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Proximal ureteric calculus — MSRA MCQ

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HardNephrolithiasisProximal ureteric calculusMSRA

A 52-year-old man attends the emergency department with 18 hours of right-sided renal colic. Low-dose non-contrast CT shows a 14 mm non-impacted proximal right ureteric stone with mild hydroureteronephrosis. There is no contralateral abnormality. His pain is now controlled with diclofenac, he is afebrile, urine culture is negative, creatinine is at baseline, and there is no sepsis or acute kidney injury. The urology team considers spontaneous passage unlikely. The local lithotripsy service can offer shockwave lithotripsy only in 5 weeks. Which is the most appropriate definitive management now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Arrange ureteroscopy within 48 hours of diagnosis

Explanation lettering: D = shown as A · C = shown as B · B = shown as C · E = shown as D · A = shown as E

This is a 14 mm ureteric, rather than renal, stone. For adult ureteric stones measuring 10–20 mm, NICE recommends ureteroscopy (URS) as the preferred intervention. Shockwave lithotripsy (SWL) is an alternative only where local facilities can achieve stone clearance within 4 weeks. Here, SWL would not be available until 5 weeks. In addition, the stone is considered unlikely to pass, which is an indication for surgical treatment within 48 hours of diagnosis even though analgesia is currently effective. A is unsuitable because the stated SWL delay exceeds the NICE condition for considering SWL in a 10–20 mm ureteric stone. B is attractive because alpha blockers may assist passage of distal ureteric stones smaller than 10 mm, but this is a proximal 14 mm stone with low likelihood of spontaneous passage. C may be used as temporary drainage in selected circumstances, particularly infection or obstruction requiring decompression, but it is not definitive stone clearance in this stable patient. D is not first-line: PCNL is considered for an impacted proximal ureteric stone after URS has failed. Therefore, timely URS is the best definitive management.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — surgical treatment of ureteric stones (2019; last reviewed 2021) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations NICE NG118: Renal and ureteric stones: assessment and management — timing of surgical treatment (2019; last reviewed 2021) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations NICE NG118: Rationale and impact — medical expulsive therapy (2019; last reviewed 2021) — https://www.nice.org.uk/guidance/ng118/chapter/Rationale-and-impact