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Proximal ureteric calculus — MSRA MCQ

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HardNephrolithiasisProximal ureteric calculusMSRA

A 43-year-old man is reviewed by the urology team 34 hours after CT-confirmed renal colic. Low-dose non-contrast CT shows a 9 mm radiopaque proximal left ureteric stone with mild hydroureteronephrosis. The stone is clearly targetable with shockwave lithotripsy (SWL). He has no fever, negative urine culture, stable renal function, and pain is controlled with oral diclofenac. The urologist considers spontaneous passage unlikely. A SWL appointment is available tomorrow morning, 45 hours after diagnosis. Which is the most appropriate definitive management?

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

Reveal the answer and explanation

Correct answer: A — Arrange shockwave lithotripsy within 48 hours of diagnosis

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

This is a ureteric, rather than renal, stone. For an adult with a ureteric stone smaller than 10 mm, NICE recommends SWL as the first definitive intervention. He requires active treatment despite satisfactory analgesia because the stone is judged unlikely to pass; NICE advises treatment within 48 hours when pain is intolerable or spontaneous passage is unlikely. The stone is radiopaque and targetable, and SWL is available within that interval, so there is no stated reason to select ureteroscopy instead. ([nice.org.uk](https://www.nice.org.uk/guidance/ng118/chapter/Recommendations?utm_source=openai)) B is attractive because a 9 mm proximal stone has a limited probability of spontaneous passage, but URS is generally reserved for a sub-10 mm ureteric stone when SWL cannot clear it within 4 weeks, is contraindicated, is not targetable, or has failed. C is inappropriate because NICE supports alpha blockers as medical expulsive therapy for distal ureteric stones under 10 mm; this stone is proximal. D wrongly delays treatment beyond the recommended urgency for a stone unlikely to pass. E is disproportionate: PCNL is considered for impacted proximal ureteric stones when URS has failed, not as first-line treatment here.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Recommendations (08 January 2019) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations NICE NG118: Renal and ureteric stones: assessment and management — Recommendations (08 January 2019) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations NICE Quality Standard QS195: Timing of surgical treatment (2020) — https://www.nice.org.uk/guidance/qs195/chapter/Quality-statement-3-Timing-of-surgical-treatment