Stones in Ureter: Effective Treatment by Experienced Urologists
Dr. Alex Shteynshlyuger is a board certified urologist in NYC who specializes in treating men and women with kidney stones and ureteral stones.
Ureteral Stones: How We Break and Remove Stones in the Ureter at New York Urology Specialists
Renal calculi (kidney stones) are small “pebbles” made up of various salts and minerals that are present in urine. As kidney stones travel from the kidney to the urinary bladder along with urine flow, kidney stones have a tendency to get stuck in the ureter as this the narrowest part of the urinary system. When a kidney stone is stuck in the ureter, it is called an obstructing ureteral stone. A ureteral stone is a kidney stone that has moved to the ureter.
Severe Pain or Fever
Ureteral stones are usually diagnosed when patients with ureteral stones develop severe pain and go to the emergency room (ER), their primary care doctor or urologist. Often patient have to wait for diagnosis or treatment. If severe pain persists and pain medications do not help often patients visit the ER again. Sometimes they get discharged again which makes kidney stones a very frustrating and painful condition. At New York Urology Specialists, we are happy to help if you’re caught in a frustrating game of waiting for treatment and being discharged from the ER.
If you develop signs of infection, emergency treatment is required as infection can spread through blood stream and cause life-threatening sepsis. If you do not feel well, have fever, chills, weakness or foul smelling urine and you have a ureteral or kidney stone, go to an Emergency Room.
Passing Ureteral Stones: Can it be Done?
Whether a patient can spontaneously pass a ureteral stone depends on the size of the stone and the location in the ureter where it gets stuck. If the stone does not pass spontaneously or with medical expulsion therapy (MET), then surgical treatment is needed to prevent the obstruction from causing damage to the kidney.
It is never a good idea to try to pass a kidney stone or ureteral stone if you have signs of infection or if your kidney function is poor.
Smaller ureteral stones that are less than 4 mm in diameter will often pass spontaneously with conservative management. Ureteral stones larger than 5 mm in size are less likely to pass. Ureteral calculi larger than 10 mm in diameter almost always require intervention.
In terms of location, ureteral stones that get stuck and block the urine flow in the upper ureter (near the kidney or at the UPJ) are less likely to pass spontaneously than those located in the middle or lower ureter (near the bladder). This is partially because larger stones tend to get stuck in the upper ureter. Stones that manage to make it to the lower ureter tend to be smaller on average.
ESWL Lithotripsy and Ureteroscopy: Effective Treatment Options for Stones in the Ureter
For ureteral stones that block the ureter and cause symptoms, two treatment options are available: (1) ESWL lithotripsy and (2) Ureteroscopy with holmium laser.
Shock-wave lithotripsy (ESWL) refers to a procedure where sound waves are used to fragment the stone into smaller particles that can pass spontaneously. With ESWL, the patient lies on a table and the shockwaves are passed from outside through the skin to the stone.
Ureteroscopy with laser lithotripsy refers to a procedure in which an instrument is passed via the urethra under anesthesia and a very precise laser is directed at the stone to break it up.
ESWL or Ureteroscopy for Ureteral Stones
The choice between ESWL or Ureteroscopy depends on stone location, stone size and patient characteristics and preferences.
Ureteroscopy is most versatile and be used in any patient in any circumstances. Any patient who cannot undergo shockwave lithotripsy can be treated with ureteroscopy and Holmium laser to break their stones as long as there is no infection or they have been pre-treated for infection. Ureteroscopy offers the best chance for successful removal of ureteral stones in one procedure.
In general shockwave lithotripsy is less invasive and associated with fewer side effects and complications than ureteroscopy but success rate in breaking stones is not as good as with ureteroscopy in particular for larger stones.
In general, the bigger the stone, the less effective ESWL is. As a matter of fact, any treatment is less effective as the stone gets bigger, but success rate of ESWL decreases to a greater extend as the ureteral stone size increases. Ureteroscopy is not as sensitive to stone size in the ureter for common ureteral stone sizes (5 mm to 12 mm).
In general, the success of shock-wave lithotripsy better in the kidney than in the ureter, but for smaller stones (6-8 mm), the success rate of shock-wave lithotripsy in the ureter is still fairly good and similar to success rate of ureteroscopy. Sometimes even smaller stones (0.4 cm – 0.6 cm) can get impacted in the ureter and erode into the ureteral wall. In those situations, the procedure tends to be more difficult and the patient may require more than one procedure to make them stone-free.
Who is a Candidate for ESWL Lithotripsy for Ureteral Stones?
- Not everyone is a good candidate for shockwave lithotripsy for ureteral stones. If a patient is not a good candidate for shockwave lithotripsy, ureteroscopy is the default best treatment option for them:
- If a stone is not visible on X-Ray, ESWL lithotripsy is not an option for ureteral stones
- If a ureteral stone is larger than 8-9 mm and very dense >900 HU (hounsfeld units), the success rate is not as good.
- If a patient is very obese, success rate of for ureteral stones is poor
- If a patient is on blood-thinners (Coumadin, aspirin, Plavix) ESWL may not be the best option
- If there are signs of infection, ESWL is not an option
- ESWL is not performed in the lower ureter in women of childbearing age (younger than 45 years old) because it is not safe for the ovaries.
Treatment of Ureteral Stones Based On Location:
- Proximal (upper) ureter stone: ESWL is preferred because it is safe and effective, especially for smaller stones.
- Distal (lower) ureteral stones: ESWL is not as effective. Success rates of breaking larger stones in the lower ureter are lower with ESWL. Ureteroscopy is the preferred treatment option for a stone in the lower ureter.
For smaller stones that have a good chance of passing spontaneously urologists will typically allow a patient to try medical expulsion therapy (MET) for 4-6 weeks as long as there are no signs of infection, kidneys are working well and pain is well controlled. This consists of drinking plenty of fluids, controlling pain with medications, and taking medications such as Flomax. Medications such as Flomax have been shown to enhance the chances of the stone passage by relaxing the muscles in the urinary system.
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.