PMC9562977_01
Portal phase of the computed tomography (CT) of the abdomen and pelvis with IV contrast injection showing a proximal ureteral and calyceal dilatation, a lower calyceal stone and a tapering of the right ureter (arrows). (A) Coronal view. (B) Axial view.
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The patient had continuous unrelenting right flank pain with a subsequent abdominopelvic ultrasound and CT scan showing the evidence of a residual 17 mm by 26 mm staghorn calculus with an average density of 470 HU residing in the inferior calyceal system, associated with a proximal ureteral and calyceal dilatation (Figure 1), nevertheless without any evidence of ureteral stone or stenosis.
X-ray fluoroscopique image (A) and schema (B) of the stenotic ureter.
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The length of the non-opacified zone and therefore of the stenosis was estimated to be of 2 cm (Figure 2).
The stenotic lesion as seen by the antegrade flexible ureteroscope.
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Using a disposable flexible ureteroscope for antegrade ureteroscopy, a pinhole lesion was observed and was considered as the stenotic lesion (Figure 3).
Ho: YAG laser incision of the stenotic lesion using the antegrade ureteroscope.
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With the aid of a 365-microm Ho: YAG laser (settings 0.4 J, 12 Hz), we managed to successfully create a small incision in the stenotic lesion (Figure 4).
Guidewire was passed from antegrade ureteroscopy (A and B). Illumination of the obstruction by the retrograde approach (C).
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A Terumo guidewire was then passed through this incision down to the bladder and retrieved through the urethral orifice as a through-and-through guidewire as such securing the ureter (Figure 5A and B). At this time, the rigid ureterscopy light was clearly seen by the antegrade flexible ureteroscope (Figure 5C).
Stenotic area post laser endoureterotomy and ureteral dilatation.
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In order to insert a retrograde 10/12 Fr ureteral access sheath, we dilated the ureter progressively with ureteral catheters of 7, 8 and 9 Fr and then we progressed with a full thickness incision beside the guidewire and under observation by the retrograde ureteroscope to ensure an efficient incision (Figure 6).