Breaking and Removing 10 mm-15 mm UPJ stone: Treatment of Large UPJ stones in NYC
Dr. Alex Shteynshlyuger is a board certified urologist in NYC who specializes in treating men and women with kidney stones and ureteral stones.
Large UPJ Stone Treatment for UPJ stones 1.1 to 1.5 cm
Stones larger than 1 cm (10 mm) at the UPJ and in the ureter are considered large stones. These are very large stones, and while miracles do happen, it is extremely rare for someone to pass a stone greater than 10 mm.
Conservative estimate is that >95% of patients would require surgical treatment for a UPJ stone of this size. Most of the time the treatment is minimally invasive without the need for ‘cutting’. Most of the time (>95% of time) Holmium laser laser or shockwave lithotripsy offer excellent success rates.
UPJ Stone and Severe Pain
Many patients with UPJ stones who have severe pain go initially to the ER with pain and have a ureteral stent placed to relieve obstruction and pain. Sometimes they are discharged from ER and go back to ER with severe pain that is not well controlled with pain medications.
In situations where patient has severe pain, I usually advise ureteral stent insertion for patients with large UPJ stones that are 10 mm, 12 mm or larger as they are very unlikely to pass and have a good chance of causing more pain. If there is no infection or other contraindications, the stone can often be broken with holmium laser and pieces retrieved in the same setting.
If a patient has renal insufficiency (kidney disease), then a stent is advised as well.
UPJ Stones and Manageable Pain and No Infection
For patients who are diagnosed with a large UPJ stone and the pain is manageable, two options are available for treatment of their stones. Shockwave lithotripsy has the advantage of being less invasive and ureteroscopy with laser lithotripsy has the advantage of greater success in removing the stone in one procedure.
Shockwave Lithotripsy for Large UPJ Stones
If the stone is not hard and dense as measured by Hounsfield units (low density), and if the patient is not overly obese, shock-wave lithotripsy is a reasonable first treatment option. About 60% of stones can be broken in one sitting, some patients may require more than one procedure.
For stones of this size (1.1 cm to 1.5 cm) that are very dense (high Hounsfield units), or in very obese patients, shock-wave lithotripsy will not typically lead to successful outcome in one treatment and ureteroscopy may be a better option in these situations.
For patients who want to avoid ureteroscopy and prefer shockwave lithotripsy, it is important to understand that about 30-50% of patients would need more than one procedure to break the stone.
Patients do not usually need a stent after shock-wave lithotripsy (ESWL) for stones of this size unless they have a solitary kidney or only one functioning kidney, in which case a stent will often be placed to protect the kidney from damage or from obstruction by small stone fragments passing down the ureter. If a stent was placed prior to shockwave lithotripsy, it will be kept until all stones are broken.
The success rate of ESWL for stones of this size is not as good, but it is still reasonable to try in patients who want to avoid ureteroscopy. It is also a reasonable option for stones that are not very dense <800 HU (based on Hounsfield units and appearance on CAT scan). For example, uric acid stones which are common and are less dense and respond better to ESWL.
Ureteroscopy with Holmium Laser for Large UPJ stones
In patients who need to be on blood thinners, ureteroscopy may also be a more reasonable option as the procedure can be performed while the patient is taking aspirin and the blood thinners may need to be stopped only for a day or two.
Ureteroscopy with laser is a good option because Holmium laser is more successful for larger ureteral stones. Although it is more invasive than shockwave lithotripsy, it is also more likely to render the patient stone-free with a single treatment.
Patients who want to have more certainty in getting rid of UPJ stones as soon as possible, ureteroscopy is the procedure of choice.
Patients with UPJ and Kidney Stones
For patients with a large stone at UPJ and additional kidney stones, the treatment options depend on the size and number of stones in the kidney. If there is only one or two kidney stones that are not very large (<1 cm) and not very dense (<900 HU), shockwave lithotripsy is a reasonable option if patient wants to minimize side effects. The UPJ stone will be treated first. Then a month later kidney stones can be treated. Because one must wait at least a month between ESWL procedures the treatment may take a few months to render patient stone-free.
Ureteroscopy with laser lithotripsy is an effective treatment option for large UPJ stones with one or two kidney stones that are 7 mm – 1 cm each. The procedure may take longer but often it is possible to break and remove all stones in one sitting.
For a large UPJ stone and multiple large kidney stones PCNL (percutaneous nephrolithotomy) is the best treatment option which usually allows the urologist to break all stones in one sitting, depending on size and location of kidney stones.
Typically but not always, after ureteroscopy, a stent (plastic tube) is inserted inside the patient between the kidney and the bladder. Typically the stent is kept for a week. Large stones that are close to a cm in size are often impacted and erode into the wall of the ureter. With large stones the stent may need to be kept in longer for as long as 6-8 weeks. If a stent is not inserted after ureteroscopy which can be done if ureteroscopy is fairly simple, a small risk of acute pain onset is possible.
Dr. Alex Shteynshlyuger is a board certified urologist in NYC who specializes in treating men and women with kidney stones and ureteral stones. He has treated hundreds of men and women with large kidney stones.