Very large lower ureteric stone without HUN

• 26 Feb 2020 12:18:13 PM
• |General Urology

50 year male patient presented with history of right flank pain and dysuria of few months.

Comments(16)

• 

  Utsav Shah

  26 Feb 2020 06:52:47 PM

  Interesting case sir!

  Never seen anything like this. 

  The absence of back pressure changes is confusing!

• 

  Jaideep Mahajani

  26 Feb 2020 07:16:59 PM

  Small stone with infection and oedema will present with hydronephrosis. But long standing large asymptomatic stone without infection many times can present without hydronephrosis. 

  Considering male patient, my first choice will be open ureterolithotomy.

  But in female patient, I will give option of URS if patient is paying. 

• 

  Dr. Anil Takvani

  27 Feb 2020 11:18:24 AM

  What will be the preference;

  Open ureterolothotomy

  Or

  URS

  Which energy source you will use to break this stone?You will just dust the stone and leave the stent or you will break stone in fragments and will retrieve with the help of forceps?
  

  Which are the difficulties or complications you are anticipating in URS of this case?

  Thanks

• 

  Dr. Anil Takvani

  27 Feb 2020 05:52:37 PM

  This patient has such a big stone in lower ureter with another small stone in mid ureter since at least 2 to 3 years. 

  Please discuss how you will tackle these stones surgically. 

  I am attaching two available images of IVU,  done before a year... 

  

• 

  Pankaj N Maheshwari

  27 Feb 2020 06:32:06 PM

  Thanks Anil for an interesting case.

  Just goes to show that there are lot of things that happen in human body that are difficult to explain!!

  My decision about treatment plan would be based on the hounsfield unit of the stone and the patients wish & desire. 

  If this is a very hard stone (say HU>1300), I may be tempted for a simple open procedure but low HU would dust very well with laser (both HoL and TFL)

  Large stones in the intra-mural ureter are difficult as there is no space for the scope and the scope tends to slip out when you try to advance the laser fiber or the forceps. gradually create space and work with sequential fragmentation and pickups. once space is created then you can dust the stone.

  In and out movement of the scope with irrigation on can evacuate a lot of dust. 

  I try to pickup or flush out as much as i can and do not leave a lot for the stent.

  I do not believe in ureteric meatotomy although i have seen few of my colleagues do it (I welcome comments on ureteric meatotomy)

  Post-procedure alpha blockers would help reduce stent dysuria and would also work as MET for the fragments. 

   

• 

  Dr. Anil Takvani

  27 Feb 2020 07:08:09 PM

  Thanks Dr.  Pankaj.

  It is always a pleasure to read your point wise and precise expert comments. 

  HU is >1500 

  There is another stone few centimeters proximal to this big stone. 

  Attaching both the reports,  recently done CT and IVU was done in May 2019. 

  
  

  

• 

  Nitesh Jain

  28 Feb 2020 07:01:58 AM

  If stone is seen or well felt by instrument with a bulge I will go ahead and do meatotomy filled by cystolitholapaxy ... in images stone looks little higher 

  
  

  Will prefer URS and use Lithoclast to fragment the stone rather than laser because it is way faster for such a large bulk and the fear of stone migrating up is less as ureter is non dilated and stone is in lower ureter 

  
  

  Repeated in and out movement most of the time clears almost all the stone 

  
  

  The other stone can be tackeled in similar way 

• 

  Venugopal P

  28 Feb 2020 09:18:23 AM

  Dear All,

  How times have changed. Now seeing a large stone in the ureter is a rarity as indicated by Utsav. In my time, it was a usual presentation. Stones of any size were encountered in the ureter and at any level. The largest I have seen in the ureter was well over 7 cms and surprisingly there were no back pressure changes on the kidney.

  The question of why there is no back pressure in this case on IVU needs some explanation. Not all large stones are obstructive as there could be space between ureteral wall and stone. I have seen many scenario’s like this. In few surprisingly, there was a spiral groove on the stone, which helped in drainage of urine across the stone. Another aspect that one will have to consider when encountering a large stone in the ureter like this is the possibility as to whether we are dealing with a secondary calculus due to a distal stricture. More often, there will be back pressure changes in such situations. But this is not the case with some Secondary stones in scenario with Pr Obstructive Large Ureter (I refrain from using the word mega ureter). Hendran has classified such ureters into three groups and one of them is with no back pressure on the kidney. Though such a picture can be seen in children also, it is more often encountered in Adults with such a condition.

  Jaideep has mentioned that he would do an Open Procedure if it is male but would do a URS in a female. I wonder why this gender bias. In fact, in my limited experience, in females such large ureteral calculus sags the ureter downwards making Ureteroscopic approach at times difficult.

  Pankaj, no doubt is an experienced Endourologist, and no doubt his preference to an endourological procedure is bound to be there. But even he has mentioned a cutoff HU for stone.  As mentioned by Anil, this stone has a higher HU. I personally would prefer open Ureterolithotomy in either sex, if the stone was this large. Additional pathology must be looked for like what was mentioned. In females of 50 years, as is mentioned as age in this case (the case posted being a male), it is likely that she may have associated pelvic organ prolapse which will in turn may draw the ureter down and make even open ureterolithotomy difficult at times.

  Ureteral Meatotomy used to be procedure that used to be practiced in the early days of URS. The scopes were of larger size and no dilatation techniques were available unlike today. Many of you may not even heard of 14 Fr Ureteroscope or even 11 Fr Ureteroscopes that were available in the early 80’s. We were performing Ureteroscopies with such scopes. One of the ways we entered the ureteroscopes into the ureter was after performing liberal ureteric meatotomy. This with modern small size scopes and availability of various dilatation techniques now available, are no longer found a necessity except as Nitesh has mentioned, a stone bulging into the lumen of the bladder from the ureter.

  I, personally would have gone for a Open Ureterolithotomy, being an old fashioned Urologist but in such large stones would assess the possibility of this being a secondary calculus.

  With warm regards,

  Venu

• 

  Dr. Anil Takvani

  28 Feb 2020 09:44:52 AM

  @ Venu Sir,

  Sir at least there need be some fusiform shape lower ureteric dilatation  to say these stones secondary. CT do not show any dilatation of ureter.

  I am not saying complete HUN.

  @ Nitesh, No stone bulge is seen as it is higher, at VUJ and not in intravesical portion of ureter. Meatotomy in that situation better to avoid.

  @ Nitesh, what are the possible difficulties or complication you are anticipating?

  In my knowledge these stones are in these position since at least 2 years, as records are available, it may be more. Lower large stone must be impacted and imbedded in mucosa. There will be lots of fibrosis around ureter. Stones are big and hard. Are these factors likely to cause troubles in URS/Open surgery?

• 

  Dr. Isteaq Shameem

  28 Feb 2020 01:22:52 PM

  Dr Isteaq Shameem

  Paradoxically no dilation can be seen even in large stone probably due to non- impaction.Since HU>1500 open ureterolithotomy will be my choice. If lasertripsy then fragmenting is better than dusting as it will require more time and in & out of scope for several times

  Thanks Dr Anil for a wonderful platform

  
  

• 

  Nitesh Jain

  29 Feb 2020 05:23:39 AM

  @anil sir, that the reason I said the stone looks a bit higher, meatotomy may not be possible ... was responding to Pankaj query about any one practising meatotomy 

  
  

  As there is no dilatation I feel it’s a non impacted stone so the fibrosis, getting embedded in mucosa or polyp should not be an issue in this case 

  
  

  Will prefer lithoclast over laser as it will be much faster and the problem of mist  and decrease vision will be least moreover it’s near VUJ chances of migration will be less 

• 

  Dr. Anil Takvani

  29 Feb 2020 03:18:50 PM

  @ Nitesh,

  !. Please review IVU pictures. 15 minutes plate only nephrogram, delayed function. 45/60 minutes plate right HUN....May 2019

  2.If no impaction we have to expect edema distal to stone of such a long duration.

  3.Stone is large 24/25 mm, hard HU>1500

  4. We may comfortably reach the stone and can start breaking the stone with lithoclast, as I agree laser dusting or breaking is not going to work in this stone and also likely to cause injuries to ureteric mucosa..

  5. But after some breaking fragments will start accumulating making further breaking difficult. Because of edema and distance from meatus and in specific VUJ is distal to stone in and out movement of ureteroscope will not help much in evacuating fragments. We have to pick up fragments periodically with forceps to bring into the bladder.

  6. It is almost not possible to fragment stone completely and evacuate in single sitting. Practicing at peripheral center I have done at least these kind of cases in double digits.As Jaydeep has mentioned costs, multiplicity and morbidity of procedure need to be explained. If patient is willing we can go ahead with URS.

  7.. I did open ureterolithotomy in this patient as patient was not willing for costs and multiple procedures.Even open uretrolithotomy is also difficult as there remains lots of periureteric fibrosis and juxta VUJ position makes dissection difficult.

  8.Stent is kept, I believe in keeping catheter for bladder drainage for 5/7 days when I operate Juxta-VUJ stone with open method.

  Thanks

  
  

  
  

• 

  Venugopal P

  01 Mar 2020 10:11:23 AM

   

  Dear All,

  What Anil has mentioned is what we are taught but in practice, many features taught are not available. I mentioned the possibility of not missing a secondary stone in such cases as additional ureteric reimplantation may be required in secondary stone in functionally obstructed large ureter. Such large ureters, if uncomplicated, can be followed up especially in adults. The best way to suspect such an event is by noting the thinness of the lower ureter (Juxtavesical). Passage of a small size catheter may be possible and hence cannot be taken as normal.

  I am happy that Shameem suggested Open Ureterolithotomy and Nitesh went ahead and performed Open Ureterolithotomy.

  The problem of why we insist on endoscopic treatment is because many of our younger generation has not seen the outer surface of the ureter as in open procedure and have very little knowledge of the Anatomy of Ureter as they see the ureter only from within.

  Nitesh rightly informed us regarding excessive periureteric fibrosis and this can at times cause considerable problems at dissection and could cause additional problems at surgery.

  With warm regards,

  Venu

   

• 

  Dr Prashant Mulawkar

  03 Mar 2020 07:25:42 PM

  Large stone, long standing. Oedema has subsided. Whatever urine was forming is coming down by the side of stone >> No hydronephrosis

  You cannot say, no backpressure changes>> function derangement is a post obstructive change

  How do I deal this? (presuming that no active infection). I usually use a double lumen ureteroscope for large calculi and completely dust the stone. With TFL (thulium fibre laser) energy of 0.025jx100Hz, there is hardly any fragment ot be licked up.

  
  

• 

  Dr. Roy Chally

  09 Mar 2020 07:22:45 AM

  Usually endourologists take two sittings to clear these large stones. The kidney has poor function which could mean poor wash out of fragments in ureter. If fragments migrate to kidney more problems. 

  Is the incidence of late onset stricture ureter, high with laser energy?

  Open/ lap / robotic will clear the stones in one sitting. Agree with what was done for the patient. Placing a stent after open ureterolithotomy a surgeons decision. 
  

  Roy Chally

• 

  Lalit Shah

  17 Mar 2020 02:22:26 PM

  For large stone of this size,open ureterolithotomy is not a bad option at all.

  Ureteric meatotomy has no role in instant case, as the stone is high up.

  I would consider endoscopic approach only if stone is soft and friable type( this Stone doesn’t fit in this)

  Stent for 4-6 weeks.

  Have seen many such large stones in various positions in ureter without significant hydronephrosis.(In lighter vein, India being Independent country, stone also is free to choose to produce hydronephrosis or not!)