A 48-year-old woman presents with recurrent episodes of right flank pain radiating to the groin, haematuria, and nausea over the past 8 months. CT urogram shows a 7 mm calculus at the right vesicoureteric junction (VUJ) with moderate proximal hydronephrosis. Renal function is normal. What is the most appropriate management?

• A Extracorporeal shock wave lithotripsy (ESWL)
• B Medical expulsive therapy with tamsulosin and analgesia
• C Ureteroscopy with laser lithotripsy ✓
• D Open ureterolithotomy

Explanation

A 7 mm stone at the VUJ is unlikely to pass spontaneously (stones larger than 6 mm have very low spontaneous passage rates) and this patient has had recurrent symptomatic episodes over 8 months with associated hydronephrosis. Ureteroscopy with holmium laser lithotripsy is the procedure of choice for distal ureteric stones of this size — it provides direct access to the VUJ, high stone-free rates (>90%), and allows simultaneous treatment of any ureteral pathology. ESWL has lower stone-free rates for distal ureteric stones compared to URS. Medical expulsive therapy is appropriate for stones 5–6 mm or smaller as a primary strategy. Open surgery is rarely required today.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.