Bilateral Flank Pain with Gross Haematuria

30 years male presented with mild pain and gross haematuria.

RFT normal, culture negative
Plain CT kub attached for review.
Please discuss treatment options:
ESWL? Chances of clearance?
RIRS? is there any possibility left lower calyceal stone can not be reached?

Bilateral Flank Pain with Gross Haematuria


  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    19 May 2020 10:38:21 AM

    Sir,site of pain is not mentioned...if it's flank pain with can be assumed that it's upper track pathology...for this ..I would like to do...CECt

    Sir,one more point is I'm concerned about gross hematuria...I would like to do...ct angiography before any intervention..

  • Prabir Basu
    Prabir Basu
    19 May 2020 11:58:33 AM

    True , somehow gross hematuria with bilateral small lower pole stones with negative culture doesn't fit in ! The bladder wall for a 30 yr old gentleman looks a bit more thickened. So , I need a contrast study , preferably a CT IVP to proceed further, to confirm there is no other pathology for the gross hematuria. Another point of focus will be the width of the left sided lower pole infundibulum. Otherwise, the left lower pole calculus has all the favourable characteristics to allow left RIRS. So bilateral RIRS , after a thorough cystoscopy ,will be my provisional approach. I will arrange for a 200 micron fibre to better reach the stones.

  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    20 May 2020 12:47:53 PM

    I agree with Dr Majumdar & Dr Basu

    Difficult to explain gross hematuria based on these calculi.
    Is he a smoker?
    I would surely ask for a CECT.
    My questions are:
    1. Both side calculi are small with favourable anatomy; why not ESWL? In this young patient with small calculi, ESWL should have a good result. 
    2. How much should we rely on the infundibular width seen on plain CT scan? It is a common experience that thin infundibulum seen on imaging may not always be narrow or stenotic. During IVU, we routinely took compression images that are not available with CT. If the patient is not well hydrated or if bladder is not full, the PCS may look collapsed.
    A very interesting recent article by Ralph Clayman group have suggested a 'DRINK' protocol for plain CT. Here each patient is instructed to ingest 1 L of water and 20 mg of oral furosemide 30 to 60 minutes before their scan (DRINK [DiuResIs Enhanced Non-contrast Computed Tomography for Kidney Stones] protocol). This may give better delineation of the PCS anatomy.

    My plan in this patient:
    CECT followed by ESWL.

    20 May 2020 11:02:24 PM

    We will like to know the duration of haematuria and if clots present and the type of clots.  This stone without any evidence of infection and obstruction does not explain gross haematuria. If the CECT is inconclusive then we should do a cystoscopy to rule out any bladder lesion as the cause of gross haematuria before we proceed to definitive management of stone.

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