Is flexible ureteroscopy with laser lithotripsy indicated for a right distal ureteral stone measuring 14 mm × 6 mm, approximately 1000 HU, with a rough surface, located about 30 mm from the vesicoureteric junction and causing moderate‑to‑severe hydronephrosis?

Flexible Ureteroscopy with Laser Lithotripsy is Indicated for This Stone

This 14 mm distal ureteral stone with moderate-to-severe hydronephrosis requires active intervention, and flexible ureteroscopy with laser lithotripsy is the appropriate treatment choice given the stone size, location, and obstructive complications. 1

Why Active Intervention is Required

• Stones >10 mm rarely pass spontaneously and typically require surgical treatment 1
• The presence of moderate-to-severe hydronephrosis indicates significant obstruction requiring relief 1
• At 30 mm from the vesicoureteric junction, this is a distal ureteral stone amenable to ureteroscopic management 1
• The rough surface and high density (1000 HU) suggest a composition that may resist spontaneous passage 2

Why Ureteroscopy Over ESWL

For distal ureteral stones >10 mm, ureteroscopy provides superior stone-free rates compared to extracorporeal shock wave lithotripsy (ESWL). 1

Stone-Free Rate Advantage

• Ureteroscopy yields significantly higher stone-free rates for distal stones, with most patients achieving clearance in a single procedure 1
• For distal stones, ureteroscopy achieves stone-free rates of 96.8% overall 2
• ESWL stone-free rates for distal stones are lower, particularly for larger stones 1

Stone Characteristics Favor Ureteroscopy

• High-density stones (1000 HU) fragment less efficiently with ESWL 3
• The rough surface suggests calcium oxalate monohydrate or other hard composition that responds poorly to shock waves 3
• Modern holmium:YAG laser ureteroscopy effectively fragments high-density stones resistant to ESWL 3, 2
• Stone size of 14 mm exceeds the optimal range for ESWL success 1

Hydronephrosis Considerations

• While the degree of hydronephrosis doesn't significantly affect ureteroscopy success rates 2, it does indicate the need for prompt intervention
• Moderate-to-severe hydronephrosis in the setting of obstruction warrants definitive stone removal rather than observation 1

Ureteroscopy Safety Profile

Complication rates for ureteroscopy are acceptably low for distal ureteral stones: 1

• Ureteral injury: 3% 1
• Stricture formation: 1% 1
• Sepsis: 2% 1
• UTI: 4% 1

Distal stone location is associated with lower complication rates compared to proximal stones 2

Pre-Procedure Requirements

Before proceeding with ureteroscopy, ensure: 1

• Urine culture is obtained and any infection is treated - untreated bacteriuria with obstruction risks urosepsis 1
• Pain is well-controlled 1
• No clinical evidence of active sepsis 1
• Adequate renal functional reserve is confirmed 1

Common Pitfalls to Avoid

• Do not perform blind basket extraction without direct ureteroscopic vision - this carries significant risk of ureteral injury 1
• All intraureteral manipulations must be performed under direct visualization 1
• Fluoroscopic imaging alone is insufficient for safe stone manipulation 1
• Consider contrast imaging if anatomy is unclear, as duplex systems can complicate stone localization 4

Patient Counseling Points

Inform the patient that: 1

• Ureteroscopy offers the highest likelihood of becoming stone-free in a single procedure for this stone size and location 1
• A temporary ureteral stent will likely be placed post-procedure 1
• The alternative (ESWL) has lower success rates for stones of this size and density, with higher likelihood of requiring repeat procedures 1, 3
• Observation is not appropriate given the stone size >10 mm and presence of significant hydronephrosis 1