Middle-Aged Woman With Ureteral Calculi
Conservative therapy. A meta-analysis by the American Urological Association Clinical Guidelines Panel found that the overall spontaneous passage rate for calculi smaller than 5 mm in the proximal ureter, mid-ureter, and distal ureter is 25%, 45%, and 75%, respectively.15 Most investigators recommend 6 weeks as the maximal duration to allow a stone to pass spontaneously, because of the risk of renal damage and ureteral stricture.16 Patients with a stone that has a low probability of spontaneous passage should be offered intervention.
Therapies that increase urine flow expedite passage of a stone. However, a Cochrane review failed to find evidence-based data that diuretic and high-volume fluid therapy is beneficial for the treatment of adult patients with uncomplicated acute ureteral colic.17
NSAIDs, such as indomethacin and diclofenac sodium, and opioids, such as morphine, meperidine, and tramadol, are indicated for acute ureteral colic.18 NSAIDs inhibit prostaglandin synthesis and result in reduction in vasodilatation, intrarenal pressure, and urinary tract inflammation.18 Adverse effects include GI hemorrhage and renal impairment, especially in patients with existing renal damage.18 Opioids offer more effective pain relief. Adverse effects of these agents include nausea, vomiting, urinary retention, and constipation. Respiratory depression and hypotension can occur with high doses.18
Medical expulsive therapy. Patients with small calculi, especially in the lower ureter, might benefit from adjuvant medical expulsive therapy.16 Studies have shown that calcium channel blockers, such as nifedipine, a1-blockers, such as tamsulosin, and corticosteroids can enhance expulsion of ureteral calculi.11,18-21 Nifedipine blocks the calcium influx necessary for smooth muscle contraction and thereby eliminates the fast uncoordinated component of ureteral smooth muscle contraction but does not affect the slower peristaltic rhythm.16,19 The medication should be used with caution in patients with cardiovascular disease because of the risk of hypotension.18
Tamsulosin blocks α1-receptors, which are present in high density in the distal ureter.19 This leads to selective relaxation of ureteral smooth muscle, with subsequent inhibition of ureteral spasms and dilatation of the ureteral lumen.20 Corticosteroids are often used in conjunction with a calcium channel blocker or an a1-blocker to reduce ureteral inflammation and edema and to facilitate expulsion of the calculus.9,21
Surgical management. Active intervention is usually indicated for ureteral calculi larger than 7 mm, calculi that cause complete ureteral obstruction, persistent pain despite adequate medication, and failure of conservative therapy.22 The options for surgical management of a ureteral calculus include ESWL and ureteroscopy.
ESWL is often preferred because the therapy is less invasive, is associated with lower morbidity, and can be performed without general anesthesia.16 ESWL is the first-line treatment for ureteral calculi that are 10 mm or smaller.2,9 This procedure works best for proximal ureteral calculi, for calculi composed of calcium oxalate dehydrate, and for struvite fragments. ESWL is less effective in fragmenting calculi that have an attenuation value on helical CT of greater than 1000 Hounsfield units, such as cystine and calcium oxalate monohydrate calculi.2 Contraindications to ESWL include pregnancy, uncontrolled coagulopathy, uncontrolled hypertension, and febrile UTI.23
Advances in flexible ureteroscopes and the introduction of the Ho:YAG laser have made ureteroscopy a safe and minimally invasive procedure in the management of ureteral calculi of all composition and sizes.2,24 The procedure has a higher success rate than ESWL.25 Flexible ureteroscopes allow access to all locations, including the lower pole of the kidney. The Ho:YAG laser can be introduced through the smallest-caliber endoscopes and can fragment any stone.6 Complications are rare; they include ureteral perforation, ureteral avulsion, ureteral mucosal abrasion, ureteral stricture, and steinstrasse.24
The routine use of stents after ureteroscopy to reduce ureteral edema, to facilitate the passage of residual fragments of calculi, and to decrease the risk of ureteral structure has been questioned.24,26 Some urologists suggest that a ureteral stent is not necessary after uncomplicated ureteroscopy.24-26
Patients with urosepsis require intravenous hydration, parenteral antibiotic therapy, and close observation, since septic shock can intervene. These patients often need emergency percutaneous nephrostomy or placement of a ureteral stent to drain the upper tract. Other indications for surgical drainage include persistent pain despite conservative management, obstruction of a solitary kidney, and deterioration in glomerular filtration rate.
Counsel adolescents and adults with ureteral calculi to increase their fluid intake to achieve a urine output of more than 2 L per day.27 Patients with oxalate calculi should avoid foods with a high content of oxalate, such as rhubarb, wheat bran, spinach, beetroot, cocoa, and nuts.22 Those with uric acid calculi should avoid foods rich in urate, such as red meat, liver, kidneys, and sardines.22
To reduce the risk of recurrence of calcium calculi, excessive restriction of calcium intake is not recommended.2,22 Instead, consumption of citrus fruit helps increase the level of urinary citrate, which forms a complex with calcium and minimizes the likelihood of calcium calculi formation.18 Advise patients to avoid excessive salt intake, because a high sodium load increases calcium excretion in the kidney.28
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