matters

• Proximal ureteral stones have lower spontaneous passage rates than distal stones 6
• Stones >6 mm in the proximal two-thirds of the ureter are more likely to require endoscopic removal 6

Definitive Treatment: Ureteroscopy

Why URS is Preferred

• Flexible ureteroscopy achieves 87% stone-free rates for proximal ureteral stones, compared to 77% with rigid ureteroscopy 2
• URS yields significantly greater stone-free rates with a single procedure compared to shock wave lithotripsy (SWL), though with slightly higher complication rates 1, 5
• For elderly patients, URS should be considered first-line if the patient is on anticoagulation therapy 1

Surgical Technique

• Use flexible ureteroscopy for this proximal location to optimize stone-free rates 2
• Employ holmium:YAG laser lithotripsy as the preferred fragmentation method 2
• Never perform blind basketing without endoscopic visualization due to high risk of ureteral injury 1, 2

Expected Complications

• Ureteral injury: 3-6% for proximal stones 1, 2
• Stricture formation: 1-4% 1, 2, 5
• Sepsis: 2-4% 1, 2, 5
• Ureteral perforation: <5% 2

Perioperative Management

Preoperative Requirements

• Obtain non-contrast CT scan to define exact stone location and degree of hydronephrosis 2, 5
• Perform urinalysis and urine culture before intervention to rule out infection 1, 5
• Ensure adequate renal functional reserve 2, 5

Stenting Strategy

• Routine stenting following uncomplicated URS is optional 3, 2
• However, clear indications for stenting include ureteral injury, stricture, solitary kidney, renal insufficiency, or large residual stone burden 3
• Given the patient's age and potential for staged procedures, consider stenting to maintain ureteral patency 2

Pain Management

• Use NSAIDs (diclofenac, ibuprofen) as first-line analgesics for renal colic 1, 5
• Reserve opioids as second-line therapy only if NSAIDs are contraindicated or insufficient 1, 5

Alternative Approaches (If URS Fails or is Contraindicated)

Percutaneous Antegrade Ureteroscopy

• Acceptable first-line treatment for large impacted stones in the upper ureter 3
• Consider if retrograde access fails 3

Shock Wave Lithotripsy

• Both SWL and URS are acceptable first-line treatments for stones of this size 1, 5
• However, URS has higher stone-free rates with single procedure 1, 5
• SWL complications include steinstrasse (4-8%), sepsis (3-5%), and UTI (4-6%) 1

Laparoscopic/Open Surgery

• Reserved only for rare cases where SWL, URS, and percutaneous URS fail or are unlikely to succeed 3
• Laparoscopic ureterolithotomy achieves 88% stone-free rates but is more invasive 3

Follow-up and Monitoring

• Perform periodic imaging to monitor stone clearance and assess for persistent hydronephrosis 1, 2
• Complete treatment within 4-6 weeks to avoid progressive kidney injury from prolonged obstruction 1, 2
• Immediate reassessment is required if symptoms worsen, fever develops, or evidence of obstruction increases 5

Critical Pitfalls to Avoid

• Do not attempt conservative management or medical expulsive therapy for a stone of this size, as spontaneous passage is negligible 2
• Do not delay treatment beyond 4-6 weeks, as prolonged obstruction can cause irreversible renal damage 1, 2, 7
• Do not proceed with definitive stone treatment if sepsis is present—decompress first, treat infection, then address the stone 3, 4
• In elderly patients, do not underestimate surgical risk—assess frailty and comorbidities carefully before proceeding 3