Dual Endoscopic Management of Bilateral Renal and Ureteric Calculi in an Elderly Patient at Institute of Urology, Jaipur

Dual Endoscopic Management of Bilateral Renal and Ureteric Calculi in an Elderly Patient at Institute of Urology, Jaipur: Urolithiasis is a prevalent condition, particularly in elderly patients, requiring prompt and effective management to prevent complications. This case report discusses the successful management of bilateral renal and ureteric stones in a 60-year-old female patient through a combination of ureteroscopy with laser lithotripsy (URSL) and percutaneous nephrolithotomy (PCNL) performed in the same sitting.

Clinical Presentation

A 57-year-old female presented to the Institute of Urology, Jaipur, with complaints of right flank pain persisting for two weeks. The pain was colicky, non-radiating, and not associated with fever or hematuria. She denied any history of prior urinary stones or urological interventions.

Investigations

1. X-ray KUB (Kidney, Ureter, and Bladder):
   • A radio-opaque calculus was identified in the right ureter (mid-ureteric region).
   • A large radiopaque shadow suggestive of a staghorn calculus was noted in the left kidney.
     
2. Ultrasound (USG) Abdomen:
   • Confirmed a calculus in the right ureter causing moderate hydronephrosis.
   • A calculus in the left renal pelvis with no gross hydronephrosis.
     
3. Blood and Urine Tests:
   • Normal renal function tests.
   • No signs of active urinary tract infection.

Diagnosis

1. Right Mid-Ureteric Calculus.
2. Left Renal Pelvic Calculus ( staghorn morphology).

Management Plan

Given the patient’s age and the bilateral stone burden, the team decided on simultaneous management of both stones to minimize anesthesia exposure and hospital visits. The chosen approach was:

• Right URSL (Ureteroscopy with Laser Lithotripsy) for the mid-ureteric calculus.
• Left PCNL (Percutaneous Nephrolithotomy) for the renal pelvic calculus.

Both procedures were performed in the same sitting under the guidance of expert urologists Dr. M. Roychowdhury and Dr. Rajan Bansal.

Procedure Details

1. Right URSL:
   
   • Ureteroscopy was performed using a semi-rigid ureteroscope.
   • The calculus was fragmented using a Holmium laser and the fragments were removed completely.
   • A double-J stent was placed to ensure ureteral healing.
     
2. Left PCNL:
   
   • Access to the renal pelvis was achieved under fluoroscopic guidance.
   • The staghorn calculus was fragmented using a pneumatic lithotripter and all fragments were retrieved.
   • A nephrostomy tube was placed for drainage postoperatively.

Outcome

• The patient tolerated the procedure well.
• Postoperative imaging confirmed complete clearance of stones on both sides.
• The nephrostomy tube was removed on day 2, and the patient was discharged without complications.

Follow-Up and Prognosis

1. Stent Removal: Scheduled after 4-6 weeks.
2. Dietary and Lifestyle Counseling: To prevent recurrence, the patient was advised on maintaining adequate hydration and dietary modifications tailored to her stone composition, which was predominantly calcium oxalate.
3. Long-Term Monitoring: Routine follow-ups and imaging to detect any recurrence.

Discussion

Managing bilateral stones in a single sitting reduces the need for repeated anesthesia and minimizes patient discomfort, particularly in elderly individuals. URSL and PCNL are highly effective and safe modalities for ureteric and renal stones, respectively.

Advantages of Single-Session Bilateral Management:

• Reduced cumulative anesthesia exposure.
• Shorter hospital stay.
• Improved patient compliance.

Conclusion

This case highlights the efficacy and safety of simultaneous URSL and PCNL for managing bilateral urolithiasis in an elderly patient. The expert multidisciplinary approach ensured excellent clinical outcomes, minimizing patient discomfort and expediting recovery.