Left ureteroscopy, laser lithotripsy, and stent placement.

PREOPERATIVE DIAGNOSIS:  Left ureteral stone.

POSTOPERATIVE DIAGNOSIS:  Left ureteral stone.

OPERATION PERFORMED:

Left ureteroscopy, laser lithotripsy, and stent placement.

ANESTHESIA: General by LMA.

INDICATIONS:  The patient is an 80-year-old man with a history of previous kidney stone who presented through the Emergency Room several days ago with left renal colic.  The patient was found to have a 7-mm stone in the mid-to-proximal ureter.  He did well and was sent home, but came back because of constipation and more abdominal pain.  On the recent repeat CT scan, it was found that the stone had migrated in the distal ureter.  The patient was therefore recommended ureteroscopy, laser lithotripsy, and stent placement.  Risks and possible complications were discussed with him in detail including excessive bleeding, infection, retained stone fragment, damage to internal organ etc.  He understood that we would only be treating his ureteral stone, not the renal stone.  He agreed to proceed.

PROCEDURE IN DETAIL:  The patient was taken to the operating room.  He was given 500 mg of IV Levaquin.  He was given a general anesthetic by LMA and positioned on the operating table in the dorsal lithotomy.  His genitalia are prepped and draped in the usual sterile fashion.  The 22-French cystourethroscope was placed through the urethra into the bladder.  The urethra was normal, prostatic urethra was with moderate trilobar hypertrophy and visual obstruction.  The bladder itself was entirely normal and the left ureteral orifice was identified and cannulated with a 0.038 flexible glide wire under direct and fluoroscopic guidance.  No radiopaque stone was seen.  The wire was manipulated past the stone up the left ureter.  Subsequently, the left ureter was passively dilated with the inner sheath of the ureteral access sheath.  Once this was done, a mini ureteroscope was placed alongside the safety wire up the left ureter to the level of the stone.  The stone was identified.  The patient had a large stone in distal ureter.  Using the holmium laser, the stone was pulverized and fragmented in multiple small fragments, which were subsequently pulled using a stone basket.  At the completion of the procedure, the distal third of the ureter was reexamined.  There were no other stones seen.  At this point, a 6 French x 22 cm double-J stent was placed under direct and fluoroscopic guidance up the left ureter and left indwelling.  The patient’s bladder was drained.  He was awakened and taken to the recovery room in stable condition.  There were no complications.  Estimated blood loss was minimal.