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Proximal ureteric calculus — MSRA MCQ

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ModerateNephrolithiasisProximal ureteric calculusMSRA

A 44-year-old man is reviewed by urology 18 hours after low-dose non-contrast CT for renal colic. CT shows a 12 mm proximal left ureteric calculus with mild hydroureteronephrosis. He is afebrile, urine culture is negative, renal function is unchanged and his pain is controlled with oral diclofenac. The stone is radiopaque and targetable with shockwave lithotripsy (SWL), but the local SWL pathway cannot achieve stone clearance within 4 weeks. The urologist considers spontaneous passage unlikely. An ureteroscopy slot is available tomorrow. What is the most appropriate definitive management plan?

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

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Correct answer: D — Offer ureteroscopy tomorrow

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

This is a 12 mm ureteric stone, placing it in the 10–20 mm category. NICE recommends offering ureteroscopy (URS) for adult ureteric stones of this size. SWL is an alternative only where local facilities can achieve stone clearance within 4 weeks; that condition is explicitly not met here. In addition, the stone is considered unlikely to pass, so definitive surgical treatment should be offered within 48 hours of diagnosis. URS tomorrow meets both the size-based treatment recommendation and the timing recommendation. A is attractive because the stone is radiopaque and targetable, but targetability alone does not override the requirement for timely clearance with SWL. B is inappropriate because NICE advises considering alpha blockers for distal ureteric stones smaller than 10 mm; this stone is proximal and 12 mm. D introduces an unnecessary delay despite an available definitive URS slot and an unlikely chance of spontaneous passage. E is not first-line for a 10–20 mm ureteric stone; PCNL may be considered for an impacted proximal ureteric stone after failed URS.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Recommendations 1.5.3 and 1.5.4 (Published 08 January 2019; minor update May 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations