What is the treatment for a 15-mm nephrolithiasis (kidney stone) in the pelvic ureteral junction with fever?

Emergency Management of Obstructive Nephrolithiasis with Fever

Urgent decompression via percutaneous nephrostomy or ureteral stenting must be performed immediately, with definitive stone treatment delayed until sepsis resolves. 1

Immediate Emergency Intervention

This clinical scenario represents obstructive pyelonephritis—a urologic emergency that can rapidly progress to sepsis and death if not promptly decompressed. 2, 3

Urgent Decompression (Within Hours)

• Perform immediate drainage via either percutaneous nephrostomy or ureteral stenting before any attempt at definitive stone removal 1, 4
• The presence of fever with an obstructing stone indicates infection above the obstruction, creating a closed-space infection under pressure 2
• Intensive care monitoring may become necessary for septic patients 1

Concurrent Antibiotic Management

• Administer broad-spectrum antibiotics immediately upon presentation, before decompression 1
• Collect urine for culture and antibiogram testing both before and after decompression 1
• Re-evaluate the antibiotic regimen once culture results return 1
• Consider that these patients are at high risk for antimicrobial-resistant pathogens, particularly if they have prior instrumentation or recurrent UTIs 3

Definitive Stone Treatment (After Infection Resolves)

Do not attempt definitive stone removal until the sepsis has completely resolved. 1

Treatment Options for 15-mm Pelviureteric Junction Stone

Once the infection clears, a 15-mm stone at the pelviureteric junction requires active removal, as conservative management is inappropriate for stones >10 mm (spontaneous passage rates are negligible). 4

First-Line Options:

• Flexible ureteroscopy (fURS) with laser lithotripsy is a primary option for this stone size and location 5
• Percutaneous nephrolithotomy (PCNL) provides higher stone-free rates for stones in the 10-20 mm range 4, 5
• For stones at the pelviureteric junction specifically, both fURS and PCNL are acceptable, with PCNL offering superior stone-free rates but higher procedural risks 5

Second-Line Option:

• Extracorporeal shockwave lithotripsy (ESWL) is less effective for stones >15 mm and should be considered second-line 5

Pre-Procedure Requirements for Definitive Treatment

• Obtain urine microscopy and culture to confirm infection clearance before stone removal 1
• Administer perioperative antibiotic prophylaxis—for PCNL, an extended preoperative course significantly reduces postoperative sepsis compared to single-dose prophylaxis in high-risk patients 1, 6
• One week of ciprofloxacin before PCNL reduces upper tract infection risk threefold in patients with stones ≥20 mm or dilated systems 6

Critical Pitfalls to Avoid

• Never attempt immediate stone removal in the presence of fever and obstruction—this dramatically increases mortality risk from uncontrolled sepsis 1, 2
• Do not delay decompression to obtain additional imaging or consultations—time to drainage directly impacts outcomes in obstructive pyelonephritis 3, 7
• Avoid single-dose antibiotic prophylaxis for eventual PCNL in this patient who has already demonstrated infection—use extended preoperative coverage 1, 6

Post-Acute Management

After successful decompression and clinical improvement:

• Maintain the nephrostomy tube or ureteral stent until infection markers normalize (fever resolution, normal white blood cell count, negative cultures) 1
• Plan definitive stone removal as a staged procedure, typically weeks after the acute episode 1
• Perform stone analysis after removal to guide recurrence prevention 5