Ureteropelvic Junction Stone Management

Introduction to Treatment Options

• For patients with ureteropelvic junction stones and moderate hydronephrosis, ureteroscopy (URS) is the recommended first-line treatment due to its superior stone-free rate compared to other interventions, as supported by the American Urological Association 1

Medical Expulsive Therapy and Observation

• For patients with no infection and controlled pain, consider observation with medical expulsive therapy (MET) using alpha-blockers, with stone-free rates averaging 35% for stones >5mm, and limit conservative therapy to a maximum of 6 weeks to avoid irreversible kidney damage 1

Interventional Procedures

• Ureteroscopy (URS) offers a superior stone-free rate (95%) compared to Shock Wave Lithotripsy (SWL) (87%) for ureteral stones <10mm, with a lower complication rate than PCNL, and the use of a safety guidewire is recommended during the URS procedure 1
• Shock Wave Lithotripsy (SWL) is an alternative, with a lower stone-free rate in a single procedure compared to URS, but the lowest morbidity and complication rate among interventional options, with complication rates ranging from 8%-10% for SWL and 12.4%-20.5% for URS 1

Peri-Interventional Care

• Administer antimicrobial prophylaxis prior to intervention based on local antibiogram, and abort the procedure and establish drainage if purulent urine is encountered during intervention, as recommended by the American Urological Association 1

Post-Interventional Care and Prevention

• Stone material should be sent for analysis to guide prevention strategies, and consider metabolic evaluation to prevent recurrence, with URS appearing to have a high success rate in pediatric/young adult patients (around 85%) 1

Important Considerations

• Do not delay intervention beyond 6 weeks if observation is chosen, as this risks irreversible kidney injury, and avoid routine stenting prior to URS in young patients, as access to the upper tract is usually possible on initial attempt, as recommended by the American Urological Association 1, 2
• Urgent drainage of the collecting system is mandatory if infection is suspected, with options including ureteral stent placement and nephrostomy tube placement, to allow for drainage of infected urine and antibiotic penetration into the affected renal unit, as recommended by the American Urological Association 2, 3
• Pre-intervention evaluation should include urinalysis, and if clinical or laboratory signs of infection are present, urine culture must be obtained, with serum electrolytes and creatinine obtained if reduced renal function is suspected, as recommended by the American Urological Association 1, 2
• Non-contrast CT scan is the preferred imaging modality for assessing the degree of hydronephrosis and anatomical factors that may complicate stone passage, as recommended by the American Urological Association 1
• Follow-up within 1-2 weeks is recommended to confirm stone passage or determine the need for intervention, with patient education crucial, and patients should be counseled on the risks of medical expulsive therapy, including associated drug side effects, as recommended by the American Urological Association 3
• Patients can be considered for discharge if there is no evidence of infection, pain is well-controlled, renal function is normal, the patient understands the follow-up plan, and the patient can comply with medical expulsive therapy, but signs of infection or sepsis, uncontrolled pain, compromised renal function, single kidney with obstruction, or patient inability to comply with follow-up are all contraindications for discharge, as stated by the American Urological Association 2, 3