Successful Bilateral URSL & DJ Stenting for Obstructive Ureteric Stones in a 29 Y.O. Male Relieving Ureteric Obstruction

The PACE Hospital's expert Urology team successfully performed Bilateral Ureteroscopic Lithotripsy (URSL) with DJ stenting on a 29-year-old male patient who presented with left flank pain. The procedure was performed to remove ureteral stones, relieve obstruction, and restore normal urinary flow.

Chief Complaints

A 29-year-old male patient with a body mass index (BMI) of 22 presented to the Urology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of left flank pain. A comprehensive evaluation was undertaken to identify the underlying cause of his symptoms.

Past Medical History

The patient had a history of open-heart surgery for a patent foramen ovale (a hole between the heart's upper chambers that remains open after birth) at the age of 7 years. No known drug allergies were reported.

On Examination

Upon admission, the patient was conscious, alert, and oriented. He was afebrile, and his vital signs were stable. Physical examination revealed mild tenderness on deep palpation of the left flank, correlating with the patient's symptoms. No abdominal masses were palpable, and there were no signs of peritonitis such as guarding, rebound tenderness, or rigidity. Cardiovascular and respiratory system examinations were within normal limits.

Diagnosis

Upon admission to PACE Hospitals, the patient was thoroughly evaluated by the Urology team, including a detailed review of his medical history and a comprehensive clinical examination. Presenting with left flank pain and a history of recurrent stones, there was a strong clinical suspicion of urinary tract obstruction caused by calculi.

The patient underwent imaging studies, including a non-contrast CT scan of the kidneys, ureters, and bladder (CT KUB), which revealed bilateral mid-ureteric calculi measuring approximately 7 mm on both sides, resulting in mild hydroureteronephrosis more pronounced on the left side. Additionally, multiple small non-obstructing renal calculi were noted bilaterally. Laboratory investigations showed normal renal function and no evidence of active infection.

Based on the confirmed findings, the patient was advised to undergo Ureteric Stone treatment in Hyderabad, India, under the expert care of the Urology Department.

Medical Decision Making

After a detailed consultation with Dr. Abhik Debnath, Consultant Laparoscopic Urologist, a comprehensive evaluation was conducted to determine the optimal diagnostic and therapeutic approach for the patient presenting with left flank pain and confirmed bilateral obstructive ureteric calculi. Based on detailed clinical evaluation and imaging studies, including non-contrast CT KUB, surgical intervention was deemed necessary.

It was determined that the patient had bilateral mid-ureteric calculi causing obstruction and mild hydroureteronephrosis, along with multiple small renal calculi. Bilateral ureteroscopic lithotripsy (URSL) with Double J (DJ) stenting was identified as the most effective intervention to relieve the obstruction, alleviate symptoms, and restore normal urinary flow.

The patient and his family were informed about his condition, the procedure, its associated risks, and its potential to alleviate symptoms and enhance his quality of life.

Surgical Procedure

Following the decision, the patient was scheduled for Bilateral Ureteroscopic Lithotripsy (URSL) and DJ stenting surgery in Hyderabad at PACE Hospitals, under the expert care of the urology department.

The procedure involved the following steps:

• Patient Preparation and Anesthesia: The patient was positioned in the lithotomy posture and general anesthesia was administered. The surgical site was sterilized, and prophylactic antibiotics were given to prevent infection before starting the procedure.

• Ureteroscopic Access and Assessment: A semi-rigid ureteroscope was introduced through the urethra to visualize both ureters. The right ureteric stones were cleared easily, while an impacted stone with surrounding edema was found in the upper left ureter.

• Laser Lithotripsy: The left ureteric calculus was fragmented using a low-energy laser, carefully to avoid ureteral injury. Stone fragments were removed or left to pass naturally to clear the obstruction.

• Double J Stenting: A Double J stent was placed in the left ureter to ensure urine flow and prevent obstruction post-surgery. Placement was confirmed under imaging, and no ureteral injury was observed.



• Procedure Completion and Recovery: The scope was withdrawn after confirming hemostasis. Stone fragments were sent for analysis, and the patient’s postoperative course was smooth. A follow-up was planned for stent removal after three months.
  

Postoperative Care

After surgery, the patient was closely monitored to ensure stability and an uncomplicated recovery. His postoperative course was uneventful. During his hospital stay, he received intravenous antibiotics to prevent infection, analgesics for pain control, and proton pump inhibitors (PPIs) to reduce gastric acid secretion and protect the stomach lining. The patient was discharged in stable condition with appropriate follow-up instructions.

Discharge Medications

The patient was prescribed a broad-spectrum antibiotic to prevent postoperative infection, an analgesic for pain relief, and a proton pump inhibitor to reduce gastric acid secretion and protect the stomach lining. Additionally, an alkalizing agent to support urinary tract health, an alpha-blocker to aid in ureteric relaxation and facilitate stone passage, and an antioxidant supplement to promote kidney health were included in the treatment plan.

Advice on Discharge 

The patient was advised to avoid weightlifting and forward bending, as well as to prevent straining during bowel movements. Prolonged travel by bus, auto, or two-wheeler needs to be avoided. Passing stones in the urine is common, and mild flank or suprapubic discomfort, occasional small amounts of blood in the urine, cloudy urine, or mild burning sensations are expected. These symptoms usually resolve within 7 to 10 days.

Dietary Advice

The patient was advised to maintain adequate hydration by drinking plenty of fluids, approximately 3 to 4 liters per day. Additionally, consumption of citrus fruits and juices was recommended to help prevent stone formation. A diet low in purines, meat, and salt was also advised to reduce the risk of recurrent stones.

Emergency Care

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms like fever, abdominal pain, bleeding, or vomiting.

Review and Follow-up Notes

The patient was advised to return for a follow-up visit with the Urologist in Hyderabad at PACE Hospitals after 3 months for evaluation and removal of the DJ stent, along with a check ureteroscopy (URS) and retrograde intrarenal surgery (RIRS).

Conclusion

This case highlights the successful management of bilateral obstructive ureteric stones in a recurrent stone-forming patient through bilateral ureteroscopic lithotripsy (URSL) with DJ stenting. The intervention effectively relieved obstruction and preserved renal function. The patient was discharged in stable condition with advice for long-term prevention and follow-up.

Urology Department | Urology Hospital in Hyderabad