What is the recommended initial management and treatment options for ureteric calculi?

Management of Ureteric Calculi

For patients with ureteric stones requiring intervention, ureteroscopy (URS) should be your first-line surgical treatment because it achieves superior stone-free rates (90-97%) in a single procedure compared to shock wave lithotripsy (SWL), despite slightly higher complication rates. 1

Initial Assessment and Risk Stratification

Before any treatment decision, you must determine three critical factors:

• Pain control status: Patient must have well-controlled pain with oral analgesics before considering conservative management 1, 2
• Infection status: Obtain urine culture before any intervention; if infection or sepsis is present, this becomes an emergency requiring immediate drainage 3, 2
• Renal function: Adequate renal functional reserve is mandatory for observation 1, 2

Critical pitfall: Never attempt conservative management in patients with signs of sepsis—this requires urgent decompression with either percutaneous nephrostomy or ureteral stenting, as antibiotics alone have a 40% mortality rate without drainage. 3

Conservative Management Algorithm (Stones ≤10 mm)

Patient Selection Criteria

Conservative management with medical expulsive therapy (MET) is appropriate when ALL of the following are met:

• Stone size ≤10 mm 1
• Pain controlled with oral medications 1, 2
• No clinical evidence of sepsis 1, 3
• Adequate renal function 1, 2
• Patient can comply with follow-up 1

Medical Expulsive Therapy Protocol

Use alpha-blockers (tamsulosin or silodosin) as your primary MET agent, as they increase spontaneous stone passage rates by 29% compared to observation alone. 1, 4 Nifedipine provides only marginal benefit (9% improvement, not statistically significant) and should not be used. 1

Important counseling point: You must inform patients that alpha-blockers are used "off-label" for this indication and discuss potential side effects including orthostatic hypotension and retrograde ejaculation. 1, 2

Pain Management Strategy

• First-line: NSAIDs (diclofenac, ibuprofen) at the lowest effective dose 2, 4
• Second-line: Opioids only when NSAIDs are contraindicated or insufficient 2

Monitoring Requirements

• Periodic imaging (preferably low-dose CT or ultrasound) to monitor stone position and assess for hydronephrosis 1, 2, 4
• Maximum observation period: 4-6 weeks to avoid irreversible kidney damage 2, 4
• Expected timeline: Most stones that pass spontaneously do so within 17 days (range 6-29 days) 4

Indications to Abandon Conservative Management

Proceed immediately to surgical intervention if ANY of the following develop:

• Uncontrolled pain despite adequate analgesia 4
• Signs of infection or sepsis 3, 4
• Development or worsening of obstruction/hydronephrosis 4
• Failure of spontaneous passage after 4-6 weeks 2, 4

Surgical Treatment Options

Stone Size >10 mm

These stones will require surgical treatment in most cases, as spontaneous passage is unlikely even with MET. 1

First-Line Surgical Modalities

Both URS and SWL are acceptable first-line treatments, but you must counsel patients on the key trade-offs: 1

Ureteroscopy (URS)

• Stone-free rate: 90-97% for distal stones, 94-97% overall for stones <10 mm 3, 2, 4
• Advantages: Highest single-procedure success rate 1
• Complications:
  • Ureteral injury: 3-6% 1, 4
  • Stricture: 1-5% depending on stone location 1, 4
  • Sepsis: 2-4% 1
  • UTI: 2-4% 1

Shock Wave Lithotripsy (SWL)

• Stone-free rate: 80-90% 3, 2, 4
• Advantages: Less invasive, lowest morbidity 2, 4
• Disadvantages: May require repeat procedures, lower single-session success 1, 4
• Complications: Sepsis 2-5%, steinstrasse 2-10% depending on location 1

Critical Procedural Guidelines

Stenting protocols:

• Do NOT routinely stent before or during SWL—it provides no benefit and increases morbidity from stent-related symptoms 1, 4
• Stenting after URS is optional for uncomplicated cases 1
• Mandatory stenting after URS if: ureteral injury, stricture, solitary kidney, renal insufficiency, or large residual stone burden 1

Safety mandate: Never perform blind basket retrieval without endoscopic visualization—this carries high risk of ureteral injury. 4

Alternative Surgical Options (Select Cases)

Percutaneous antegrade ureteroscopy is indicated for: 1

• Large impacted stones in upper ureter 1
• Combined renal and ureteral stone removal 1
• Ureteral stones after urinary diversion 1
• Failed retrograde access to large, impacted upper ureteral stones 1

Laparoscopic or open ureterolithotomy should be considered only when SWL, URS, and percutaneous approaches fail or are unlikely to succeed (e.g., very large impacted stones, multiple ureteral stones). 1 Laparoscopic ureterolithotomy achieves 88% stone-free rates for large/impacted calculi. 1

Emergency Management: Obstructive Pyelonephritis

If sepsis is present with obstructing stone, this is a urological emergency:

1. Immediate urinary decompression via percutaneous nephrostomy (preferred, 92% survival vs 60% with medical therapy alone) or retrograde ureteral stenting 3
2. Broad-spectrum antibiotics: Third-generation cephalosporin (ceftazidime) as first-line empiric therapy 3
3. Adjust antibiotics based on culture results at 48-72 hours 3
4. Delay definitive stone treatment until infection completely resolved and full antibiotic course completed 1, 3

Pediatric Considerations

Both SWL and URS are effective in children, with treatment choice based on child's size and urinary tract anatomy. 1 The small pediatric ureter and urethra favor the less invasive SWL approach. 1 Complication rates are comparable to adults. 1, 4

Special Stone Compositions

Uric acid stones: Offer oral chemolysis with alkalinization (citrate or sodium bicarbonate to achieve pH 7.0-7.2), which has 80.5% success rate. 4, 5

Cystine stones: First-line therapy includes increased fluid intake, sodium/protein restriction, and urinary alkalinization to pH 7.0; add cystine-binding thiol drugs (tiopronin) if unresponsive. 4