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Proximal ureteric calculus — MSRA MCQ

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HardNephrolithiasisProximal ureteric calculusMSRA

A 52-year-old man is reviewed in a stone clinic 6 days after low-dose non-contrast CT for left renal colic. CT shows an 8 mm radiopaque proximal left ureteric calculus with mild hydroureteronephrosis. He is now afebrile, has a negative urine culture, normal renal function and adequately controlled pain. The stone is targetable with shockwave lithotripsy (SWL), which is available within 2 weeks. He has no solitary kidney and no history of ureteric surgery. He asks whether a ureteric stent should be inserted first to protect renal function. 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: E — Proceed with shockwave lithotripsy without pre-treatment ureteric stenting

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

This is a targetable ureteric stone smaller than 10 mm in a clinically stable adult. NICE recommends SWL as first-line definitive treatment in this group, with ureteroscopy reserved for situations such as inability to achieve SWL clearance within 4 weeks, a contraindication to SWL, failure to target the stone, or previous SWL failure. Importantly, NICE advises against pre-treatment ureteric stenting before SWL in adults. A is attractive because stenting may appear to decompress the collecting system, but there is no sepsis, acute kidney injury, solitary kidney or uncontrolled pain requiring urgent drainage. B is an appropriate alternative only when SWL is unsuitable or cannot provide timely clearance; neither applies here. C is used for urgent decompression of an obstructed infected system or other situations requiring drainage, which this patient does not have. E may be considered for a distal ureteric stone under 10 mm, but this stone is proximal and a definitive, timely SWL pathway is available. Therefore, SWL without pre-treatment stenting is the appropriate plan.

Reference: Renal and ureteric stones: assessment and management (NG118) — Recommendations (Published 2019) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations Renal and ureteric stones: assessment and management (NG118) — Recommendations (Published 2019) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations