How did it Happen

A 22 year old female came with clinical picture of left sided ureteric colic. On investigation she was found to have a left sided ureteric stone and multiple bladder stones. Xray KUB confirmed the diagnosis (Figure 1a). She was admitted and was started on tamsulosin 0.4 mg daily while she was planned for intravenous urography. On day 2 of admission she passed 2 stones of size 13 mm and one stone of size 15 mm. Thereafter conservative treatment was continued and on day 5 she passed two stones of 15 mm and a stone of 22 mm (Figure 1b and 1c). X-ray KUB was repeated which showed no radio opaque shadow (Figure 1d). As per the guidelines of American Urology Association [1], patients with ureteral stones >10 mm could be observed or treated with MET, in most cases such stones will require surgical treatment. No recommendation can be made for spontaneous passage (with or without medical therapy) for patients with large stones. For stones more than 10 mm conservative management alone is insufficient [2]. Several studies have studied the effects of medical expulsive therapy but in stones not larger than 15 mm [3]. We are astonished by the results of conservative management in this case and want to know the view of your readers for the likely reason and whether to give medical therapy in all patients with larger stones before planning for any surgical intervention.