Is a 4.5mm stone in the distal right ureter, causing mild right hydroureteronephrosis, indicated for Extracorporeal Shock Wave Lithotripsy (ESWL)?

From the Guidelines

Extracorporeal shock wave lithotripsy (ESWL) is not the preferred treatment option for this 4.5 mm stone in the right hemi-pelvis causing mild hydroureteronephrosis, as ureteroscopy (URS) has a higher stone-free rate in a single procedure, especially for distal ureteral stones. According to the most recent and highest quality study 1, URS is recommended as first-line therapy for patients with mid or distal ureteral stones who require intervention. The study found that URS has a significantly higher stone-free rate compared to ESWL, with a stone-free rate of 90% for URS versus 72% for ESWL.

The procedure of choice should be based on the location of the stone, with URS being preferred for distal ureteral stones. The patient should be counseled on the attendant risks and benefits of each treatment modality, including stone-free rates, anesthesia requirements, need for additional procedures, and associated complications.

Some key points to consider when deciding on a treatment plan include:

• The size and location of the stone
• The patient's overall health and medical history
• The potential risks and benefits of each treatment option
• The need for additional procedures or interventions

In this case, since the stone is located in the distal ureter, URS is the recommended treatment option. However, ESWL may still be considered if the patient declines URS or if there are any contraindications to URS. The patient should be informed that URS is associated with a higher stone-free rate, but also has higher complication rates compared to ESWL.

It's also important to note that the patient should be followed with periodic imaging studies to monitor stone position and to assess for hydronephrosis, as recommended by the guidelines 1. Additionally, the patient should be counseled on the importance of increasing fluid intake to 2-3 liters daily before and after the procedure to help flush out stone fragments, and pain management options should be discussed.

From the Research

Evaluation of Mild Right Hydroureteronephrosis with Suspected Stone

• The patient has mild right hydroureteronephrosis with a suspected stone at the right hemi-pelvic region, measuring about 4.5 mm.
• The stone is located in the distal right ureter, which could not be clearly identified.

Treatment Options for Nephrolithiasis

• According to 2, Extracorporeal shock wave lithotripsy (ESWL) is an important treatment for nephrolithiasis, especially for small stones.
• The study also mentions that observation for small, asymptomatic renal stones is a reasonable strategy, and medical expulsive therapy with an alpha blocker may have a beneficial effect for passage of ureteral stones.
• However, the study does not provide specific guidance on the treatment of stones in the distal ureter.

Indications for ESWL

• There is no direct evidence in the provided studies that specifically addresses the indication for ESWL in a patient with a 4.5 mm stone in the distal right ureter.
• However, based on the general principles of nephrolithiasis management, ESWL may be considered as a treatment option for small stones in the ureter, depending on the patient's symptoms and overall clinical scenario 2.
• Further evaluation and consultation with a urologist are necessary to determine the best course of treatment for this patient.