Management of Ureteral Obstruction in Emergency Settings: Surgical vs. Conservative Approaches: A Systematic Review

Abstract

Background: Ureteral obstruction in emergency situations is a serious condition that can cause kidney failure, sepsis, or other life-threatening problems if not treated right away. The decision between surgical and conservative management is contingent upon the etiology, severity of obstruction, patient stability, and resource availability. A methodical evaluation of these methodologies is crucial to facilitate evidence-based decision-making.

Objective: To systematically evaluate and compare the efficacy, safety, and outcomes of surgical versus conservative management strategies for ureteral obstruction in emergency contexts.

Methods: A thorough literature search was performed utilizing PubMed, Scopus, Web of Science, and Cochrane Library until 2010-2025. Acceptable studies comprised randomized controlled trials, cohort studies, and case series assessing adult patients with acute ureteral obstruction. Information regarding the type of intervention (surgical versus conservative), indications, short- and long-term outcomes, complications, and mortality was extracted. Standard tools were used to check for bias, and the results were put together in a narrative form because the study designs were very different from each other.

Results: A total of 43 studies met the inclusion criteria, encompassing 7,850 patients with acute ureteral obstruction. Surgical management (ureteral stenting or percutaneous nephrostomy) was reported in 61% of cases, primarily in patients presenting with sepsis, bilateral obstruction, or significant renal impairment. Conservative management was applied in 39% of patients, mainly those with unilateral obstruction, small distal stones (<10 mm), and stable vital signs. Surgical approaches achieved rapid decompression in over 90% of cases, with complication rates ranging from 8%–15%, most commonly infection, bleeding, or stent migration. Conservative strategies demonstrated spontaneous stone passage in 65%–80% of selected patients but required secondary intervention in up to 30% due to persistent pain, infection, or progression of obstruction. Mortality was higher among untreated or delayed-intervention groups, emphasizing the importance of timely decompression. Overall, surgical management provided superior short-term outcomes in unstable patients, while conservative treatment was safe and effective in carefully selected, stable cases.

Conclusion: Surgical interventions, such as ureteral stenting and percutaneous nephrostomy, continue to be the preferred initial approaches for unstable patients or those with infection and compromised renal function. Conservative strategies, including analgesia, hydration, and monitoring, are appropriate for stable patients with uncomplicated obstruction, especially from small calculi with a significant probability of spontaneous passage. The selection of management should be tailored, considering the patient's condition, etiology, and resource availability. More high-quality studies are needed to improve standardized protocols for emergency practice.