Unconventional Use of the Lithoclast to Aid in the Treatment of Large Distal Ureteral Stone Burden in a Patient With a Ureterocele

Abstract

Large ureteral stone burden can present significant challenges for the urologist to treat. Here we present the retrograde use of the Lithoclast Select, in a dilated distal ureter after incision of a ureterocele. The patient is a 64 year-old female with large distal ureteral stone burden, with approximately 15 1-2 cm stones. She presented with significant right flank pain, urinary urgency, frequency, dysuria, and recurrent urinary tract infections. A 22-French rigid cystoscope was inserted into the bladder. Urethral outlet was normal. Patient was noted to have 2 right-sided ureteral orifices, consistent with a completely duplex system. At the medial right ureteral orifice a very large ureterocele was noted. The lower pole system was scoped and stone free. The ureter to the upper pole moiety was scoped and a large stone burden within the distal ureter was visualized. The Plasmacise Gyrus was used to incise the anterior part of the ureter by inserting the Plasmacise into the ureteral orifice and tenting it anteriorly. The 24-French nephroscope was then inserted into the distal ureter. Graspers were used to extract many fragments however several were unable to be extracted from the distal ureter due to their size and thus were fragmented and evacuated with the ultrasonic lithoclast within the distal ureter. A 365-µ laser fiber was also used to fragment some of the stones. There were no complications. CT Scan 4 months post operatively was negative for stone recurrence. Last follow up was 15 months postprocedure where the patient was doing well. Utilization of the rigid nephroscope and ultrasonic lithotripter in a female patient with a dilated distal ureter with a capacious or incised ureterocele is safe and effective, allowing for treatment of greater than 15 cm total distal ureteral stone burden.