A urology team is reviewing the charts of five patients presenting with various manifestations of nephrolithiasis and ureterolithiasis. Each patient requires a highly specific management approach based on stone size, location, concomitant comorbidities, and clinical stability. Match each patient's clinical presentation with the most appropriate definitive management step or surgical intervention.
- A 32-year-old pregnant woman at 28 weeks gestation presents with right flank pain, a temperature of 39.4°C (102.9°F), and a 10-mm obstructing right proximal ureteral calculus.Urgent placement of a percutaneous nephrostomy tube or double-J ureteral stent
- A 58-year-old man with normal renal function presents with a 3.2-cm infectious staghorn calculus filling the left renal pelvis and extending into the lower pole calyx.Percutaneous nephrolithotomy (PCNL)
- A 65-year-old man with a 1.4-cm left lower pole renal calculus presents for elective management; he recently underwent placement of a coronary drug-eluting stent and is on uninterrupted aspirin and clopidogrel.Flexible ureteroscopy with holmium laser lithotripsy
- A 45-year-old woman with a 1.2-cm radiopaque calculus in the right renal pelvis and a BMI of 22 kg/m² desires the least invasive outpatient treatment option.Extracorporeal shock wave lithotripsy (ESWL)
- A 42-year-old man presents with a 6-mm distal ureteral calculus, normal vital signs, no leukocytosis, and mild intermittent pain that is well-controlled with oral NSAIDs.Medical expulsive therapy with alpha-1 receptor antagonists
Cevap
The presentations map to precise, guideline-based surgical interventions: infected obstructing stones require urgent decompression, staghorn calculi (>2 cm) require PCNL, continuous antiplatelet therapy mandates flexible ureteroscopy, small renal pelvis stones are eligible for ESWL, and uncomplicated small distal stones warrant medical expulsive therapy.
Each match strictly adheres to the American Urological Association (AUA) guidelines for the surgical management of stones. Infected obstructing stones require immediate decompression (stent/nephrostomy). Large stones >2 cm require PCNL. Bleeding diathesis or continuous dual antiplatelet therapy mandates ureteroscopy, as ESWL and PCNL are contraindicated. Small, uncomplicated renal stones are well-suited for non-invasive ESWL. Small distal ureteral stones in stable patients warrant a trial of medical expulsive therapy.
Adım Adım Çözüm
Anahtar Kavram
Surgical and medical management of nephrolithiasis and ureterolithiasis is dictated by stone size, location, presence of infection, and patient comorbidities (e.g., pregnancy, coagulopathy).
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