Ureteroscopy and Laser Lithotripsy for Ureteral and Renal Stones in a Patient with a Nephrostomy Tube

Ureteroscopy is a minimally invasive surgical procedure used for the diagnosis and treatment of ureteral and renal pathology, most often urolithiasis. The presence of a percutaneous nephrostomy tube, commonly placed for urgent decompression of an obstructed kidney, often in obstructing stone disease, introduces unique perioperative considerations. Indications for ureteroscopy in this setting involve persistent obstruction with failure of spontaneous stone passage when percutaneous nephrolithotomy is not indicated. Surgical treatment aims to remove obstructing calculi, restore antegrade urinary drainage, and prevent long-term complications such as decline of renal function. Ureteroscopy involves cystoscopic access, ureteroscopic stone fragmentation, and extraction. When coupled with antegrade access as provided by a nephrostomy tract, it enables combined antegrade and retrograde (“rendezvous”) approaches. In this video, we present a case of a patient with a left-sided distal ureteral stone, nonobstructing renal stones, and an indwelling nephrostomy tube who underwent definitive management with ureteroscopy and laser lithotripsy.

Ureteroscopy; nephrostomy tube; ureteral calculi; endourology.

Urolithiasis is a common condition worldwide, with lifetime prevalence estimated at approximately 11%.¹ Ureteroscopy is one of the mainstay treatments for symptomatic or obstructing stones, with stone-free rates typically exceeding 85% depending on stone size and location.² Placement of a percutaneous nephrostomy tube is often required as an urgent temporizing measure in patients with obstructing calculi complicated by infection or sepsis.³ Following stabilization, these patients frequently require definitive treatment of the obstructing stone. The presence of a nephrostomy tube does not contraindicate ureteroscopy, and in some instances, combined antegrade and retrograde techniques can facilitate stone removal.⁴

The patient is a 28-year-old female with a history of UTI and recurrent nephrolithiasis.  She had prior right-sided ureteroscopy for stone disease two months prior to presentation and was known to tolerate indwelling ureteral stents poorly. She presented with a new obstructing 6-mm left-sided ureteral stone with moderate hydronephrosis. There was no acute kidney injury, no leukocytosis, and her urinalysis was not concerning for infection. The indication for renal decompression was intractable pain even with significant amounts of narcotics. She elected for left nephrostomy tube placement due to inability to tolerate indwelling ureteral stents for a prolonged period of time. She was scheduled for outpatient ureteroscopy for definitive stone management after failure of passage of her left obstructing ureteral stone and non-obstructing stones.

At the time of outpatient evaluation, the patient was afebrile, hemodynamically stable, and in no acute distress. The abdomen was soft and non-tender. The left nephrostomy tube was in situ, draining clear yellow urine. There was no costovertebral angle tenderness or suprapubic pain.

Non-contrast CT abdomen pelvis showed 6-mm distal obstructing stone with moderate upstream hydronephrosis and fat stranding on the left side. Additionally, there were numerous non-obstructing renal stones on the left side measuring up to 6 mm.

In conservatively managed patients, ureteral stones less than 6 mm have around a 50–68% of spontaneous passage. The likelihood of passage depends upon location within the ureter as well as the time allowed for passage, up to four weeks. Spontaneous passage is unlikely for ureteral stones greater than 10 mm in size, particularly in the proximal ureter.⁵ Obstructing ureteral calculi can cause progressive hydronephrosis, recurrent urinary tract infection, sepsis, and eventual permanent loss of renal function.⁶ While decompression relieves obstruction and reduces infection risk, the underlying stone must be definitively treated to allow for natural antegrade urinary flow.

Management options for this patient included:

• Ureteroscopy with holmium laser lithotripsy: minimally invasive, high success rates, appropriate for proximal stones < 2 cm.
• Percutaneous nephrolithotomy (PCNL): usually reserved for larger stone burdens (> 2 cm) or complex renal stones.⁷
• Given the stone size and location, ureteroscopy offered the least invasive and most effective approach.

The patient’s 6-mm distal ureteral stone was unlikely to pass spontaneously as the patient had already been observed for several weeks and failed conservative therapy previously. Definitive removal was essential. Ureteroscopy with laser lithotripsy was selected because it offered a minimally-invasive, outpatient approach with a high likelihood of complete stone clearance. A ureteral access sheath was not used as she had a known distal ureteral stone and a semirigid ureteroscope was used to laser lithotripsy this stone. After this, the decision was made to pass a flexible ureteroscope to address the nonobstructing renal stones as she had a pre-existing nephrostomy tube.

Ureteroscopy has become the most performed endourologic procedure for ureteral calculi, with high efficacy and safety profiles.^2,7 In patients with indwelling nephrostomy tubes, ureteroscopy remains feasible and effective. Some urologists utilize a combined antegrade and retrograde (“rendezvous”) technique, particularly for impacted proximal stones or complex anatomy.⁴ In our case, standard retrograde ureteroscopy was sufficient.

The patient underwent cystoscopy, retrograde access to the left ureter, flexible ureteroscopy, and holmium:YAG laser lithotripsy. The stone was fragmented into small dust-sized pieces. Pan ureteroscopy and antegrade and retrograde ureterograms showed no injury to the ureter. A double-J ureteral stent was placed to ensure ureteral patency and prevent obstruction from residual fragments or edema. This was attached with a string to an 18-Fr Foley catheter, to be removed one week postoperatively at home by the patient. The nephrostomy tube was able to be removed at the time of the procedure due to evidence of complete stone treatment during the case.

Intraoperative complications of ureteroscopy can include ureteral wall injury, false passage, or perforation. Postoperative complications include hematuria, infection/sepsis, stent-related symptoms and stricture.⁸ In this case, no complications occurred. The patient was discharged home the next day due to prior difficulties with pain control. Patient has not followed-up and has had issues with compliance with scheduled follow-ups historically, though she has not represented up to 7 months later within our hospital system for symptoms related to renal colic or nephrolithiasis.

• Rigid cystoscope.
• Semirigid and flexible ureteroscopes.
• Holmium:YAG laser system.
• Sensor Nitinol Guidewire with Hydrophilic Tip (Boston Scientific).
• Single Action Pumping System (Boston Scientific).
• 6-Fr by 26-cm double-J ureteral stent.

Nothing to disclose.

The patient referred to in this video article has given her informed consent to be filmed and is aware that information and images will be published online.