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Difficulty: MediumUrologic Surgery

Match each clinical presentation of nephrolithiasis or ureterolithiasis with the most appropriate surgical or procedural intervention.

  • A 28-year-old woman with a 2.8-cm staghorn calculus in the right renal pelvis and associated mild hydronephrosis.Percutaneous nephrolithotomy (PCNL)
  • A 45-year-old man with a 9-mm calculus in the distal left ureter and persistent severe pain refractory to oral analgesics.Ureteroscopy with laser lithotripsy
  • A 32-year-old pregnant woman at 26 weeks gestation with a 7-mm obstructing calculus in the distal ureter and intractable nausea.Temporary ureteral stent placement
  • A 50-year-old man with a symptomatic 1.2-cm radiopaque calculus located in the left renal pelvis, with no distal obstruction.Extracorporeal shock wave lithotripsy (ESWL)

Answer

The correct matches align percutaneous nephrolithotomy for the large staghorn calculus, ureteroscopy for the distal ureteral stone, temporary stenting for the pregnant patient, and ESWL for the uncomplicated 1.2-cm renal pelvic stone.
Each clinical scenario requires a specific urologic intervention based on established guidelines: PCNL for massive stone burden (> 2 cm), ureteroscopy for distal ureteral stones, temporary stenting for patients where definitive treatment is contraindicated (pregnancy), and ESWL for uncomplicated small renal stones.

Step-by-Step Solution

1
Evaluate the 2.8-cm staghorn calculus.
Requires Percutaneous nephrolithotomy (PCNL).
Stones > 2 cm are too large for ESWL or standard ureteroscopy to clear efficiently in a single setting without a high risk of obstruction by fragments.
2
Evaluate the 9-mm distal ureteral stone.
Requires Ureteroscopy with laser lithotripsy.
Distal ureteral stones are poorly targeted by ESWL due to the surrounding pelvic bones; ureteroscopy provides direct visualization, excellent access, and immediate clearance.
3
Evaluate the pregnant patient with an obstructing stone.
Requires Temporary ureteral stent placement.
Definitive surgical procedures involving radiation (fluoroscopy) or acoustic shock waves are contraindicated in pregnancy; immediate decompression is the safest priority.
4
Evaluate the 1.2-cm renal pelvic stone.
Requires Extracorporeal shock wave lithotripsy (ESWL).
Uncomplicated renal stones < 2 cm are ideal candidates for this non-invasive procedure, which fragments the stone to allow spontaneous passage.

Key Concept

Surgical management of nephrolithiasis is determined by stone size (> 2 cm vs. < 2 cm), location (renal pelvis vs. distal ureter), and patient-specific contraindications (e.g., pregnancy).
Estimated Time:1m 30s
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Urologic Surgery

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