Combining Retroperitoneal Laparoscopic Ureterolithotomy and Flexible Ureteroscopy for Effective Removal of a Large Ureteral Stone: A Case Report

Introduction

The reported mean diameter of ureteral stones ranges from 3.7 mm to 6.7 mm [1,2]. In most cases, ureteral stones smaller than ~5 mm pass spontaneously [3]. However, when the stone size exceeds approximately 11–22% of the ureter’s inner diameter, obstruction and associated complications may occur, rendering conservative treatment ineffective [4]. According to the 2024 European Association of Urology (EAU) guidelines, ureteroscopy (URS; antegrade or retrograde) and shockwave lithotripsy (SWL) are recommended for ureteral stones >10 mm [5]. However, the stone-free rate for SWL decreases significantly for stones >20 mm [6]. Increasing stone size and severe hydronephrosis can lead to stone impaction, making guidewire placement and flexible ureteroscopy (FURS) difficult or impossible [7]. Consequently, the optimal treatment for large ureteral stones (LUSs) remains a topic of debate. Retroperitoneal laparoscopic ureterolithotomy (RLU) is considered a feasible alternative when URS and SWL fail to remove LUS. However, RLU is associated with longer operative times, extended hospital stays, and higher complication rates [8]. Here, we present a successful case of RLU combined with antegrade flexible ureteroscopy (aFURS), performed through a previously established percutaneous nephrostomy (PCN) tract, to achieve complete LUS removal in a single procedure.

Case Report

A 65-year-old woman with a 6-month history of persistent left flank pain and intermittent hematuria was referred to our institute. Computed tomography (CT) identified an LUS as the underlying cause. Upon admission, her vital signs were stable. Contrast-enhanced CT revealed a left bullet-shaped LUS measuring approximately 50 mm in diameter (mean CT value: 1342.7 HU; max CT value: 1803.0 HU; Figure 1A, 1D) accompanied by ipsilateral renal atrophy and significant hydronephrosis. Biochemicals showed elevated creatinine levels (98 μmol/L).

Urgent PCN was performed for decompression. Under ultrasound guidance, a nephrostomy puncture was made through the 11th intercostal space into the middle calyx, and a 14-Fr nephrostomy tube was placed, yielding 70–90 mL of dark red fluid. The patient remained stable postoperatively and was discharged on the third day to recover renal function at home.

She was followed up 47 days after PCN. A repeat CT scan showed improvement in left hydronephrosis and revealed an insignificant stone in the right kidney (Figure 1B, 1E). 99mTc-DTPA renal dynamic imaging indicated significantly reduced perfusion of the left kidney, with a split renal function percentage of 18.02% (compared to 81.98% on the right) and a glomerular filtration rate of 10.62 mL/min (compared to 48.30 mL/min on the right; Figure 2). Due to the severity of the LUS burden, elective surgery was planned to achieve complete stone clearance using RLU combined with aFURS.

Under general anesthesia, the patient was initially placed in the supine position, and a 16-Fr Foley catheter was inserted. She was then carefully repositioned to the right lateral decubitus position. The PCN tube was trimmed and the area disinfected. A 10-mm trocar was inserted at the mid-axillary line above the iliac crest for the camera port, with working ports placed below the 12th rib at the posterior axillary line (10-mm trocar) and at the subcostal anterior axillary line (5-mm trocar).

Under laparoscopic guidance, the dilated left proximal ureter was identified (Figure 3). A grasper was used to clamp the ureter just above the impacted stone to prevent migration. A full-thickness ureteral incision approximately 3 cm in length was made over the stone. The stone (15×15×42 mm), which was firmly adhered to the mucosa, split into 2 pieces during removal.

To ensure complete stone clearance and assess for potential ureteral injury, a guidewire was introduced through the PCN tract, and a 16-Fr peel-away sheath was placed. The flexible ureteroscope was inserted, continuous fluid irrigation (approximately 60 ml/minute flow rate) was performed to ensure a clear visual field, and confirmed there were no residual stones on the ureter mucosa or significant ureteral injury. The flexible ureteroscope was withdrawn. A 5-Fr Marflow ureteral stent was then inserted, and a new 14-Fr nephrostomy tube was retained. The ureteral incision was closed in an interrupted manner using 4-0 Vicryl® sutures, and a 14-Fr drainage tube was placed. The total operative time was 165 minutes, with negligible blood loss.

The patient had an uneventful recovery. Her postoperative creatinine level improved to 73 μmol/L. The Foley catheter, drainage tube, and PCN tube were removed on the second, third, and fifth postoperative days, respectively, and she was discharged with oral antibiotics.

She returned to the outpatient clinic 1 month postoperatively for ureteral stent removal. A follow-up CT scan confirmed complete left stone clearance, and the intact stent was retrieved without complications (Figure 1C, 1F). At her 3-month follow-up, she remained asymptomatic, and ultrasound evaluation confirmed no evidence of ureteric stricture.

Discussion

The management of large ureteral stones (LUS) in this patient posed significant challenges, including compromised renal function, hydronephrosis, stone impaction with strong adherence to the ureteral mucosa, and the risk of iatrogenic ureteric stricture. Due to the stone burden, a retrograde approach for ureteral stent placement was not feasible; therefore, percutaneous nephrostomy (PCN) was performed to provide urgent decompression of the obstructed collecting system. The small volume of dark red drainage fluid was likely due to the release of retained blood. Her creatinine levels and urine output were closely monitored in the outpatient setting, and preoperative evaluation of the left kidney was conducted radiographically before proceeding to stone removal.

The ideal stone management procedure should achieve a high stone clearance rate, be completed in a single session, and remain minimally invasive. Flexible ureteroscopy (FURS) is increasingly utilized as a first-line treatment for urolithiasis; however, reported stone-free rates show significant variability, ranging from 52.2% to 90.2% in real-world data [8,9]. In contrast, shockwave lithotripsy (SWL) often requires multiple sessions (an average of 1.5 sessions) depending on factors such as stone size and patient age [10]. The stone-free rate for SWL after a single session can be as low as 46.7% for ureteral stones but may increase to 90.0% after 3 sessions [11]. Comparatively, studies indicate that FURS achieves significantly higher stone-free rates than SWL, with rates of 89.5% versus 72.7%, respectively (P=0.036) [12].

RLU combined with aFURS proved to be a safe and effective approach for managing LUS in a single session, with no complications. Advancements in endourological techniques, such as URS and percutaneous nephrolithotomy, have significantly reduced the need for open or laparoscopic stone surgeries. However, the role of RLU for LUS removal remains underexplored, despite studies reporting a >95% treatment success rate [13]. Notably, the EAU guidelines recommend RLU in cases where surgical expertise is available, emphasizing the importance of surgeon proficiency in endourological instrumentation and laparoscopic techniques.

Previous studies have described the combined use of RLU and retrograde FURS for removing residual ureteropelvic junction stones alongside multiple renal stones, with the scope introduced through a third working port for ureterostomy [14]. In this case, introducing the scope through the existing PCN tract provided greater accuracy in access and potentially minimized the risk of injury to nearby organs.

The challenges of stone impaction and adherence to the ureteral mucosa made extraction difficult. While preoperative CT imaging provided essential diagnostic details such as stone size and location, intraoperative evaluation through RLU and FURS enabled a comprehensive assessment of the ureter’s inner and outer condition. This approach avoided the need for open surgery and minimized the risk of iatrogenic complications, including ureteral perforation, stricture, or leakage [15]. While barbed sutures secured with Hem-o-locks are used during partial nephrectomy to avoid knot tying and speed the suture placement, we advise against using this for closing the ureter as it can inadvertently irritate the ureter [16]. Additional measures, such as avoiding clamping of the ureteral wall, using non-electrosurgical tools for incisions, and performing longitudinal ureteral incisions closed with transverse suturing techniques (similar to the Heineke-Mikulicz technique), were employed to reduce the risk of ureteral stricture formation. Other specialized visualization techniques, such as intra-ureteral injection of indocyanine green and visualization under near-infrared fluorescence or narrow-band imaging could also provide better visualization of the ureteral stricture [17,18]. However, given that the surgical team was more proficient at endourological stone removal, these techniques were not applied. At the 3-month follow-up, the patient remained asymptomatic, and no postoperative complications were observed.

In summary, the early establishment of a PCN tract created favorable conditions for the subsequent combined procedure by allowing additional irrigation and surveillance, which facilitated enhanced stone clearance and surgical success. However, the positive outcome was also largely attributed to the surgeon’s proficiency in laparoscopic techniques, which minimized ureteral injury. While RLU and FURS are efficient, the ultimate success of such procedures depends on the surgeon’s extensive experience and expertise.

Conclusions

RLU combined with aFURS offers a viable treatment option for LUS when conventional approaches such as URS and SWL are not feasible. This case reinforces the need for a multidisciplinary approach and surgical proficiency to achieve optimal outcomes in patients with challenging stone burdens.