Abstract
We report the case of a 75-year-old female with a history of recurrent nephrolithiasis and pyonephrosis, who presented with a large left renal pelvic–calyceal calculus in staghorn configuration. The patient, with significant comorbidities including diabetes mellitus and hypertension, underwent successful percutaneous nephrolithotomy (PCNL) with complete stone clearance under the expert care of Dr. M. Roychowdhury and Dr. Rajan Bansal at the Institute of Urology, Jaipur. This case highlights the efficacy and safety of PCNL even in elderly patients with recurrent stone disease and compromised renal anatomy.
Introduction
Management of nephrolithiasis in elderly patients presents unique challenges due to multiple comorbidities, altered renal function, and increased procedural risk. When complicated by pyonephrosis, timely decompression and definitive management are essential to prevent sepsis and preserve renal function.
Percutaneous nephrolithotomy (PCNL) remains the gold standard for large and complex renal calculi, offering high stone clearance rates with minimal morbidity. This case exemplifies a successful outcome in a high-risk patient with recurrent urolithiasis.
Case Presentation
A 75-year-old female, a known case of diabetes mellitus and hypertension on regular medication, presented to the Institute of Urology, Jaipur with a history of recurrent left-sided flank pain and intermittent fever. She had a known diagnosis of left pyonephrosis and nephrolithiasis.
Past Surgical History:
- Left RIRS
- Right laser URS and left mini PCNL
- Right laser URS
- Cystoscopy, left retrograde pyelography (RGP), and ureteroscopy (URS)-guided DJ stenting for pyonephrosis
She was now admitted for definitive stone clearance at our centre.
Investigations
- Serum Creatinine: 0.72 mg/dL
- CT Whole Abdomen: Large staghorn configuration calculus in the lower pelvicalyceal system of the left kidney with features of pyeloureteritis and DJ stent in situ.
- Normal left renal excretory function
- Right kidney normal with unobstructed drainage
- Mildly delayed drainage on the left side
- Fatty hepatomegaly noted
- Chest X-Ray: NAD
- ECG: TWNL (T waves normal)
Procedure and Findings
On 03/11/2025, the patient underwent Cystoscopy, Left JJR (Double J stent replacement), RGP, and PCNL with fresh DJ stenting under general anesthesia.
Intraoperative Findings and Steps:
- Cystoscopy revealed normal urethra and normal bladder mucosa.
- Both ureteric orifices were normally located.
- Left JJR was done, and RGP performed showing a dilated system with lower calyceal stone burden.
- Urethral catheter placed; patient repositioned prone.
- Left lower posterior calyceal puncture was made under fluoroscopic guidance.
- 22 Fr tract was established.
- The large stone was fragmented using a lithoclast, achieving complete clearance.
- A fresh DJ stent was inserted to ensure drainage.
- Nephrostomy tube placed for postoperative monitoring.
- Procedure was completed uneventfully.
Postoperative Course
The patient tolerated the procedure well. Her postoperative period was uneventful.
Postoperative imaging (X-ray and ultrasound) showed:
- Hepatomegaly with Grade I fatty changes
- Post-PCNL changes with mild residual hydronephrosis
- DJ stent and nephrostomy tube in situ
- No residual calculus or perinephric collection seen
The nephrostomy tube was removed after satisfactory output and imaging confirmation of unobstructed drainage. The patient remained afebrile and pain-free throughout her hospital stay and was discharged in stable condition.
Discussion
Recurrent nephrolithiasis with pyonephrosis in elderly diabetic patients carries significant risk for renal function deterioration and septic complications. Initial decompression by DJ stenting, followed by delayed definitive stone removal, is the standard two-stage approach to minimize infection risk.
In this patient, multiple prior interventions and anatomical changes posed additional technical challenges. Despite these complexities, laparoscopic and endoscopic expertise at the Institute of Urology, Jaipur enabled complete clearance through a single-access PCNL without complications.
The careful choice of calyceal entry, efficient fragmentation, and meticulous postoperative care ensured a successful outcome.
This case demonstrates that age and comorbidities are not contraindications for PCNL when performed by experienced urologists in a tertiary setup. Early intervention in such patients prevents recurrent infection, preserves renal function, and improves quality of life.
Expertise and Institutional Excellence
Under the leadership of Dr. M. Roychowdhury and Dr. Rajan Bansal, the Institute of Urology, Jaipur has established itself as a center of excellence for complex stone surgeries, minimally invasive urology, and reconstructive procedures.
Both surgeons have pioneered safe, precise, and patient-focused surgical practices, especially in elderly and high-risk patients. Their clinical outcomes and compassionate approach have earned the Institute outstanding patient satisfaction and top-rated reviews on Google, making it one of India’s most trusted urology centers.
Conclusion
This case reaffirms the safety and effectiveness of PCNL for large renal calculi even in elderly patients with recurrent urolithiasis and comorbidities like diabetes and hypertension.
The surgical expertise of Dr. M. Roychowdhury and Dr. Rajan Bansal, combined with advanced facilities at the Institute of Urology, Jaipur, ensures optimal outcomes with minimal complications, setting a benchmark for comprehensive urological care in India.
