What is the significance of a 4 cm calculus at the left ureterovesical (ureterovesicular) junction, indicating a left mid-pole renal calculus that has migrated distally?

From the Guidelines

The patient with a 4 cm calculus at the left ureterovesicular junction requires immediate urological intervention, likely surgical removal via ureteroscopy with laser lithotripsy or possibly percutaneous nephrolithotomy, given the large size of the stone and its potential to cause significant morbidity and mortality. The stone's migration from the kidney to the ureterovesicular junction indicates it has already traveled through most of the ureter, but its large size makes spontaneous passage extremely unlikely 1.

Key Considerations

• The size of the stone (4 cm) is significantly larger than those that typically pass spontaneously (usually <6mm), posing risks of complete urinary obstruction, kidney damage, and infection.
• Ureteroscopy with laser lithotripsy is a highly effective treatment option for ureteral stones, with high stone-free rates and low complication rates, as demonstrated in recent studies 1.
• Percutaneous nephrolithotomy may also be considered for large stones like this one, given its effectiveness in removing large renal stones.

Management Approach

• Urgent referral to a urologist for surgical removal of the stone is recommended.
• While awaiting intervention, pain management with NSAIDs like ketorolac (10mg every 6 hours) or opioids if needed, plus alpha-blockers such as tamsulosin (0.4mg daily) to help relax the ureter may be beneficial.
• Hydration with 2-3 liters of fluid daily is important to maintain urine flow.
• Symptoms to monitor include severe flank pain, fever, vomiting, or inability to urinate, which would require emergency care.

Evidence-Based Recommendations

• The American Urological Association recommends ureteroscopy as the first-line treatment for mid and distal ureteral stones, given its high stone-free rates and low complication rates 1.
• The use of laser lithotripsy during ureteroscopy has been shown to be highly effective in breaking up large stones, making it a suitable option for this patient's condition 1.

From the Research

Diagnosis and Treatment Options

• A 4 cm calculus at the left ureterovesicular junction represents a left mid pole renal calculus which has passed distally in the interim.
• The optimal treatment for ureteral calculi depends on the size and location of the stone, as well as the patient's overall health and preferences.

Treatment Modalities

• Extracorporeal shock wave lithotripsy (ESWL) is a non-invasive treatment option that uses shock waves to break up the stone into smaller pieces that can then pass out of the body in the urine 2, 3, 4, 5.
• Ureteroscopy with holmium laser lithotripsy is a minimally invasive treatment option that uses a small scope to visualize the stone and a laser to break it up into smaller pieces 3, 5, 6.
• Percutaneous nephrostolithotomy is a more invasive treatment option that involves making a small incision in the back to insert a scope and remove the stone 2.

Effectiveness of Treatment Modalities

• ESWL has been shown to be effective for smaller stones (< 1 cm), but may have a higher retreatment rate and lower stone-free rate compared to ureteroscopy 3, 4, 5.
• Ureteroscopy with holmium laser lithotripsy has been shown to be effective for larger stones (> 1 cm) and may have a higher stone-free rate and shorter treatment duration compared to ESWL 3, 5, 6.
• The choice of treatment modality depends on the individual patient's circumstances and should be made in consultation with a healthcare provider 2, 3, 4, 5, 6.