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gency requiring prompt drainage by a ureteral catheter or a percutaneous nephrostomy tube Antibiotics alone are inadequate unless obstruction is drained
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A Ureteral Stones
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Impediment to urine flow by ureteral stones usually occurs at three sites: (1) at the ureteropelvic junction, (2) at the crossing of the ureter over the iliac vessels, and finally (3) as the ureter enters the bladder at the ureterovesicular junction Prediction of spontaneous stone passage is difficult Stones less than 6 mm in diameter as seen on a plain abdominal radiograph will usually pass spontaneously Conservative observation with appropriate pain medications is appropriate for the first 6 weeks There is new evidence that oral corticosteroids, blockers, and calcium channel blockers may enhance stone passage of observed ureteral stones -Blockers are safe and well tolerated Typical agents and dosages are tamsulosin, 04 mg orally once daily; terazosin, 5 mg orally once daily; or doxazosin, 4 mg orally once daily If spontaneous stone passage has failed, either because of lack of progression of the stone or intolerance of the pain, therapeutic intervention is required Distal ureteral stones are best managed either with ureteroscopic stone extraction or in situ extracorporeal shock wave lithotripsy (SWL) Ureteroscopic stone extraction involves placement of a small endoscope through the urethra and into the ureter Under direct vision, basket extraction or fragmentation followed by extraction is performed Complications during endoscopic retrieval increase as the duration of conservative observation increases beyond 6 weeks Indications for earlier intervention include severe pain unresponsive to medications, fever, persistent nausea and vomiting requiring intravenous hydration, social requirements requiring return to work, or anticipated travel Most upper tract stones that enter the bladder can exit the urethra with minimal discomfort In situ SWL, an alternative, utilizes an external energy source that is focused upon the stone This focused energy is additive, resulting in minimal tissue insult except at the focus where the stone is positioned with the aid of fluoroscopy or ultrasonography This can be performed under anesthesia as an outpatient procedure and usually results in stone fragmentation Most stone fragments will pass uneventfully within 2 weeks, but those that have not passed within 3 months are unlikely to pass without intervention Women of childbearing age are best not treated with SWL for a stone in the lower ureter, as the impact upon the ovary is unknown Proximal and midureteral stones those above the inferior margin of the sacroiliac joint can be treated with SWL or ureteroscopy SWL is delivered directly to the stone (in situ) without the need to push the stone back into the renal pelvis To help ensure adequate drainage after SWL, a double J ureteral stent is frequently placed Double J stents do not ensure passage of stone fragments after SWL Occasionally, stone fragments will obstruct the ureter after SWL Conservative management will usually result in spontaneous resolution with eventual passage of the stone fragments If this is unsuccessful, adequate proximal drainage through a percutaneous nephrostomy tube will facilitate passage In rare instances, ureteroscopic extraction will be required
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Struvite stones are synonymous with magnesium-ammoniumphosphate stones They are commonly seen in women with recurrent urinary tract infections recalcitrant to appropriate antibiotics They rarely form as ureteral stones without prior upper tract endourologic intervention Frequently, a struvite stone is discovered as a large staghorn calculus forming a cast of the renal collecting system Struvite stones are radiodense Urinary pH is high, usually above 72 These stones are formed secondary to urease-producing organisms, including Proteus, Pseudomonas, Providencia, and, less commonly, Klebsiella, Staphylococcus, and Mycoplasma An E coli urinary tract infection is not consistent with an infectious reservoir originating from a struvite calculus These frequently large stones are relatively soft and amenable to percutaneous nephrolithotomy Appropriate perioperative antibiotics are required They can recur rapidly, and efforts should be taken to render the patient stone-free Postoperative irrigation through nephrostomy tubes can eliminate small fragments Acetohydroxamic acid is an effective urease inhibitor, but it is poorly tolerated by most patients because of its gastrointestinal toxicity
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