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Symptomatic proximal ureteric calculus — MSRA MCQ

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HardNephrolithiasisSymptomatic proximal ureteric calculusMSRA

A 68-year-old man re-attends 30 hours after low-dose non-contrast CT confirmed a 9 mm proximal left ureteric calculus with moderate hydroureteronephrosis. He has ongoing severe renal colic and vomiting despite diclofenac and paracetamol. He is afebrile and haemodynamically stable; urine culture is negative and creatinine is unchanged from baseline. The stone is radiopaque and targetable with shockwave lithotripsy (SWL). The lithotripsy service can provide treatment tomorrow. What is the most appropriate definitive management plan?

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Correct answer: D — Arrange shockwave lithotripsy tomorrow without pre-treatment ureteric stenting

This man requires definitive intervention within 48 hours because he has a ureteric stone with ongoing pain that is not tolerated despite appropriate analgesia. For an adult ureteric stone smaller than 10 mm, NICE recommends SWL as the first surgical treatment where it is targetable and can be delivered promptly. These conditions are explicitly met: the stone is 9 mm, radiopaque and targetable, and SWL is available tomorrow. Pre-treatment ureteric stenting should not be offered routinely before SWL in adults. URS is a reasonable alternative when SWL cannot provide clearance within 4 weeks, is contraindicated, is not targetable or has previously failed; none applies here. Alpha-blocker medical expulsive therapy may be considered for distal, not proximal, ureteric stones smaller than 10 mm, and discharge is inappropriate given uncontrolled symptoms. PCNL is not first-line for a 9 mm proximal ureteric stone; it is reserved for selected impacted proximal stones after URS failure.

Reference: NICE NG118: Renal and ureteric stones: assessment and management (Published January 2019; current NICE PDF May 2026) — https://www.nice.org.uk/guidance/ng118/resources/renal-and-ureteric-stones-assessment-and-management-pdf-66141605137093