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A 54-year-old woman has a severe ureteral colic. An intravenous pyelogram shows a 7-mm ureteral stone at the ureteropelvic junction. She has a normal coagulation profile. Which of the following would most likely be the best therapy in this case?
A. Plenty of fluids and analgesics and await spontaneous passage
B. Extracorporeal shock wave lithotripsy (ESWL)
C. Endoscopic retrograde basket extraction
D. Endoscopic retrograde laser vaporization of the stone
E. Open surgical removal
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The correct answer is B. Extracorporeal shock wave lithotripsy (ESWL) is the most commonly used method to fragment urinary stones and allow their passage. Pregnancy and coagulation problems are contraindications. The first one is ruled out by her age, the second one we have been told she does not have.
Waiting for spontaneous passage (choice A) would have been perfect for a much smaller stone (3 mm) that had already negotiated most of the ureter. A 7-mm stone way up at the ureteropelvic junction has a very small chance of spontaneous passage.
Retrograde endoscopic approaches (choices C and D) are more invasive than ESWL. They would not be the first choice for this scenario.
Open surgical removal (choice E) would have been good for a much bigger stone. A huge target (a stone 3 cm or larger) could indeed be fragmented by ESWL, but then we would be contending with dozens of still very large stones. In those cases, a direct approach to extract the huge intact stone would work better.
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agree best therapy is B but if asked initila step -- fluids 1st
