Urgent ureterorenoscopy as a primary treatment for ureteral stone: why not?

To evaluate the feasibility of urgent ureteroscopy (uURS) and elective ureteroscopy (eURS) in the management of patients with renal colic due to ureteral stones. Patients who were operated for ureteral stones between September 2020 and March 2022 were determined retrospectively. The patients who were operated within the first 24 h constituted the uURS group, while the patients who were operated after 24 h were classified as eURS. No limiting factors such as age, gender and concomitant disease were determined as inclusion criteria. Patients with bilateral or multiple ureteral stones, bleeding diathesis, patients requiring emergency nephrostomy or decompression with ureteral JJ stent, and pregnant women were not included. The two groups were compared in terms of stone-free rate, complications, and overall outcomes. According to the inclusion-exclusion criteria, a total of 572 patients were identified, including 142 female and 430 male patients. There were 219 patients in the first group, the uURS arm, and 353 patients in the eURS arm. The mean stone size was 8.1 ± 2.6. The stone-free rate was found to be 87.8% (502) in general, and 92 and 85% for uURS and eURS, respectively. No major intraoperative or postoperative complications were observed in any of the patients. Urgent URS can be performed effectively and safely as the primary treatment in patients with renal colic due to ureteral stones. In this way, the primary treatment of the patient is carried out, as well as the increased workload, additional examination, treatment and related morbidities are prevented.

A machine learning model for predicting surgical intervention in renal colic due to ureteral stone(s) < 5 mm.

A 75-89% expulsion rate is reported for ureteric stones ≤ 5 mm. We explored which parameters predict justified surgical intervention in cases of pain caused by < 5 mm ureteral stones. We retrospectively reviewed all patients with renal colic caused by ureteral stone < 5 mm admitted to our urology department between 2016 and 2021. Data on age, sex, body mass index, the presence of associated hydronephrosis/stranding on images, ureteral side, stone location, medical history, serum blood count, creatinine, C-reactive protein, and vital signs were obtained upon admission. XGboost (XG), a machine learning model has been implemented to predict the need for intervention. A total of 471 patients (median age 49, 83% males) were reviewed. 74% of the stones were located in the distal ureter. 160 (34%) patients who sustained persistent pain underwent surgical intervention. The operated patients had proximal stone location (56% vs. 10%, p < 0.001) larger stones (4 mm vs. 3 mm, p < 0.001), longer length of stay (3.5 vs. 3 days, p < 0.001) and more emergency-room (ER) visits prior to index admission (2 vs. 1, p = 0.007) compared to those who had no surgical intervention. The model accuracy was 0.8. Larger stone size and proximal location were the most important features in predicting the need for intervention. Altogether with pulse and ER visits, they contributed 73% of the final prediction for each patient. Although a high expulsion rate is expected for ureteral stones < 5 mm, some may be painful and drawn out in spontaneous passage. Decision-making for surgical intervention can be facilitated by the use of the present prediction model.

The identification of pregnant women with renal colic who may need surgical intervention.

BACKGROUND: Renal colic is a surgical emergency in pregnancy that is caused by a range of non-obstetric factors and known to occur more frequently during the second and third trimesters. Several studies have reported that up to 70-80% of stones pass spontaneously during pregnancy. There are some patients will not pass their stones and will ultimately require surgical intervention. Through retrospective analysis of the clinical data of 212 pregnant women with renal colic, the predictive factors of pregnant women with renal colic in need of surgical intervention were determined. METHODS: We conducted a retrospective review of 212 pregnant women presenting with renal colic between 1st January 2009 and 31st December 2020. Univariate and multivariate analyses identified a range of predictive variables for surgical intervention. In addition, we used receiver operating characteristic curve analysis to evaluate the predictive power of our model and created a nomogram for clinical application. RESULTS: Of the 212 patients presenting with acute renal colic in pregnancy, 100 patients (47.2%) underwent surgical intervention and 112 patients (52.8%) were treated conservatively. Univariate analysis identified significant differences between the two groups with regards to fever, the duration of pain, white blood cells, C-reactive protein, ureteral stone size, hydronephrosis, and stone location. Multivariate analysis further identified a number of independent predictors for surgical intervention, including fever, a duration of pain ≥ 4 days, a ureteral stone size ≥ 8 mm, and moderate or severe hydronephrosis. CONCLUSIONS: We identified several independent predictors for surgical intervention for renal colic in pregnancy. Fever, a duration of pain ≥ 4 days, a ureteral stone size ≥ 8 mm, and moderate/severe hydronephrosis, play significant roles in predicting surgical intervention. Our nomogram can help to calculate the probability of surgical intervention in a simple and efficient manner. Prospective studies are now required to validate our model.

[UROLOGICAL CONSULT FOR PATIENT WITH RENAL COLIC BEFORE DISCHARGE FROM THE EMERGENCY DEPARTMENT (ED): THE OUTCOME EFFECT ON SPONTANEOUS STONE EXPULSION AND RE-VISIT TO ED].

INTRODUCTION: Renal colic due to ureterolithiasis is a frequent reason for visiting the emergency departments (ED). The majority of those patients are managed non-surgically and will experience a spontaneous stone expulsion. The ED at our hospital works as a unified department, which is a well-established practice in Europe and North America. AIMS: Assess the outcome of urological consultation in the ED for patients with urolithiasis. METHODS: A retrospective cohort examined 402 ureterolithiasis patients proven by abdominal CT-scan at the ED. Patients were divided into 3 groups: Group1: patients were discharged after evaluation by ED physician alone. In Group 2: patients were discharged after being evaluated by an ED physician and urologist. In Group 3: patients who were admitted to the Urology Department. Clinical, laboratory and imaging parameters were examined as well as patients' outcomes: spontaneous stone expulsion, re-visit to ED and surgical intervention. RESULTS: There were not significant differences between group 1 and 2 regarding age, stone size, stone location, WBC levels, stone expulsion rate or surgical intervention. Group 1 had a significant higher rate of ED re-visits compared with group 2 (79 (43.3%) vs. 12 (17.9%). p=0.0002). Group 3 had significantly higher stone size, creatinine levels, inflammatory markers, proximal stone location and surgical interventions. CONCLUSIONS: ED working as a unified department provides excellent management to patients with renal colic due to ureterolithiasis, with a high rate of spontaneous stone expulsion and urologist referral to admissions and surgical interventions. Nevertheless, urological consultation significantly decreases re-visits to ED.

Derivation of a clinical predicting rule for obstructive urolithiasis and alternative diagnosis requiring urgent intervention: the CLAD score.

Most patients with renal colic are discharged from the emergency department (ED) after evaluation and pain alleviation. These patients may not require urgent imaging by computed tomography. We derived a clinical prediction score in patients with renal colic to identify those at very low risk for complications and alternative diagnoses requiring urgent intervention. This retrospective chart review was carried out in 2 ED at an urban university hospital from January to December 2015. All patients with a diagnosis of renal colic were included. The primary outcome was an intervention required for renal colic or alternative diagnoses within 7 days of ED presentation. A stepwise logistic regression was used to assess factors associated with the outcome. A score was derived as a weighted sum of these predictors and its performance was calculated. The database was submitted to the French National Commission for Data Protection and Liberties (CNIL): declaration n°2164898v0 (03/22/2018). 871 with complete data were analyzed. In 94 (11%) patients, an intervention was performed for obstructive urolithiasis or alternative diagnosis. Five factors were most predictive of intervention: age > 45 years (1 point), a history of urologic surgery (1 point), pulse > 100 bpm (1 point), temperature > 37.8 °C (2 point), and urine dipstick negative for blood (1 point), yielding a score of 0-6 points (the Complicated uroLithiasis and Alternative Diagnosis (CLAD) score). The area under the curve of the receiver operating characteristic curve was 0.82 (95% CI 0.77-0.87). We derived a clinical score for renal colic that predicted the presence of obstructive urolithiasis and acute alternative diagnoses requiring intervention.

Predicting emergency interventions in patients with acute ureteral colic using acute renal colic scoring system in a Pakistani cohort.

OBJECTIVE: To evaluate the acute renal colic score (ARC) in predicting the need of emergency intervention (EI) in patients with ureteric colic secondary to a ureteral stone. PATIENT AND METHODS: In an emergency room (ER) of a university hospital, we conducted a prospective cohort study over a period of 6 months. ARC score was calculated using four parameters, i.e., serum creatinine, total white cell count (TLC), stone length and level. Primary outcome measure was EI, which was defined as the need of endourological intervention within 48 h of presentation. ARC was calculated for each patient against the two possible outcomes, i.e., EI vs. no EI. The need of intervention was based on patient-related clinical factors and the decision of the attending urologist. RESULTS: The study included 132 patients. EI was performed in 85 patients (64.4%). URS was the most common intervention performed in 81 (95.3%) patients, followed by the a insertion of a double J stent in two (2.4%) patients for forniceal rupture and high TLC count and percutaneous nephrostomy in two (2.4%) patients for raised creatinine and TLC. All four variables in ARC score including serum creatinine (p < 0.001), TLC (p < 0.001), stone size (p < 0.001) and stone level (p < 0.001) were found to be significantly associated with need for EI. Using ROC the sensitivity and specificity of the score was 92.9% and 87.5%, respectively, with AUC of 0.93. CONCLUSIONS: ARC score is highly sensitive and specific in determining the need of EI in patients with uncomplicated ureteric colic within 48 h of initial presentation.

Hospitalización en paciente con cólico renal: Caracterización clínico-epidemiológica en el Hospital Clínico Herminda Martín, período marzo 2014 - marzo 2019 / Hospitalization in a patient with renal colic: Clinical-epidemiological characterization at the Herminda Martín Clinical Hospital, period March 2014 - March 2019

INTRODUCCIÓN: El cólico renal es una condición médica común en los servicios de urgencia. Representa la manifestación clínica más frecuente de urolitiasis, cuya patogenia es multifactorial, con tasas de prevalencia varía de 1% a 20% y una recurrencia a 10 años del 42% al 50%. OBJETIVO: Establecer el perfil clínico-epidemiológico, como también el diagnóstico y manejo de los pacientes hospitalizados por cólico renal en el Hospital Clínico Herminda Martín (HCHCM). MATERIAL Y MÉTODO: Estudio descriptivo retrospectivo en pacientes hospitalizados con diagnóstico de cólico renal en el HCHM de Chillán en el período marzo 2014-marzo 2019. Se estudiaron las variables: sexo, edad, presentación clínica de ingreso, factores de riesgo asociados, motivo de hospitalización, resultados imagenológicos y manejo clínico. Resultados. El 52,45% correspondió a pacientes de sexo masculino, encontrándose la mayor cantidad de pacientes en el intervalo de 40-49 años. La obesidad, antecedente de urolitiasis e hipertensión arterial fueron las patologías asociadas más frecuentes. En la mayoría de los pacientes, el motivo de la hospitalización fue la refractariedad al tratamiento analgésico, alcanzando un 86,76%. El 56,37% de los pacientes recibió manejo médico expulsivo y a un 19,11% de los pacientes se le realizó una intervención quirúrgica durante la hospitalización. CONCLUSIÓN: El perfil de éstos pacientes no sólo permite establecer medidas que podrían evitar un evento litiásico, sino que además se demuestra la necesidad de realizar un manejo óptimo que puede evitar reconsultas, sobrecarga de los servicios de urgencia, aumento de días cama y complicaciones.

INTRODUCTION: Renal colic is a common condition in the emergency department. It represents the most frequent clinical manifestation of urolithiasis, whose prevalence rate varies between 1% to 20%. Its pathogenesis is multifactorial, with a recurrence of 10 years from 42-50%. OBJECTIVE: Establish the clinical-epidemiological profile, as well as the diagnosis and management of patients hospitalized for renal colic at the Herminda Martín Clinical Hospital(HCHM). MATERIALS AND METHODS: A retrospective descriptive study of hospitalized patients diagnosed with renal colic at the HCHM, March 2014-March 2019, the variables were studied: sex, age, the clinical presentation of admission, associated risk factors, the reason for hospitalization, imaging results, and management. Results: 52.45% were male patients, with the highest number of patients in the range of 40-49 years. Obesity, a history of urolithiasis and hypertension, occurred more frequently within the associated pathologies. In most patients, refractable to analgesic treatment was the reason for hospitalization, reaching 86.76%. 56.37% of patients received expulsion medical management, and 19.11% of patientshad surgeryduring hospitalization. CONCLUSION: The profile of these patients not only allows them to establish measures that could prevent a lithiasis event but also shows the need for effective management of patients who can avoid reconsults, an overload of emergency services, increasedbed days and complications

Early Surgical Intervention for Symptomatic Renal and Ureteral Stones is Associated With Reduced Narcotic Requirement Relative to Trial of Passage.

OBJECTIVES: To evaluate if trial of passage (TOP) or initial surgical intervention resulted in less narcotic analgesia utilization in patients with acute renal colic due to stone disease. METHODS: We retrospectively evaluated 135 patients with acute renal colic due to nephroureterolithiasis managed by a single surgeon. Patients were standardly offered TOP or surgical intervention with ureteroscopy (URS). A subset of patients were stented with delayed URS due to presence of infection, pain, or a nonaccommodating ureter. Our standard practice is narcotic-free URS, prescribing a stent cocktail including non-steroidal anti-inflammatories. We compared rates of narcotic prescription over the entire treatment course for patients electing TOP vs surgery (primary or delayed URS). We secondarily analyzed rates of surgical intervention among initial TOP. RESULTS: We included 135 patients, with 69 (51.1%) TOP as initial treatment, 39 (28.9%) stent with delayed URS, and 27 (20.0%) primary URS. Thirty-nine (56.5%) TOP patients underwent URS at a median time of 18 days (IQR 6-31 days) from diagnosis. More TOP patients required a narcotic prescription (60.9% vs 35.9% vs 33.3%, respectively; P = .010) compared to patients undergoing initial stent or URS. However, when an opioid prescription was provided, the total morphine milligram equivalents prescribed among each group was not statistically significant. CONCLUSION: Patients electing initial treatment with TOP for renal colic due to stone disease were more likely to require narcotic prescriptions than patients electing initial surgical intervention.

Kidney stones and the opioid epidemic: recent developments and review of the literature.

PURPOSE OF REVIEW: A public health emergency has been declared in response to rising opioid addiction and opioid-related deaths in the United States. As kidney stones have been identified as an important source of initial and repeated opioid exposures, this review seeks to describe the scope of the problem and report relevant alternatives to opioid analgesia for stones. RECENT FINDINGS: Recent literature summarizing the extent of opioid use among those with stones is reviewed. A number of opioid-minimizing strategies and analgesic regimens have been proposed and studied. A review of these modifications and alternatives is provided. SUMMARY: Both symptomatic renal colic and surgical interventions to address stones may prompt need for analgesia. Reducing prescribed opioids reduces both patient use and risk of diversion. Modifications in surgical technique, administration of local anesthetics, and use of systemic nonopioid analgesics have all been successfully employed.

Early ureteroscopic lithotripsy in acute renal colic caused by ureteral calculi.

PURPOSE: We aimed at comparing the success and complications of early semirigid ureteroscopy (URS) and elective URS in ureteral calculi with renal colic that do not respond to analgesics. METHODS: We retrospectively analyzed the data of 690 patients with obstructive ureteral stones who underwent URS with stone retrieval. 247 patients who underwent early URS within the first 12 h were classified as group I and 443 patients who underwent elective URS as group II. Both groups were compared in terms of age, sex, creatinine, eGFR, stone size, laterality, location and number of stones, type of lithotriptor, presence of hydronephrosis and success and complication rates. RESULTS: The mean age of the patients was 50.4 (18-89 years) (p > 0.05). There was no statistically significant difference between the groups in terms of age, eGFR, side, presence of hydronephrosis, fever, mucosal damage, stone migration, perforated ureter, ureteral avulsion, ureteral stent insertion at the end of the surgery and sepsis (p > 0.05). Both groups had male dominance (p > 0.05). Creatinine was significantly lower in Group I (p < 0.05). The mean stone size was also significantly lower in Group I (p < 0.05). Middle and proximal ureteral calculi were more common in Group II (p < 0.05). Multiple stones were higher in Group II (p < 0.05). The dominant type of lithotriptor used was pneumatic in Group I and laser in Group II (p < 0.05). Stone-free rates (SFRs) were higher in Group I (98% vs 90% in the first month) (p < 0.05). Postoperative hematuria and infection were more common in Group II (p < 0.05). CONCLUSIONS: In selected cases, early ureteroscopy is an effective and safe method for distal ureteral calculi smaller than 10 mm that are painful and resistant to analgesic treatment.

Use of Point-of-Care Ultrasound to Assess and Guide Renal Stent Repositioning in the Pediatric Emergency Department.

Point-of-care ultrasound can be used as an assessment tool during the evaluation of children with renal colic. We discuss the case of a 7-year-old girl presenting to the pediatric emergency department with left flank pain, vomiting, and urinary incontinence status post-left renal stent placement. Renal ultrasound revealed ureteral obstruction caused by renal stent displacement. Point-of-care ultrasound performed by pediatric emergency department physicians was used to assess renal stent location, repositioning, and confirmation of the new location by the urology team. We discuss the role of transabdominal point-of-care ultrasound for the evaluation and treatment of the symptomatic child with recent ureter stent placement.

Predictors of surgical intervention following initial surveillance for acute ureteric colic.

PURPOSE: To identify clinical and stone-related factors predicting the need for surgical intervention in patients who were clinically considered appropriate for non-surgical intervention. PATIENTS AND METHODS: We conducted a retrospective review of a contemporary cohort of patients who were selected for surveillance following presentation with acute ureteric colic. Data on patient demographic and stone variables, inpatient management and long-term outcomes were evaluated. Multivariate logistic regression was used to generate a nomogram predicting need for surgical intervention. The accuracy of the nomogram was subsequently validated with an independent cohort of patients presenting with ureteric colic. RESULTS: Of 870 study eligible patients presenting with acute ureteric colic, 527 were initially treated non-surgically and included in the analysis. 113 of these eventually required surgical intervention. Median time from first presentation to acute surgery was 11 (IQR 4-82) days. In our final MVA analysis, duration of symptoms more than 3 days, not receiving alpha-blockers, positive history of previous renal calculi and stone location, burden and density were independent predictors of need for surgical intervention. Patients who required opioid analgesia were more likely to have surgical intervention; however, this did not reach statistical significance. The area under the curve (AUC) of the final model was 0.802. The nomogram was validated with a cohort of 210 consecutive colic patients with AUC of 0.833 (SE 0.041, p < 0.001). CONCLUSIONS: We have identified independent predictors of the need for surgical intervention during an episode of renal colic and formulated a nomogram. Combined with the diligent use of acute ureteroscopy at our centre, this nomogram may have clinical utility when making decisions regarding treatment options with potential healthcare cost savings.

Flexible Ureterorenoscopy for Renal and Proximal Ureteral Stone in Patients with Previous Ureteral Stenting: Impact on Stone-Free Rate and Morbidity.

OBJECTIVE: To analyze results (stone-free rate [SFR]) and complications after flexible ureterorenoscopy (f-URS) for renal or lumbar ureteral lithiasis in patients with a previous ureteral stenting (US). PATIENTS AND METHODS: We conducted a single-center retrospective study, including all f-URS procedures achieved in our department, between January 2004 and December 2010, for renal or lumbar ureteral urinary lithiasis. In total, 497 procedures were performed: 316 procedures in patients with a ureteral stent placed before the surgery for renal colic, sepsis, or renal failure (group 1) and 181 procedures in patients without US (group 2). Success was defined as a complete SFR at 6-month follow-up. Surgical morbidity was defined using the Clavien-Dindo grading system. RESULTS: Groups 1 and 2 were well balanced in terms of demographic data, number, and size of stones. Ureteral location was significantly higher in group 1 (30.2% vs 16.3%, p = 0.0006). Surgery characteristics were similar in both groups. By univariate analysis, SFR tended to be slightly higher in the group with prior ureteral stenting (72% vs 63%, p = 0.05). SFR for ureteral location was also higher after previous ureteral stenting (81.5% vs 59.4%, p = 0.023). By multivariate analysis, only stone size and number were correlated with f-URS failure. Complication rate was comparable in both groups (10.7% vs 11.8%, p = 0.7). CONCLUSION: Technical aspects of the f-URS procedure were not modified by ureteral stenting. We found that f-URS in patients with ureteral stenting was not associated with a better SFR, except in case of ureteral location in univariate analysis. Ureteral stenting was not independently related to f-URS outcome by multivariate analysis.

Buckshot colic: utilizing holmium:yag laser for ureteroscopic removal of a bullet fragment within the proximal ureter.

Buckshot colic is a rare phenomenon, presenting as firearm-induced urinary tract obstruction. We present a case of gunshot-induced ureteral obstruction in a 49-year-old male, treated endoscopically with the holmium:YAG (holmium) laser. CT revealed a 1 cm bullet fragment within the left proximal ureter. A percutaneous nephrolithotomy was performed utilizing the holmium laser to fragment the metal into basket-retrievable pieces. At 4 month follow up the patient is without evidence of stricture. To our knowledge, this is the first reported utilization of the holmium laser to treat "buckshot colic". Endoscopy with holmium laser appears a feasible and safe treatment option.

Flexible and rigid ureteroscopy in outpatient surgery.

BACKGROUND: Outpatient surgery is critical to improve health care costs. The aim of the study was to prospectively evaluate the results of outpatient treatment of upper tract urinary stones by rigid or flexible ureteroscopy in a routine care setting. METHODS: A database was created at the creation of the outpatient surgery department. 87 patients underwent 100 ureteroscopic procedures for urinary lithiasis from June 2013 to March 2015. RESULTS: Most of our patients were male with 53 men (sex ratio M/F 1.13), with a mean age of 52.9 ± 15 years old (23.4-82.4). 44 % of ureteroscopies performed were flexible ureteroscopies, 31 % rigid ureteroscopies and 25 % associated rigid and flexible ureteroscopies. The average stone load was 10.1 ± 5.7 mm (2-30) The mean operating time was 58.3 ± 21.1 min (20-150). 82.9 % of patients had a single urinary stone and 17.1 % (n = 14) had 2 or more. 114 stones were treated, 57,1 % intrarenal. There were 6 (6 %) postoperative complications: three Clavien stage 2 infections; three Clavien stage 3b complications (two renal colics requiring ureteral stenting 48 h after discharge and 1 symptomatic perirenal urinoma 48 h after discharge). There was one intraoperative complication (1 %): a ureteral wound with contrast leakage. The rate of transfer to conventional hospitalization was 2.2 %. Stone size influenced the stone-free status (p < 0.0001) and the need for more than one session. There was a significant correlation between operative time and stone size above 10 mm (p < 0.0001). CONCLUSIONS: Flexible and rigid ureteroscopy are safe and efficient procedures for upper urinary tract stones and can be carried out in an outpatient department. Stone size had an impact on postoperative stone-free status and operative time.

Application of Ureteroscope in Emergency Treatment with Persistent Renal Colic Patients during Pregnancy.

BACKGROUND: Although the application of ureteroscopy in the treatment of ureteral calculi during pregnancy has been on the rise, for persistent renal colic patients without ultrasound-detected ureteral calculi, it may represent a clinical dilemma due to the potential risks for both mother and fetus. OBJECTIVE: The aim of the present study is to present our experience with the application of the ureteroscope in the emergency treatment of persistent renal colic patients during pregnancy. METHODS: From March 2009 to September 2014, a total of 117 pregnant women who received ureteroscopy for persistent renal colic were retrospectively analyzed. Patients were divided into three groups according to duration of the persistent renal colic: Group A (within 12 hours; 24 cases); Group B (12 to 24 hours; 76 cases); and Group C (more than 24 hours; 17 cases). The stone-free rate, complications, and other qualitative data were analyzed. RESULTS: Of the 117 patients, 31 patients who were found not to have renal or ureteral calculi received ureteroscopic double-J (DJ) stent insertion, whereas 86 patients who were found with ureteral calculi received ureteroscopic lithotripsy (URSL) and DJ stent insertion. Among them, 24 patients (27.9%) were found with ureteral calculi by ureteroscopy rather than ultrasound. In addition, 73 patients (84.9%) had complete fragmentation of calculi; 12 patients (10.3%) had a threatened abortion (the rates of threatened abortion in Groups A, B and C were 8.3% vs. 6.5% vs. 29.4%; Group C compared with Groups A and B, p<0.05), and one patient (1.2%) had urosepsis (in Group C). However, these complications were cured with conservative treatment, without postpartum infant and maternal complications. CONCLUSION: For pregnant patients with persistent renal colic/ureteral calculi and hydronephrosis, ureteroscopic DJ stent insertion and URSL are effective and safe options when conservative treatment fails, even if no urinary calculi were found by ultrasound. At the same time, for patients with persistent renal colic during pregnancy, early application of ureteroscopy may reduce the risk of preterm birth.

Unsuccessful Medical Expulsive Therapy: A Cost to Waiting?

OBJECTIVE: To compare clinical outcomes between patients with ureteral stones who underwent an unsuccessful trial of medical expulsive therapy (MET) and patients who did not attempt MET. METHODS: We reviewed the clinical records of all potential candidates for MET who were referred from the emergency department to a subspecialty stone clinic. RESULTS: Of 348 potential candidates, 133 patients (38%) went directly to surgery (NMET) and 215 patients (62%) initiated MET. In the latter group, MET was unsuccessful in 45 patients (21%) (UMET). Stone symptoms were the primary rationale for surgery in 20 (44%) UMET patients and 69 (52%) NMET patients. The UMET patients were more likely to be younger and have smaller, more distal stones than NMET patients. All stones were cleared by ureteroscopy. The average interval from stone clinic assessment to surgery was longer in the UMET patients (17 days) than in the NMET patients (1 day; P <.001). The UMET patients underwent more preoperative computed-tomography scans (2.1) than did the NMET patients (1; P <0.001). There were no differences between the 2 groups in the residual stone burden, pre- or postoperative repeat visits to the emergency department, or repeat surgery. CONCLUSION: In this population, we did not observe any detrimental impact of an unsuccessful trial of MET (beyond the additional time and imaging costs). If more confident and effective symptom control could be achieved, expansion of utilization and duration of MET may be a path to improved patient outcomes and cost control.