Pelvi-ureteric junction (PUJ) calculi can present with intermittent flank pain and may progress to hydronephrosis if left untreated. With advancements in endourology, Retrograde Intrarenal Surgery (RIRS) has emerged as a safe and effective minimally invasive treatment option. We report a case of a 34-year-old female with a right PUJ calculus successfully managed with RIRS and DJ stenting, highlighting diagnostic evaluation, treatment decision-making, and postoperative outcome.
Introduction
Renal calculi remain a common urological problem, particularly affecting young and middle-aged adults. Stones located at the pelvi-ureteric junction can impair urinary drainage, leading to hydronephrosis and recurrent pain. Early diagnosis and timely intervention are crucial to prevent renal damage. RIRS has gained popularity due to its high stone-free rates, minimal morbidity, and rapid recovery.
Case Presentation
A 34-year-old female presented to the urology outpatient department with complaints of right flank pain, intermittent in nature, for the past few weeks. The pain was dull aching, non-radiating, and not associated with fever, hematuria, dysuria, or urinary frequency. There was no history of trauma or injury. She had a past history of renal calculi, treated conservatively.
On physical examination, the patient was hemodynamically stable. Abdominal examination revealed mild right flank tenderness with no palpable mass. Systemic examination was unremarkable.
Investigations
Initial evaluation included ultrasonography (USG) of the abdomen, which revealed:
- A 16 mm calculus at the right pelvi-ureteric junction (PUJ)
- Mild right-sided hydronephrosis
Further investigations were carried out to assess renal function and surgical fitness:
- Serum creatinine: 0.7 mg/dL (within normal limits)
- Intravenous Pyelogram (IVP): Confirmed right PUJ calculus with mild hydronephrosis and preserved renal function
- Electrocardiogram (ECG): Normal
- Chest X-ray (CXR): Normal
- Echocardiography: Normal
Treatment Planning and Decision
After a detailed discussion with the patient regarding the available treatment options, including conservative management, shock wave lithotripsy (SWL), and endourological intervention, the risks and benefits of each modality were explained. Considering the stone size, location at PUJ, presence of hydronephrosis, and the patient’s preference for definitive treatment, surgical removal of the stone was planned.
Surgical Procedure
The patient underwent Right Retrograde Pyelography (RGP) followed by Retrograde Intrarenal Surgery (RIRS) under appropriate anesthesia. Intraoperatively, the calculus at the right PUJ was visualized and successfully fragmented using endoscopic techniques. Complete stone clearance was achieved.
A Double J (DJ) ureteral stent was placed at the end of the procedure to ensure adequate drainage and facilitate healing.
Postoperative Course
The postoperative period was uneventful. The patient remained stable, with adequate urine output and significant relief from flank pain. She was mobilized early and tolerated oral intake well.
The patient was discharged on the next day, with advice regarding hydration, medications, and follow-up for stent removal.
Further Management and Follow-up
Given her history of recurrent renal calculi, the patient was advised to undergo a complete metabolic evaluation to identify any underlying metabolic abnormalities predisposing her to stone formation. Dietary counseling and preventive strategies were discussed to reduce the risk of recurrence.
Discussion
PUJ calculi pose a therapeutic challenge due to their location and potential to cause obstruction. RIRS offers a minimally invasive, effective solution with high success rates, especially for stones less than 2 cm. In this case, early intervention helped relieve symptoms and prevented progression of hydronephrosis. The role of metabolic evaluation is crucial in patients with recurrent stone disease to prevent future episodes.
Conclusion
This case highlights the successful management of a right PUJ calculus using RIRS with DJ stenting in a young female patient. RIRS is a safe and effective modality with minimal morbidity, short hospital stay, and excellent patient outcomes. A comprehensive metabolic work-up is essential in recurrent stone formers to ensure long-term prevention.
Institutional Expertise and Facilities
This case was managed at the Institute of Urology, Jaipur, a dedicated tertiary care center offering comprehensive urological and allied surgical services under one roof. The institute is equipped with state-of-the-art endourology infrastructure, advanced imaging facilities, modern operation theatres, and minimally invasive surgical technologies that enable safe and effective management of complex urological conditions.
The procedure was performed under the expert care of Dr. M. Roychowdhury and Dr. Rajan Bansal, both highly experienced urologists with extensive expertise in the management of renal stone disease, including RIRS, PCNL, URS, and advanced endourological interventions. Their patient-centric approach, meticulous surgical planning, and adherence to evidence-based practices ensure optimal clinical outcomes with minimal morbidity.
In addition to surgical excellence, the Institute of Urology provides comprehensive services including outpatient consultation, diagnostic imaging, laboratory investigations, metabolic evaluation for stone disease, preventive counseling, and long-term follow-up, ensuring holistic care for patients with urological disorders. The institute’s integrated model allows seamless coordination between diagnosis, treatment, and prevention, particularly important in recurrent stone formers such as the patient described in this report.
This case underscores the effectiveness of Retrograde Intrarenal Surgery (RIRS) in the management of PUJ calculi with mild hydronephrosis, offering excellent stone clearance with minimal invasiveness and rapid recovery. Early intervention, individualized treatment planning, and postoperative preventive strategies—including metabolic evaluation—are essential to achieving long-term success in recurrent stone disease. The availability of advanced technology and experienced urologists at specialized centers like the Institute of Urology, Jaipur plays a pivotal role in delivering high-quality urological care.
