RIRS for Upper Ureteric Calculus with Hydronephrosis: Upper ureteric calculi, especially when associated with hydronephrosis and comorbid conditions, require timely and precise intervention to prevent renal damage. Retrograde Intrarenal Surgery has emerged as an effective minimally invasive technique for managing such cases. We report a case of a middle-aged female with a left upper ureteric calculus and moderate hydronephrosis, successfully treated with RIRS and DJ stenting, resulting in excellent clinical outcomes.
Introduction
Urolithiasis involving the upper ureter can lead to obstruction and progressive renal impairment if not treated promptly. Advances in endourology, particularly flexible ureteroscopy (RIRS), have significantly improved the management of ureteric and renal calculi with reduced morbidity and faster recovery.
Patients with comorbidities such as diabetes mellitus and hypertension require careful perioperative planning to ensure safe and effective outcomes.
Case Presentation
A middle-aged female presented with complaints of intermittent left flank pain for several weeks. There were no associated lower urinary tract symptoms, fever, or hematuria.
She was a known case of:
- Diabetes mellitus
- Hypertension
Both conditions were well-controlled on medication.
Past surgical history included:
- Total laparoscopic hysterectomy (8 years prior)
- Ureteroscopic intervention (5 years prior)
There was no history of drug allergies.
Investigations
Laboratory evaluation revealed:
- Serum creatinine: 1.33 mg/dL
Ultrasonography (USG) findings:
- Small non-obstructive calculus in the upper pole of the right kidney
- Moderate hydronephrosis of the left kidney with thinning of renal parenchyma
- Calculus measuring approximately 12.4 mm at the pelvi-ureteric junction (PUJ) of left kidney
Intravenous pyelography (IVP) showed:
- Normally functioning right kidney with small calculi
- Left upper ureteric calculus with moderate to gross hydronephrosis
- Delayed excretion from the left kidney
Chest X-ray and other preoperative evaluations were within normal limits.
Diagnosis
- Left upper ureteric calculus (approximately 12.4 mm) near PUJ
- Moderate hydronephrosis with delayed renal function
- Small right renal calculus
- Comorbid diabetes mellitus and hypertension
Treatment Plan
Considering the stone size, location, hydronephrosis, and patient comorbidities, a minimally invasive endourological approach was planned.
Surgical Procedure
The patient underwent:
- Cystoscopy
- Left retrograde pyelography (RGP)
- Retrograde Intrarenal Surgery with laser lithotripsy
- Double J (DJ) stenting
under general anesthesia.
Intraoperative Findings
- Normal urethra and bladder on cystoscopy
- Bilateral ureteric orifices in normal position
- Left upper ureteric calculus located near the PUJ
Procedure Details
- RGP confirmed the location and anatomy
- Flexible ureteroscopy (RIRS) was performed
- The stone was fragmented using laser lithotripsy (dusting technique)
- Complete fragmentation achieved
- DJ stent was placed to ensure drainage
- Foley catheterization was done at the end of the procedure
The patient tolerated the procedure well without complications.
Postoperative Course
The postoperative period was uneventful.
- The patient remained hemodynamically stable
- Adequate urine output was maintained
- No signs of infection or complications were noted
She showed significant symptomatic relief and was discharged in stable condition after appropriate postoperative care.
Discussion
Upper ureteric calculi near the PUJ can cause significant obstruction, leading to hydronephrosis and progressive renal damage if untreated. Early diagnosis and intervention are critical, particularly in patients with comorbid conditions.
Retrograde Intrarenal Surgery offers several advantages:
- Minimally invasive approach
- High stone clearance rates
- Reduced postoperative pain
- Short hospital stay
- Faster recovery
Laser lithotripsy allows effective fragmentation even in difficult locations such as the PUJ.
In this case, RIRS was particularly advantageous due to:
- Moderate hydronephrosis
- Comorbid diabetes and hypertension
- Previous surgical history
The use of DJ stenting ensured adequate drainage and prevention of postoperative obstruction.
Conclusion
Flexible ureteroscopy (RIRS) is a safe and highly effective treatment modality for upper ureteric calculi, even in patients with comorbid conditions. Early intervention can prevent long-term renal damage and provide excellent symptomatic relief.
Clinical Message
- Upper ureteric stones near PUJ should be treated promptly
- RIRS is a preferred minimally invasive option with excellent outcomes
- Patients with comorbidities require individualized and expert care
Best Hospital in Jaipur for Kidney Stones Treatment
The procedure was successfully performed at the Institute of Urology, Jaipur, a center equipped with advanced endourological technology and comprehensive patient care services. Under the expert guidance of Dr. M. Roychowdhury and Dr. Rajan Bansal, complex urological cases are managed with precision and excellent outcomes. The institute offers complete facilities including consultation, diagnostics, minimally invasive surgery, and follow-up care under one roof.
