Is a right lower ureteric stone measuring 14 × 6 mm with a density of 1000 Hounsfield units, rough surface, located 30 mm from the vesico‑ureteric junction and causing moderate to severe right hydronephrosis indicated for flexible ureteroscopy with laser lithotripsy and double‑J stent placement?

Flexible Ureteroscopy with Lithotripsy and DJ Stent Placement is Indicated

Yes, this 14 × 6 mm lower ureteric stone with moderate to severe hydronephrosis requires urgent ureteroscopic intervention with laser lithotripsy and double-J stent placement. This stone exceeds the size threshold for conservative management and has already caused significant obstruction.

Why Intervention is Mandatory

Stone Size Exceeds Conservative Management Threshold

• Stones >10 mm are not candidates for medical expulsive therapy and require surgical intervention. 1
• Your stone measures 14 mm in maximum diameter, placing it well beyond the conservative management cutoff. 1
• The spontaneous passage rate for stones >10 mm is extremely low, and attempting conservative management risks irreversible renal damage. 1

Presence of Moderate to Severe Hydronephrosis

• Moderate to severe hydronephrosis indicates significant obstruction and higher risk of stone passage failure, mandating intervention. 2
• Recent evidence shows that larger stones (>10 mm) cause higher-grade hydronephrosis and have decreased passage rates through the ureter. 3
• The presence of moderate to severe hydronephrosis is associated with prolonged stone clearance time and need for repeat treatments if conservative approaches are attempted. 4

Stone Characteristics Predict Poor Spontaneous Passage

• The rough surface appearance on imaging (1000 HU density) suggests a calcium-based stone that will not pass spontaneously at this size. 2, 1
• High attenuation values (1000 HU) indicate a dense calcium stone that is resistant to spontaneous passage but amenable to laser lithotripsy. 2, 1
• The stone's location 30 mm from the vesicoureteric junction places it in the lower ureter where impaction is common, especially with stones >10 mm. 5

Recommended Intervention Strategy

Ureteroscopy is the Preferred Approach

• Flexible or semirigid ureteroscopy with holmium laser lithotripsy should be performed as the definitive first-line surgical treatment. 1, 6
• Ureteroscopy achieves stone-free rates of 90-95% for stones in this size range and location. 1
• The holmium laser can readily fragment stones with high attenuation values and rough surfaces. 2

Double-J Stent Placement

• Post-operative double-J stent placement should be strongly considered given the stone size, degree of hydronephrosis, and likely ureteral inflammation. 1, 6
• While routine post-operative stenting is not mandatory after uncomplicated ureteroscopy, the presence of moderate to severe hydronephrosis and a large stone burden warrants stent placement to ensure adequate drainage during healing. 1
• The stent will prevent ureteral obstruction from post-operative edema and facilitate passage of any residual fragments. 1

Pre-operative Requirements

• Obtain urine microscopy and culture before intervention to exclude or treat urinary tract infection. 1
• Administer antimicrobial prophylaxis within 60 minutes prior to the procedure, covering gram-positive and gram-negative uropathogens. 6
• Pre-operative ureteral stenting is not required, as successful ureteroscopic access is achievable on the initial attempt in most cases. 1

Why Conservative Management is Contraindicated

• The maximum duration of conservative management is 4-6 weeks for stones ≤10 mm; beyond this, intervention should not be delayed to avoid irreversible kidney damage. 1, 6
• Your stone at 14 mm already exceeds the size for any trial of conservative management. 1
• Attempting medical expulsive therapy with alpha-blockers would be futile and delay necessary intervention, risking permanent renal injury. 1, 6

Alternative: Shock Wave Lithotripsy is Less Optimal

• While shock wave lithotripsy (SWL) is an option for stones <10 mm, it is less effective for stones of this size and density. 1
• SWL yields stone-free rates of only 80-85% and often requires multiple sessions, with even lower success rates for larger stones. 1
• The high attenuation value (1000 HU) and rough surface may indicate a stone composition more resistant to shock wave fragmentation. 2
• Given the existing moderate to severe hydronephrosis, ureteroscopy offers more definitive single-session treatment. 1

Common Pitfalls to Avoid

• Do not attempt conservative management or medical expulsive therapy for stones >10 mm, as this delays necessary intervention and risks irreversible renal damage. 1, 6
• Do not proceed with intervention if active infection is present without first establishing drainage and administering appropriate antibiotics. 6
• Do not omit post-operative stenting in cases with significant pre-existing hydronephrosis, as this increases risk of post-operative obstruction. 1