Renal calculi involving the renal pelvis and calyceal system are commonly encountered in urological practice and may require staged management depending on the clinical scenario. This case report highlights the successful treatment of left renal pelvic and lower calyceal calculi in a middle-aged male with a prior history of DJ stenting. The patient underwent definitive management with flexible ureteroscopy and laser lithotripsy (RIRS), followed by fresh DJ stenting. The procedure was well tolerated, and the postoperative course was uneventful. This case emphasizes the role of staged endourological intervention in achieving optimal outcomes in patients with complex stone disease.
Introduction
Kidney stone disease continues to be a significant health concern worldwide, with increasing incidence due to lifestyle and dietary factors. Advances in endourology, particularly Retrograde Intrarenal Surgery, have revolutionized the management of renal calculi, offering a minimally invasive and highly effective treatment option.
In cases where initial drainage is required due to obstruction or infection, temporary DJ stenting is often performed, followed by definitive stone management. This staged approach ensures patient safety while allowing optimal surgical outcomes.
Case Presentation
A 45-year-old male presented for definitive management of known left renal pelvic and lower calyceal calculi. The patient had previously undergone cystoscopy, retrograde pyelography (RGP), and ureteroscopy-guided DJ stenting approximately two weeks prior, in view of obstructive uropathy with mild hydronephrosis.
The patient reported a history of recurrent lithuria occurring 4–5 times in the past. He was a known case of diabetes mellitus and was on regular medication. There was no history of drug allergies.
Clinical Findings and Investigations
Baseline investigations were carried out to assess renal function and overall fitness for surgery.
- Serum Creatinine: 0.8 mg/dL (within normal limits)
- X-ray KUB: Revealed left renal pelvic and lower calyceal calculi with DJ stent in situ
- ECG: Within normal limits
- Chest X-ray: No active disease
- 2D Echocardiography:
- Concentric left ventricular hypertrophy (LVH)
- Mild mitral regurgitation (MR)
- Trivial tricuspid regurgitation (TR)
- Left ventricular ejection fraction (LVEF): 60%
These findings confirmed that the patient was fit for definitive endourological intervention.
Diagnosis
- Left renal pelvic and lower calyceal calculi (post DJ stent status)
- Type 2 Diabetes Mellitus
Treatment Plan
After detailed counselling regarding available treatment options, risks, benefits, and expected outcomes, the patient consented to undergo definitive stone management using flexible ureteroscopy.
Surgical Procedure
The patient underwent:
- Cystoscopy
- Left DJ stent removal (stent exchange/removal)
- Flexible ureteroscopy (RIRS)
- Laser lithotripsy
- Fresh DJ stenting
Intraoperative Findings
- Urethra was normal
- Previously placed DJ stent was successfully removed
- Flexible ureteroscopy revealed calculi in the renal pelvis and lower calyx
- Stones were fragmented using laser lithotripsy (dusting technique)
- Adequate clearance was achieved
- A fresh DJ stent was placed to ensure postoperative drainage
- Patient was catheterized at the end of the procedure
Postoperative Course
The patient tolerated the procedure well.
- No intraoperative complications
- Stable postoperative recovery
- No significant pain, hematuria, or infection
- Uneventful hospital stay
The patient was discharged in stable condition with advice for follow-up and stent removal at an appropriate interval.
Discussion
Management of renal calculi has evolved significantly with the advent of minimally invasive techniques such as Retrograde Intrarenal Surgery. RIRS offers several advantages, including:
- No external incision
- Minimal blood loss
- Short hospital stay
- Rapid recovery
- High stone clearance rates
In the present case, a staged approach was adopted. Initial DJ stenting helped relieve obstruction and allowed passive ureteral dilation, facilitating easier access during the definitive RIRS procedure.
Role of DJ Stenting
Pre-stenting has been shown to:
- Improve ureteral access
- Reduce intraoperative complications
- Increase success rates of RIRS
Postoperative stenting:
- Prevents ureteral obstruction due to edema
- Facilitates drainage
- Reduces risk of complications
Special Considerations
1. Diabetes Mellitus
Patients with diabetes are at higher risk of:
- Infection
- Delayed healing
Careful perioperative monitoring is essential.
2. Recurrent Stone Disease
History of lithuria suggests:
- Underlying metabolic predisposition
- Need for metabolic evaluation
Preventive strategies should be emphasized postoperatively.
Outcome and Follow-Up
The procedure achieved successful fragmentation and clearance of stones. The patient remained stable postoperatively and was advised:
- Timely follow-up
- DJ stent removal
- Metabolic workup
- Lifestyle and dietary modifications
Conclusion
This case highlights the effectiveness of staged endourological management in patients with renal calculi. Flexible ureteroscopy (RIRS) with laser lithotripsy is a safe and highly effective treatment modality, particularly in patients with prior stenting.
Early intervention, appropriate surgical planning, and postoperative care are crucial for optimal outcomes.
Expertise and Institutional Excellence
Management of complex renal stone disease requires a combination of advanced technology and clinical expertise. At the Institute of Urology, Jaipur, a wide range of urological conditions are treated using state-of-the-art equipment and minimally invasive techniques.
Under the expert guidance of Dr. M. Roychowdhury and Dr. Rajan Bansal, patients receive individualized, evidence-based care tailored to their specific condition.
The institute offers comprehensive services under one roof, including consultation, diagnostics, advanced endourology procedures such as Retrograde Intrarenal Surgery, and long-term follow-up—making it one of the most advanced tertiary care urology centers in Jaipur, Rajasthan.
