In your opinion observe or treat this stone?
Stone info.Non obstructing renal pelvic stone measuring 9 mm with mean density of 1300 HU, Radiopaque (K.U.B)- most likely calcium oxalate stone (Physician opinion after taking history).
Relevant history:
53 Y Female, underwent vaginal hysterectomy (one month ago) accompanied by ureteral stent for prolapsed uterus that was followed by hydronephrosis ( Right sided mild to moderate hydro-uretero-nephrosis is seen, the ureter is diffusely dilated along its length till the vesical attachment with few kinks at its upper third in absence of any stones or obstructing lesions.
Left sided mild to moderate hydro-uretero-nephrosis is seen, the ureter is diffusely dilated along its length till the vesical attachment in absence of any ureteric stones or obstructing lesions)
She also has non-alcoholic fatty liver disease.
So in your opinion given the above info.should she observe and wait or undergo SWL?
In my opinion this patient must be treated because is a stone of almost 1,0 cm in the pelvis renal and there is great chance of developing episodes of obstruction. neverthless I think SWL will no be the best choice for her because of the 1300 UH. I think I should do a flexible renalureteroscopy with laser to treat this stone, since there is no sign of obstruction bilateraly, despite the hydroureteronephrosis
Dr.David, why not try ESWL first, and if it didn't work, we can try the other alternatives since also the small size of the stone, there is a high chance of sucess.(while avoiding the invasiveness of the surgery)
There is no doubt that you can try ESWL first. Anoher factor that predicts the success of ESWL is the distance stone skin in the TC. If you have a distance greater than 10 cm is a bad sign for success. So, if you have a stone of almost 1,0 cm with a UH higher than 1000 and a distance stone skin higher than 10 cm , you have a high probability of insucces in the ESWL and in this case you should consider flexible nefroureterolitotripsy as first choice to spare the patient one procedure.
But as I said is not wrong to do the ESWL and in the inssucess of the procedure try flexible uretero. I just tried to think more academic
Dr.David, what do you mean by " there is great chance of developing episodes of obstruction. " What is the mechanism behind developing into obstructive stone although it wasn't?
The stone in the renal pelvis works like a valve mechanism. It goes to the jup cause the obstruction, sometimes it stucks in the jup and sometimes it goes back to the renal pelvis.
So Dr.David, when can I know that there is obstruction and instead of being in the renal pelvis, it gets stuck in the junction?
sure its a renal pelvis stone
sooner or later it will move
and be obstructive
In my opinion this patient must be treated because is a stone of almost 1,0 cm in the pelvis renal and there is great chance of developing infection, I think SWL will be the best choice .
Of course you have to treat
1. DJ Stent and ESWL OR
2. ESWL OR
3. Flexible URS +Laser
So Dr. David Jacques Cohen , the patient did indeed complain of episodic pain (Some days), does this occassional pain indicate obstruction? David Jacques Cohen
Yes. Intermittent obstruction. In my opinion this patient should be treated. Besides that, the patient is not assymptomatic anymore.
There are some issues that may delay the intervention for 1-3 weeks, is this period long enough to cause renal complications?
Treatment can be postponded till enssurance of clear path for stone clearance, the patient have bilateral HUN probabley due to kinking, the presence of jj stents inside provide good apportunity for ESWL
In my opinion ESWL is the way. Because there is JJ stend RIRS may be an option.
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