A giant ureteric calculus.

Ureteric stones are usually small and symptomatic. We present a case of a 35-year old female who presented with minimally symptomatic right distal ureteric calculus with proximal hydroureteronephrosis. Laparoscopic right ureterolithotomy was performed and a giant ureteric calculus measuring 11 cm Χ 1.5 cm, weighing 40 g was retrieved.

INTRODUCTION

Ureteral stones are usually small in size and, depending on their size, may pass spontaneously. However, stones larger than 1 cm in diameter and more than 0.1 g are less likely to pass spontaneously. An impacted calculus may continue to increase in its longitudinal diameter rather than the transverse diameter after some time and becomes oblong shaped. We report a case of a large ureteric calculus of 11 cm in length and 40 g in weight, which was removed laparoscopically.

CASE REPORT

A 35-year-old lady presented with complaints of episodic pain in the right lumbar region for 1 year. Previously she was treated and the symptom subsided. On evaluation found to have large calculus in the right lower ureter causing severe proximal Hydroureteronephrosis and her physical examination was unremarkable. An X-ray of the kidney-ureter-bladder region showed a long slender calculus in the right lower ureter [Figure 1]. Her renal function was normal. Intravenous urography revealed good excretion of contrast from the left kidney, but no excretion was observed on the right side. Tc99 DTPA renal scan revealed right kidney has less function as compared to the left kidney.

Figure 1

Intravenous urography shows non-excreting right kidney with the normal left side and the right lower ureteric calculus

She underwent laparoscopic right ureterolithotomy with removal of a giant ureteric calculus, 11 cm in longitudinal and 1.5 cm in transverse length [Figure 2]. The stone weighed 40 g. Post-operatively she recovered well and discharged and she remained well in follow-up.

Figure 2

Large ureteral calculus approx. 11 cm length

DISCUSSION

Ureteric stones which exceed 5 cm in size are termed giant ureteric calculi and are rare.[12] The largest calculus so far reported was by Mayer, which measured 11 cm × 5.5 cm × 5 cm and weighted 286 g while the longest stone reported was by Taylor,[3] which was 21.5 cm in length. In India, the largest ureteric stone reported is 13 cm long and weighed 90 g.[4] Laparoscopic ureterolithotomy allows a minimally invasive approach to managing these cases.

Extracorporeal shock wave lithotripsy, ureteroscopic removal and open surgery are the commonly employed modalities of treatment. Recently, laparosopic ureterolithotomy, which is minimally invasive alternative to open surgery, has been described for the treatment of large ureteral stones.[5]

The need for the open surgery for treatment of urinary stones is 2.7%. The main advantages are decreased post-operative pain, shorter hospital stay and quicker convalescence in comparison to open surgery.

It is not essential to reach the distal end of the stone during dissection. A small ureterotomy incision can be placed at the proximal end of the stone, followed by simple manipulation can retrieve the entire stone [Figure 3].

Figure 3

Intraoperative laparoscopic view showing incised right lower ureter with impacted calculus