Upper ureteric stone treatment depends on the stone size, pain, fever, urine blockage, kidney swelling and kidney function. A small stone may pass with medicines and close follow-up. But a larger stone, repeated severe pain, fever, persistent blockage, a single kidney or rising creatinine may need active treatment such as ESWL, ureteroscopy/URSL with laser, DJ stenting or, rarely, PCNL. In adults with suspected stone pain, CT KUB is usually the most useful test. NICE recommends urgent low-dose non-contrast CT within 24 hours for adults with suspected renal colic; ultrasound is preferred first in pregnancy and children.

What is an upper ureteric stone?

The ureter is the thin tube that carries urine from the kidney to the urinary bladder. An upper ureteric stone means a stone is stuck in the upper part of this tube, close to the kidney. It is also called a proximal ureteric stone.

This location matters because the stone can block urine drainage from the kidney. When urine cannot drain properly, the kidney may swell. This swelling is called hydronephrosis.

Mild swelling may settle once the stone passes or is removed. But persistent blockage, infection or reduced kidney function should not be ignored.

Symptoms of an upper ureteric stone

An upper ureteric stone may cause:

• Severe side or back pain.
• Pain that comes in waves.
• Pain moving towards the abdomen, groin or testis.
• Nausea or vomiting.
• Burning urination.
• Frequent urination.
• Blood in urine.
• Fever or chills if infection is present.
• Reduced urine output in severe blockage.

Stone pain can be very intense. NICE recommends NSAIDs as first-line pain relief for suspected renal colic when suitable, IV paracetamol if NSAIDs are not suitable or not enough, and opioids only when both are unsuitable or inadequate. NICE also advises against antispasmodics for renal colic.

Upper ureteric stone treatment: Can I wait or do I need surgery?

This is usually the patient’s main question.

You may be able to wait with medicines if:

• The stone is small.
• Pain is controlled.
• There is no fever.
• Urine infection is not present.
• Kidney function is normal.
• You can come for follow-up.
• Imaging does not show dangerous obstruction.

You may need active treatment if:

• The stone is unlikely to pass.
• Pain keeps coming back.
• Pain is not controlled with medicines.
• The kidney remains swollen.
• Fever or urine infection is present.
• Creatinine is rising.
• You have a single functioning kidney.
• The stone is large, hard or impacted.

EAU guidelines list low chance of spontaneous passage, persistent pain despite medicines, persistent obstruction and renal insufficiency as indications for ureteric stone removal. They also state that treatment selection depends on stone size, location, density, associated kidney stones, body habitus, anatomy, bleeding risk and other patient factors.

Can an upper ureteric stone pass naturally?

Yes, some upper ureteric stones can pass naturally. But upper ureteric stones pass less easily than stones lower down in the ureter.

EAU guidelines report spontaneous passage in about 49% to 52% of upper ureteric stones, compared with higher passage rates for mid and lower ureteric stones. For stones less than 5 mm, passage is more likely, but it still depends on the patient and CT findings.

Observation does not mean “ignore it.” It means controlled waiting with a plan.

Medicines for upper ureteric stone

Medicines may be used when the stone is small and the patient is stable.

They may include:

• Pain relief.
• Anti-vomiting medicines.
• Medicines to relax the ureter in selected cases.
• Hydration advice.
• Follow-up imaging.

Medical expulsive therapy is more useful for lower/distal ureteric stones than upper ureteric stones. NICE recommends alpha blockers mainly for distal ureteric stones less than 10 mm, and EAU says the greatest benefit is likely in distal ureteric stones more than 5 mm.

For upper ureteric stones, medicines may reduce symptoms and help selected patients, but they do not guarantee stone passage.

ESWL for upper ureteric stone

ESWL means extracorporeal shock wave lithotripsy. It breaks the stone using shock waves from outside the body. No telescope is passed into the ureter.

ESWL may be suitable when:

• The stone is small, commonly less than 10 mm.
• The stone is visible and targetable.
• There is no uncontrolled infection.
• The stone is not very hard on CT.
• The stone is not severely impacted.
• The patient wants a non-invasive option.
• Follow-up is possible.

NICE recommends SWL for ureteric stones less than 10 mm. For 10-20 mm ureteric stones, NICE recommends ureteroscopy, with SWL considered only if local facilities can achieve clearance within 4 weeks.

Advantages of ESWL

• No cut.
• Non-invasive.
• Usually day-care.
• Faster recovery for many patients.
• No telescope inside the ureter.

Limitations of ESWL

• Stone fragments must pass naturally.
• Repeat sessions may be needed.
• Pain can occur while fragments pass.
• Hard stones may not break well.
• Impacted stones may not clear well.
• Targeting may be difficult in some patients.

EAU notes that stone density, stone burden, skin-to-stone distance and hydronephrosis can negatively affect SWL success.

URSL / ureteroscopy with laser

URSL means ureteroscopic lithotripsy. A thin telescope is passed through the urine passage into the bladder and then into the ureter. The stone is seen directly and broken using laser. The pieces may be removed or allowed to pass.

URSL may be preferred when:

• The stone is more than 10 mm.
• Pain is repeated or severe.
• The stone is impacted.
• ESWL has failed.
• ESWL is unlikely to work.
• The stone is hard on CT.
• There is significant kidney swelling.
• Faster stone clearance is preferred.

EAU advises that ureteroscopy has a better chance of achieving stone-free status with a single procedure, while SWL generally has lower morbidity but may need more retreatment.

Advantages of URSL

• Direct visual treatment.
• Better chance of one-sitting clearance.
• Useful for hard stones.
• Useful for impacted stones.
• Useful when ESWL targeting is difficult.
• Flexible ureteroscopy/RIRS may treat associated kidney stones in selected cases.

Possible symptoms after URSL

• Burning urination.
• Mild blood in urine.
• Frequency or urgency.
• Flank discomfort.
• DJ stent-related symptoms.
• Rarely, fever, infection, ureter injury or later narrowing.

NIDDK describes ureteroscopy as a hospital procedure done with anaesthesia, where the doctor can remove the stone or break it into smaller pieces; many patients can go home the same day.

DJ stent for upper ureteric stone

A DJ stent is a soft tube placed inside the ureter. One end sits in the kidney and the other end sits in the bladder. It helps urine drain from the kidney to the bladder.

A DJ stent may be placed:

• Before stone removal if there is infection or severe obstruction.
• After URSL if there is swelling, bleeding or ureter injury risk.
• If the ureter is tight and a second-stage procedure is safer.
• In a blocked infected kidney as urgent drainage.
• If kidney function is affected.
• If residual fragments need time to pass.

A DJ stent does not always remove the stone. Sometimes it is a temporary safety step before the final stone procedure.

NICE advises not to routinely offer post-treatment stenting after uncomplicated ureteroscopy for ureteric stones less than 20 mm. In practice, stenting depends on what the urologist finds during the procedure.

PCNL or antegrade URSL for large upper ureteric stones

For a large, hard or impacted upper ureteric stone, especially when normal ureteroscopy from below is difficult or has failed, the urologist may approach the stone from the kidney side. This is called an antegrade approach and is similar to PCNL.

EAU mentions percutaneous antegrade removal as an option for selected large, impacted proximal ureteric stones, especially stones more than 15 mm in a dilated collecting system or when retrograde access is difficult.

This is not needed for most patients, but it can be useful for difficult stones.

Laparoscopic or open stone removal

Laparoscopic or open removal is rarely needed today. It may be considered only when ESWL, URSL or PCNL are unlikely to work or have failed.

EAU recommends open or laparoscopic stone removal only in rare cases where SWL, retrograde or antegrade ureteroscopy and PCNL fail or are unlikely to succeed.

ESWL vs URSL for upper ureteric stone

A simple way to explain it: ESWL is less invasive, but URSL is usually more definitive. For a small favourable upper ureteric stone, ESWL may be a good option. For a larger, hard or impacted stone, URSL often gives faster clearance.

Recovery after upper ureteric stone treatment

Recovery depends on the treatment used.

After observation, repeat imaging is important to confirm that the stone has passed and kidney swelling has settled.

After ESWL, stone fragments may pass over days to weeks. Mild pain, burning urination and blood in urine can happen while fragments pass.

After URSL, many patients return to light routine in a few days. If a DJ stent is placed, there may be frequency, urgency, burning, mild blood in urine and flank pain during urination. These symptoms usually improve after stent removal.

After PCNL or antegrade treatment, hospital stay and recovery may be longer than ESWL or URSL.

Preventing another stone

Stone treatment is only one part of care. Prevention matters because stones can recur.

General prevention advice may include:

• Drink enough water to keep urine pale.
• Avoid frequent dehydration.
• Reduce excess salt.
• Do not unnecessarily restrict dietary calcium.
• Analyse the stone if it is removed or passed.
• Check serum calcium when advised.
• Consider 24-hour urine testing in recurrent stone formers.

NICE recommends stone analysis, serum calcium testing and prevention advice including adequate fluid intake, salt reduction and normal calcium intake.

Consultation checklist

Bring these to your urology visit:

• CT KUB film/report or USG KUB report.
• Urine routine report.
• Urine culture, if done.
• Serum creatinine and blood reports.
• Fever records or hospital discharge summary, if any.
• Previous stone surgery records.
• Current medicines, especially blood thinners.
• Diabetes, BP, heart or kidney disease records.
• Stone fragments, if passed.

FAQs about upper ureteric stone treatment

Related reading

• DJ Stent Removal: When Is a DJ Stent Removed?
• Lower Ureteric Stone Treatment
• Mid Ureteric Stone Treatment
• Can a 10 mm Kidney Stone Pass Naturally?
• Treatment for 1 cm Kidney Stone: ESWL, RIRS or Mini-PCNL?
• Kidney Stone Treatment in Latur
• URSL Surgery in Latur

References