PMC7399460_01
CT scan showed right complete staghorn stone with left proximal ureteral stone.
RRU-12-287-g0002.jpg
PMC7399460_01_RRU-12-287-g0002.jpg
F0001
Noncontrast computerized tomography (CT) scan revealed right complete staghorn stone sized 46x30x24 mm (stone burden: 50,985 mm3 with sphere formula) with grade II hydronephrosis and left proximal ureteral stone sized 31x16x13 mm with grade IV hydronephrosis (Figure 1).
Coronal (A) and sagittal (B) plane view of the right ureter reconstruction showed no ureteric stone, kinking, or stenosis.
RRU-12-287-g0003.jpg
PMC7399460_01_RRU-12-287-g0003.jpg
F0002
We made sure that there was no ureteric stone, kinking, or stenosis in the right side (Figure 2).
The patient was placed in modified-lithotomy position. The left leg was in lithotomy position, while the right leg was abducted as laterally as possible.
RRU-12-287-g0004.jpg
PMC7399460_01_RRU-12-287-g0004.jpg
F0003
The patient was placed in a modified-lithotomy position with maximal abduction of the right leg (Figure 3).
(A) Appearance of ureteral catheter (arrow) in collecting system during insertion; (B) Water jet appearance (arrow) when normal saline was flushed from the ureteral catheter.
RRU-12-287-g0005.jpg
PMC7399460_01_RRU-12-287-g0005.jpg
F0004
First, appearance of ureteral catheter in ultrasound images during insertion (Figure 4A). Third, there was water-jet appearance on the ultrasound when normal saline was flushed from the ureteral catheter (Figure 4B).
During puncture and stone fragmentation, the right leg was returned to the center to avoid disturbance of puncture site and limitation of nephroscope movement.
RRU-12-287-g0006.jpg
PMC7399460_01_RRU-12-287-g0006.jpg
F0005
After the cystoscopy procedure, the right leg was moved back medially to avoid disturbance of puncture site and limitation of nephroscope movement (Figure 5).
Ultrasound showed the tip of puncture needle (arrow) had reached the target calyx.
RRU-12-287-g0007.jpg
PMC7399460_01_RRU-12-287-g0007.jpg
F0006
Some adjustments of the needle were performed to identify the needle tip eventually reaching the intended calyx (Figure 6).
Irrigation solution that were pumped via the ureteral catheter increased the collecting system visualization and prevented stone fragments migration.
RRU-12-287-g0008.jpg
PMC7399460_01_RRU-12-287-g0008.jpg
F0007
Normal saline that wsa pumped from the ureteral catheter prevented the migration of stone fragments into the ureter and increased the collecting system visualization (Figure 7).
The stone was visualized with 30 Fr rigid nephroscope (A) and fragmented with combination of pneumatic and shock pulse lithotripters (B). There was no residual stone after the PCNL procedure (C).
RRU-12-287-g0009.jpg
PMC7399460_01_RRU-12-287-g0009.jpg
F0008
During this procedure, there was no residual stone, confirmed with both ultrasound and nephroscope (Figure 8).
(A) Evacuated stone fragments during the procedure; (B) Postoperative KUB photo showed no residual stone in the right kidney with correctly positioned DJ stent.
RRU-12-287-g0010.jpg
PMC7399460_01_RRU-12-287-g0010.jpg
F0009
Evacuated stone fragments were shown in Figure 9A. Postoperative kidney ureter bladder (KUB) photo showed no residual stone on the right kidney (Figure 9B).