Ureteroscopy is a minimally invasive surgical procedure used for the diagnosis and treatment of ureteral and renal pathology, most often urolithiasis. The presence of a percutaneous nephrostomy tube, commonly placed for urgent decompression of an obstructed kidney, often in obstructing stone disease, introduces unique perioperative considerations. Indications for ureteroscopy in this setting involve persistent obstruction with failure of spontaneous stone passage when percutaneous nephrolithotomy is not indicated. Surgical treatment aims to remove obstructing calculi, restore antegrade urinary drainage, and prevent long-term complications such as decline of renal function. Ureteroscopy involves cystoscopic access, ureteroscopic stone fragmentation, and extraction. When coupled with antegrade access as provided by a nephrostomy tract, it enables combined antegrade and retrograde (“rendezvous”) approaches. This video presents a case of a patient with a left-sided distal ureteral stone, nonobstructing renal stones, and an indwelling nephrostomy tube who underwent definitive management with ureteroscopy and laser lithotripsy.
The case demonstrates the use of ureteroscopy with laser lithotripsy in the treatment of an obstructed left proximal ureteral stone with forniceal rupture. The patient presented to the emergency department with the signs and symptoms of a ureteral stone and was taken for imaging and a diagnostic ureteroscopy. Following confirmation of the diagnosis, the patient was scheduled for ureteroscopy with laser lithotripsy.
A guidewire was placed, followed by visualization with a retrograde pyelogram and a subsequent flexible ureteroscopy. Laser lithotripsy was performed to fragment the stone. Following fragmentation, the renal pelvis and calyces were visualized to examine for retrograde movement of stone fragments. A confirmatory retrograde pyelogram was then performed, followed by placement of a temporary stent for fluid drainage. The patient was then discharged with opioids for pain medication and prophylactic antibiotics to prevent urinary tract infections and the subsequent risk of urosepsis.
Urolithiasis is one of the most common and costly benign urologic conditions in the United States. While there are many options for managing urolithiasis ranging from conservative medical expulsive therapy to shockwave lithotripsy to percutaneous nephrolithotomy, ureteroscopy with laser lithotripsy is one of the most frequently performed minimally invasive urologic surgeries for treatment. In this video, we present a case of a patient with a ureteral stone that was treated with ureteroscopy, laser lithotripsy, and basket stone extraction. As part of the procedure, the patient also underwent a retrograde pyelogram and a ureteral stent exchange.
Ryan A. Hankins, MD Assistant Professor of Urology Specialty Director of Urology MedStar Georgetown University Hospital
The patient in this case is a 76-year-old male who was admitted to the ER two weeks prior and was found to have an obstructing, 1-cm left proximal ureteral stone with a forniceal rupture. A left ureteral stent was placed, and he was started on antibiotics. In this video, Dr. Ryan Hankins at MedStar Georgetown University Hospital performs definitive management of the stone with a left ureteroscopy, laser lithotripsy, and stent replacement.
