Successful Ureteroscopy (URS) and RIRS for Bilateral Ureteric Stones in a 24 Y.O. Male
PACE Hospitals
PACE Hospitals’ expert Urology team successfully performed Right Ureteroscopy (URS), Left Retrograde Intrarenal Surgery (RIRS), and Bilateral Double-J (DJ) Stenting on a 24-year-old male patient diagnosed with a right distal ureteric calculus and left upper ureteric calculus. The procedures were undertaken to remove the ureteric stones, relieve urinary tract obstruction and flank pain, restore normal urine flow, and prevent stone-related complications while preserving kidney function.
Chief Complaints
A 24-year-old male patient with a body mass index (BMI) of 19 presented to the Urology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of bilateral flank pain.
Past Medical History
The patient had no significant past medical history, previous urological surgeries, or chronic medical illness. No known drug allergies or other relevant medical conditions were reported.
On Examination
On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. General physical examination was normal. Abdominal examination revealed bilateral flank tenderness without abdominal distension or palpable masses. There were no clinical signs of urinary tract infection or acute abdomen. Cardiovascular, respiratory, and neurological examinations were within normal limits.
Diagnosis
Upon admission to PACE Hospitals, the Urology team conducted a detailed clinical assessment, including a review of the patient's symptoms and physical examination. To determine the cause of the bilateral flank pain, a computed tomography (CT) scan of the kidneys, ureters, and bladder was performed.
The CT scan revealed a 2 mm right distal ureteric calculus at the vesicoureteric junction (VUJ) and an 8 mm left upper ureteric calculus. These findings were consistent with bilateral ureteric stone disease causing the patient's flank pain.
Routine preoperative investigations, including complete blood count, urine examination, renal function tests, serum electrolytes, liver function tests, coagulation profile, viral screening, blood grouping, and pre-anaesthetic evaluation, were reviewed and found suitable for surgery. These investigations helped assess renal function, rule out active infection, and determine the patient's fitness for anaesthesia and endourological intervention.
Based on the clinical and radiological findings, the patient was diagnosed with a Ureteric Calculus Treatment in Hyderabad, India, under the expert care of the Urology Department at PACE Hospitals.
Medical Decision Making (MDM)
After a detailed consultation with Dr. Abhik Debnath (Consultant Laparoscopic Urologist), a comprehensive evaluation was performed to determine the most appropriate treatment for the patient's bilateral ureteric stones.
Considering the patient's bilateral flank pain and CT scan findings of a 2 mm right distal ureteric calculus and an 8 mm left upper ureteric calculus, the Urology team assessed the size, location, and likelihood of spontaneous stone passage. Routine preoperative investigations, including complete blood count, urine examination, renal function tests, serum electrolytes, liver function tests, coagulation profile, viral screening, and pre-anaesthetic evaluation, showed acceptable parameters for endourological intervention.
Based on the clinical assessment, imaging findings, and preoperative evaluation, it was determined that right ureteroscopy (URS), left retrograde intrarenal surgery (RIRS), and bilateral Double-J (DJ) stenting under general anaesthesia would provide the most effective treatment. The procedures were planned to achieve complete stone clearance, relieve urinary obstruction and flank pain, restore normal urine flow, and preserve kidney function.
The patient was counselled regarding the diagnosis, planned procedures, expected benefits, possible risks, postoperative recovery, temporary DJ stents, dietary and hydration advice, and the importance of regular follow-up for stent removal.
Surgical Procedure
Following the treatment decision, the patient was scheduled to undergo Right Ureteroscopy (URS), Left Retrograde Intrarenal Surgery (RIRS), and Bilateral Double-J (DJ) Stenting in Hyderabad at PACE Hospitals, under the expert care of the Urology Department.
The procedure involved the following steps:
- Patient Preparation and Anaesthesia: After obtaining informed consent and completing the pre-anaesthetic evaluation, the patient was taken to the operating room and administered general anaesthesia under strict aseptic precautions.
- Right Ureteroscopy (URS): A 6/7.5 Fr ureteroscope was introduced through the urinary tract to access the right distal ureter. The right distal ureteric calculus was identified and removed successfully.
- Left Retrograde Intrarenal Surgery (RIRS): Sheathless flexible retrograde intrarenal surgery was performed to access the left upper ureteric calculus through the urinary tract.
- Laser Lithotripsy: Complete fragmentation of the left ureteric stone was achieved using a 200-micron Holmium laser fibre at 1 Joule and 10 Hz. No ureteric mucosal injury was noted at the completion of the procedure.
- Bilateral Double-J Stent Placement: A 5 Fr × 26 cm Double-J stent was placed in each ureter to maintain urinary drainage and facilitate healing following stone treatment.
- Completion of the Procedure: Haemostasis was confirmed, the instruments were removed, and the procedure was completed successfully without any intraoperative complications.
Postoperative Care
The postoperative period was uneventful, and the patient remained hemodynamically stable throughout the hospital stay. He received supportive treatment for infection prevention, pain relief, hydration, and overall postoperative recovery, along with counselling. Adequate oral intake was encouraged, and the patient recovered well without any procedure-related complications before discharge.
Discharge Medications
Upon discharge, the patient was prescribed medications for infection prevention, pain relief, fever control, nutritional support, and overall postoperative recovery. He was advised to continue the prescribed medications as directed by the treating urologist.
Advice on Discharge
The patient was advised to maintain adequate hydration by drinking 2–3 litres of fluids per day, follow a low-purine and low-salt diet, and include citrus fruits and juices in the diet as advised. He was instructed to avoid weightlifting, forward bending, and strenuous physical activities until review.
Emergency Care
The patient was advised to report to the emergency ward at PACE Hospitals in case of development of symptoms such as fever, severe abdominal or flank pain, persistent vomiting, difficulty passing urine, reduced urine output, blood in the urine, or any other concerning symptoms.
Review and Follow-up Notes
The patient was advised to return for a follow-up consultation with the Urologist in Hyderabad at PACE Hospitals after three months for cystoscopy, bilateral Double-J (DJ) stent removal, and assessment of postoperative recovery.
Conclusion
This case highlights the successful management of a right distal ureteric calculus and left upper ureteric calculus through right ureteroscopy (URS), left retrograde intrarenal surgery (RIRS), and bilateral Double-J (DJ) stenting. The procedure achieved successful stone clearance without complications, and the patient had an uneventful recovery before being discharged in a hemodynamically stable condition with appropriate postoperative advice and follow-up.
Role of Ureteroscopy (URS) and Retrograde Intrarenal Surgery (RIRS) in Ureteric Stone Treatment
URS and RIRS are widely used minimally invasive procedures for the treatment of ureteric and kidney stones that are unlikely to pass spontaneously or are causing significant symptoms. These procedures allow direct visualisation and fragmentation or removal of stones without the need for large surgical incisions. The use of laser lithotripsy and temporary Double-J (DJ) stents helps improve stone clearance, restore normal urine flow, and support healing of the urinary tract. Regular follow-up with a urologist/ urology doctor is important to monitor recovery and ensure timely stent removal.
Frequently Asked Questions (FAQs)
What is the difference between kidney stones and ureteric stones?
Kidney stones form inside the kidneys, while ureteric stones are stones that have moved into the ureters, the tubes that carry urine from the kidneys to the bladder. Ureteric stones are more likely to block urine flow and cause sudden, severe flank pain.
Can small ureteric stones pass on their own?
Yes, some small ureteric stones, especially those less than 5 mm in size, may pass naturally with adequate hydration and medical treatment. However, larger stones or stones causing severe pain, blockage, infection, or reduced kidney function may require a procedure to remove them.
When is surgery recommended for ureteric stones?
Surgery or a minimally invasive procedure is recommended when a stone is too large to pass on its own, causes severe or persistent pain, blocks urine flow, leads to infection, affects kidney function, or does not pass despite medical treatment.
What is the difference between URS and RIRS procedures?
Ureteroscopy (URS) is used to treat stones located in the ureter, while Retrograde Intrarenal Surgery (RIRS) is mainly used to treat stones within the kidney or the upper part of the urinary tract. Both procedures are performed through the natural urinary passage without making any external cuts.
Is DJ stent removal painful?
DJ stent removal is usually a quick outpatient procedure. Most patients experience only mild discomfort or a brief burning sensation during removal, which settles soon afterwards. The treating urologist will explain the procedure and help make the process as comfortable as possible.
What precautions should be followed while a DJ stent is in place?
Patients should drink plenty of fluids, take prescribed medications regularly, avoid strenuous activities if advised, and attend follow-up appointments on time. If symptoms such as severe pain, fever, difficulty passing urine, or heavy bleeding occur, they should seek medical attention immediately.
Why is a low-salt diet recommended after stone treatment?
A high-salt diet increases the amount of calcium excreted in the urine, which can raise the risk of forming certain types of urinary stones. Reducing salt intake may help lower the chance of stone recurrence and support overall kidney health.
Why is a low-purine diet advised for some patients with urinary stones?
Purines are substances found in foods such as red meat, organ meats, and some seafood. When purines are broken down, they produce uric acid. In people who are prone to uric acid stones, reducing purine-rich foods may help lower the risk of new stone formation.
Can citrus fruits help prevent kidney stones?
Yes, citrus fruits such as lemons and oranges contain citrate, which can help reduce the formation of certain types of kidney stones. Including citrus fruits or their juices as part of a balanced diet, along with adequate hydration, may help reduce the risk of recurrence.
Is regular follow-up necessary after DJ stent placement?
Yes, regular follow-up is important to monitor recovery, assess the urinary tract, and ensure the DJ stent is removed at the appropriate time. Leaving a temporary stent in place for longer than recommended may increase the risk of complications such as infection, stone formation, or stent encrustation.
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