What is the most appropriate additional treatment for a 38-year-old woman with a 4-hour history of left flank pain radiating to the groin, diagnosed with an 11-mm proximal ureteral stone and dilation of the renal calyces, and already initiated on analgesics?

From the Guidelines

The most appropriate additional treatment for this patient is C Tamsulosin. This 38-year-old woman has an 11-mm proximal ureteral stone with evidence of obstruction (dilated renal calyces). Tamsulosin, an alpha-1 adrenergic receptor blocker, is recommended as medical expulsive therapy for ureteral stones, as it relaxes the smooth muscle of the ureter, facilitating stone passage and reducing pain 1. While stones larger than 10 mm (like this 11-mm stone) have a lower likelihood of spontaneous passage, a trial of medical expulsive therapy with tamsulosin is still appropriate as initial management before considering more invasive approaches, such as ureteroscopy or shock-wave lithotripsy (SWL) 1. Some key points to consider in the management of this patient include:

• The patient should be advised to strain their urine to check for stone passage and to return if symptoms worsen, fever develops, or pain becomes uncontrollable despite analgesics, as these may indicate the need for urologic intervention.
• Tamsulosin is typically dosed at 0.4 mg orally once daily until stone passage or for up to 4 weeks.
• If observation with or without medical expulsive therapy is not successful after four to six weeks, the clinician should offer definitive stone treatment, with ureteroscopy being a recommended approach for proximal ureteral stones due to its high stone-free rates in a single procedure 1. The decision to proceed with more invasive treatment should be based on a shared decision-making approach, taking into account the patient's preferences, symptoms, and the potential risks and benefits of each treatment option 1.

From the Research

Treatment Options for Ureteral Stones

The patient presents with a 4-hour history of left flank pain radiating to the groin, and a noncontrast helical CT scan shows an 11-mm stone in the proximal ureter. Considering the size and location of the stone, the following treatment options are available:

• Intravenous 0.9% saline: This option is primarily for hydration and may not directly address the stone obstruction.
• Lithotripsy: This is a viable option for stones in the proximal ureter, especially if the stone is causing significant obstruction and pain.
• Tamsulosin: This medication can help with stone passage by relaxing the ureteral muscles, but its effectiveness may vary depending on the stone size and location.
• Observation: This approach may be considered if the stone is small and not causing significant symptoms, but the patient's current pain and stone size may require more active treatment.

Recommended Treatment

Based on the studies, lithotripsy appears to be a suitable option for this patient. According to 2, extracorporeal shock wave lithotripsy (ESWL) has a high success rate for stones with low density and smaller size. Although the stone size in this case is 11 mm, which may be considered relatively large, ESWL can still be effective. Additionally, 3 suggests that patient selection and technical factors, such as skin-to-stone distance and stone density, can impact the success of lithotripsy. Since the patient has a proximal ureteral stone, lithotripsy may be a suitable option.

Considerations

It is essential to consider the patient's overall health and the potential risks and benefits of each treatment option. As mentioned in 4, the selection of patients eligible for ESWL depends on the location and size of the stones and the overall health of the patient. In this case, the patient is otherwise well, and the stone is causing significant pain, making lithotripsy a reasonable option. Furthermore, 5 compares ESWL to percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS), suggesting that ESWL may be less effective for lower pole kidney stones but can still be a viable option for proximal ureteral stones.

Stone Size and Location

The size and location of the stone are crucial factors in determining the best treatment approach. As noted in 6, stone size and location correlated significantly with treatment outcomes regarding the need for further treatment and stone fragmentation. In this case, the 11-mm stone in the proximal ureter may require more active treatment, such as lithotripsy, to ensure adequate stone clearance and relief of symptoms.