Abstract
We report a case of a 55-year-old male presenting with a large impacted right upper-mid ureteric calculus measuring approximately 25 mm, associated with moderate hydroureteronephrosis and cortical thinning of the right kidney. The case highlights the decision-making process in managing a poorly functioning hydronephrotic kidney, the intraoperative challenges encountered, and the successful laparoscopic management under the expertise of Dr. M. Roychowdhury and Dr. Rajan Bansal at the Institute of Urology, Jaipur.
Introduction
Large impacted upper ureteric calculi (>20 mm) pose significant surgical challenges, especially when associated with secondary renal parenchymal thinning and compromised renal function. Although minimally invasive modalities like ureteroscopy (URS) and retrograde intrarenal surgery (RIRS) are preferred, anatomical factors such as ureteral kinking or stricture may preclude endoscopic access. Laparoscopic ureterolithotomy remains a highly effective alternative in such complex cases, offering complete stone clearance with minimal morbidity.
Case Presentation
A 55-year-old male presented to the Institute of Urology, Jaipur with complaints of intermittent right flank pain for several months, occasionally associated with nausea and decreased urine output.
Investigations:
Ultrasound KUB revealed a large right upper ureteric calculus measuring approximately 25 mm, with moderate hydroureteronephrosis. The right renal cortex appeared thinned to 7–8 mm, suggestive of chronic obstruction.
A DTPA renal scan demonstrated a grossly hydronephrotic, poorly functioning right kidney, confirming chronic obstructive uropathy.
After detailed counselling regarding prognosis and treatment options, including the possibility of renal function recovery after relief of obstruction, the patient and family consented for surgical management.
Procedure and Findings
Under general anesthesia, the patient underwent Cystoscopy, Diagnostic URS, and Right Laparoscopic Ureterolithotomy with DJ Stenting.
Intraoperative details:
- Cystoscopy revealed a normal urethra and bladder.
- URS revealed a large impacted calculus in the upper ureter, with a sharp kink and narrowing distal to the stone.
- The ureteroscope could not be negotiated beyond this point despite careful attempts; hence, RIRS was abandoned.
- The team proceeded with a three-port laparoscopic ureterolithotomy.
- The colon was reflected medially to expose the ureter.
- A large upper ureteric stone was visualized, and ureterotomy was performed over the calculus.
- The stone was carefully extracted and sent for analysis.
- A DJ stent was placed to ensure urinary drainage.
- The ureter was approximated with 4-0 Vicryl sutures, ensuring watertight closure.
- A drain tube was placed, and all laparoscopic ports were closed meticulously.
Outcome:
The procedure was uneventful. The patient’s postoperative recovery was smooth, with satisfactory drain output and no complications. The drain was removed on postoperative day two, and the patient was discharged in stable condition.
Discussion
Impacted upper ureteric stones, particularly those exceeding 2 cm, are challenging due to chronic inflammation, periureteric fibrosis, and anatomical distortion. When endoscopic advancement is limited by sharp angulation or luminal narrowing, laparoscopic ureterolithotomy remains the treatment of choice, providing complete stone clearance in a single session with excellent visual control and minimal tissue trauma.
In this case, the surgical judgment to shift from endoscopic to laparoscopic approach exemplified sound intraoperative decision-making—a hallmark of experienced urological surgeons. Despite poor renal function and cortical thinning, the kidney was preserved, providing the patient with the best chance for residual renal recovery after obstruction relief.
Expertise at the Institute of Urology, Jaipur
This case underscores the unmatched expertise of Dr. M. Roychowdhury and Dr. Rajan Bansal, who are widely recognized across India for their mastery in managing complex and high-risk urological cases.
At the Institute of Urology, Jaipur, they have successfully performed thousands of endourological and laparoscopic surgeries, including RIRS, PCNL, laparoscopic pyeloplasty, ureterolithotomy, and partial nephrectomy, earning the institution a reputation as a national center of excellence.
Both Dr. Roychowdhury and Dr. Bansal have been at the forefront of advancing minimally invasive urology in India, integrating precision, technology, and patient-centric care. Their consistent surgical outcomes and compassionate approach have garnered rave patient reviews and top ratings on Google, reflecting their commitment to excellence and trust built among patients nationwide.
Conclusion
For large impacted upper ureteric calculi, especially in the presence of anatomical challenges or poor renal function, laparoscopic ureterolithotomy remains a safe, definitive, and highly effective approach.
Under the expert leadership of Dr. M. Roychowdhury and Dr. Rajan Bansal at the Institute of Urology, Jaipur, complex stone surgeries are handled with unparalleled precision, offering patients across India the highest standards of urological care.
