Management of ureteral calculi
- Glenn M Preminger, MD
Glenn M Preminger, MD
- Section Editor — Renal Ureteral Stones
- Professor of Urologic Surgery
- Duke University Medical Center
- Director of Education
- Endourological Society
- Section Editors
- Stanley Goldfarb, MD
Stanley Goldfarb, MD
- Editor-in-Chief — Nephrology
- Section Editor — Mineral and Bone Metabolism
- Section Editor — Renal Ureteral Stones
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Michael P O'Leary, MD, MPH
Michael P O'Leary, MD, MPH
- Section Editor — Urology
- Professor of Surgery, Harvard Medical School
- Senior Urologic Surgeon, Brigham and Women's Hospital
The likelihood of spontaneous passage of a ureteral stone is related to both stone size and location. Most stones ≤4 mm in diameter pass spontaneously. Stone diameter ≥5 mm is associated with a progressive decrease in the spontaneous passage rate, which is unlikely with stones ≥10 mm in diameter. Proximal ureteral stones are also less likely to pass spontaneously. The data supporting these conclusions are presented elsewhere. (See "Diagnosis and acute management of suspected nephrolithiasis in adults".)
The management of ureteral calculi by stone location within the ureter will be reviewed here. Further discussion regarding the techniques utilized to treat ureteral calculi (including associated complications), the diagnosis and acute management of nephrolithiasis, and the significance of residual stones after stone removal are presented separately. (See "Options in the management of renal and ureteral stones in adults" and "Diagnosis and acute management of suspected nephrolithiasis in adults" and "Clinical significance of residual stone fragments following stone removal".)
OVERVIEW OF MANAGEMENT OPTIONS
The optimal approach of managing ureteral calculi varies with the size and location of the stone, and the presence and/or absence of patient comorbidities.
Emergency therapy — In septic patients with obstructing stones, urgent decompression of the collecting system with either percutaneous drainage or ureteral stenting is indicated in combination with appropriate antimicrobial therapy . Definitive treatment of the stone should be delayed until sepsis is resolved. Additional indications for urgent decompression include bilateral obstruction with acute kidney injury and unilateral obstruction with acute kidney injury in a solitary kidney.
Medical therapy — In a patient who has a newly diagnosed ureteral stone <10 mm and whose symptoms are controlled, observation with periodic evaluation is an option for initial treatment. Such patients may be offered an appropriate medical therapy to facilitate stone passage during the observation period. Patients who elect for an attempt at spontaneous passage or medical expulsive therapy should have well-controlled pain, no clinical evidence of sepsis, and adequate renal functional reserve. Patients should be followed with periodic imaging studies to monitor stone position and to assess for hydronephrosis. (See "Diagnosis and acute management of suspected nephrolithiasis in adults" and "Evaluation of the adult patient with established nephrolithiasis and treatment if stone composition is unknown".)
- Borofsky MS, Walter D, Shah O, et al. Surgical decompression is associated with decreased mortality in patients with sepsis and ureteral calculi. J Urol 2013; 189:946.
- Segura JW, Preminger GM, Assimos DG, et al. Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. The American Urological Association. J Urol 1997; 158:1915.
- Kourambas J, Byrne RR, Preminger GM. Does a ureteral access sheath facilitate ureteroscopy? J Urol 2001; 165:789.
- Aboumarzouk OM, Kata SG, Keeley FX, et al. Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi. Cochrane Database Syst Rev 2012; 5:CD006029.
- Matlaga BR, Jansen JP, Meckley LM, et al. Treatment of ureteral and renal stones: a systematic review and meta-analysis of randomized, controlled trials. J Urol 2012; 188:130.
- Cui X, Ji F, Yan H, et al. Comparison Between Extracorporeal Shock Wave Lithotripsy and Ureteroscopic Lithotripsy for Treating Large Proximal Ureteral Stones: A Meta-analysis. Urology 2015; 85:748.
- Irwin BH, Desai M. Ureteroscopic superiority to extracorporeal shock wave lithotripsy for the treatment of small-to-medium-sized intrarenal non-staghorn calculi. Urology 2009; 74:256.
- Pareek G, Armenakas NA, Panagopoulos G, et al. Extracorporeal shock wave lithotripsy success based on body mass index and Hounsfield units. Urology 2005; 65:33.
- Preminger GM. Technique versus technology: what is the most appropriate method for the removal of ureteral calculi. J Urol 1994; 152:66.
- Hemal AK, Goel A, Goel R. Minimally invasive retroperitoneoscopic ureterolithotomy. J Urol 2003; 169:480.
- Fetner CD, Preminger GM, Seger J, Lea TA. Treatment of ureteral calculi by extracorporeal shock wave lithotripsy at a multi-use center. J Urol 1988; 139:1192.
- Goethuys H, Winnepenninckx B, Van Poppel H, Baert L. The new generation Siemens Multiline lithotripter tube "M": early results in ureteral calculi. J Endourol 1996; 10:403.
- Honey RJ, Schuler TD, Ghiculete D, et al. A randomized, double-blind trial to compare shock wave frequencies of 60 and 120 shocks per minute for upper ureteral stones. J Urol 2009; 182:1418.
- Coe FL, Parks JH, Asplin JR. The pathogenesis and treatment of kidney stones. N Engl J Med 1992; 327:1141.
- Smith LH, Drach G, Hall P, et al. National High Blood Pressure Education Program (NHBPEP) review paper on complications of shock wave lithotripsy for urinary calculi. Am J Med 1991; 91:635.
- Ehreth JT, Drach GW, Arnett ML, et al. Extracorporeal shock wave lithotripsy: multicenter study of kidney and upper ureter versus middle and lower ureter treatments. J Urol 1994; 152:1379.
- Salem HK. A prospective randomized study comparing shock wave lithotripsy and semirigid ureteroscopy for the management of proximal ureteral calculi. Urology 2009; 74:1216.
- Agarwal MM, Naja V, Singh SK, et al. Is there an adjunctive role of tamsulosin to extracorporeal shockwave lithotripsy for upper ureteric stones: results of an open label randomized nonplacebo controlled study. Urology 2009; 74:989.
- Erhard M, Salwen J, Bagley DH. Ureteroscopic removal of mid and proximal ureteral calculi. J Urol 1996; 155:38.
- Wu CF, Shee JJ, Lin WY, et al. Comparison between extracorporeal shock wave lithotripsy and semirigid ureterorenoscope with holmium:YAG laser lithotripsy for treating large proximal ureteral stones. J Urol 2004; 172:1899.
- Dretler SP. Ureteroscopy for proximal ureteral calculi: prevention of stone migration. J Endourol 2000; 14:565.
- Sofer M, Watterson JD, Wollin TA, et al. Holmium:YAG laser lithotripsy for upper urinary tract calculi in 598 patients. J Urol 2002; 167:31.
- Krambeck AE, Murat FJ, Gettman MT, et al. The evolution of ureteroscopy: a modern single-institution series. Mayo Clin Proc 2006; 81:468.
- Schatloff O, Lindner U, Ramon J, Winkler HZ. Randomized trial of stone fragment active retrieval versus spontaneous passage during holmium laser lithotripsy for ureteral stones. J Urol 2010; 183:1031.
- Wang CJ, Huang SW, Chang CH. Randomized trial of NTrap for proximal ureteral stones. Urology 2011; 77:553.
- Mugiya S, Ozono S, Nagata M, et al. Retrograde endoscopic management of ureteral stones more than 2 cm in size. Urology 2006; 67:1164.
- Hruza M, Schulze M, Teber D, et al. Laparoscopic techniques for removal of renal and ureteral calculi. J Endourol 2009; 23:1713.
- Singh V, Sinha RJ, Gupta DK, et al. Transperitoneal versus retroperitoneal laparoscopic ureterolithotomy: a prospective randomized comparison study. J Urol 2013; 189:940.
- Teichman JM. Clinical practice. Acute renal colic from ureteral calculus. N Engl J Med 2004; 350:684.
- Bierkens AF, Hendrikx AJ, De La Rosette JJ, et al. Treatment of mid- and lower ureteric calculi: extracorporeal shock-wave lithotripsy vs laser ureteroscopy. A comparison of costs, morbidity and effectiveness. Br J Urol 1998; 81:31.
- Kourambas J, Delvecchio FC, Preminger GM. Low-power holmium laser for the management of urinary tract calculi, structures, and tumors. J Endourol 2001; 15:529.
- Farsi HM, Mosli HA, Alzimaity M, et al. In situ extracorporeal shock wave lithotripsy for primary ureteric calculi. Urology 1994; 43:776.
- Phipps S, Stephenson C, Tolley D. Extracorporeal shockwave lithotripsy to distal ureteric stones: the transgluteal approach significantly increases stone-free rates. BJU Int 2013; 112:E129.
- Netto Júnior NR, Claro Jde A, Esteves SC, Andrade EF. Ureteroscopic stone removal in the distal ureter. Why change? J Urol 1997; 157:2081.
- Teh CL, Zhong P, Preminger GM. Laboratory and clinical assessment of pneumatically driven intracorporeal lithotripsy. J Endourol 1998; 12:163.
- Arrabal-Polo MA, Arrabal-Martín M, Miján-Ortiz JL, et al. Treatment of ureteric lithiasis with retrograde ureteroscopy and holmium: YAG laser lithotripsy vs extracorporeal lithotripsy. BJU Int 2009; 104:1144.
- Harmon WJ, Sershon PD, Blute ML, et al. Ureteroscopy: current practice and long-term complications. J Urol 1997; 157:28.
- Borboroglu PG, Amling CL, Schenkman NS, et al. Ureteral stenting after ureteroscopy for distal ureteral calculi: a multi-institutional prospective randomized controlled study assessing pain, outcomes and complications. J Urol 2001; 166:1651.
- Byrne RR, Auge BK, Kourambas J, et al. Routine ureteral stenting is not necessary after ureteroscopy and ureteropyeloscopy: a randomized trial. J Endourol 2002; 16:9.
- Graff J, Diederichs W, Schulze H. Long-term followup in 1,003 extracorporeal shock wave lithotripsy patients. J Urol 1988; 140:479.
- OVERVIEW OF MANAGEMENT OPTIONS
- Emergency therapy
- Medical therapy
- Surgical therapy
- - Ureteroscopy versus shock wave lithotripsy
- PROXIMAL URETERAL CALCULI
- Shock wave lithotripsy
- Flexible ureteroscopy
- Holmium laser lithotripsy
- Percutaneous antegrade approach
- Retroperitoneal laparoscopy
- MID-URETERAL CALCULI
- DISTAL URETERAL STONES
- RECURRENT STONE FORMATION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS