Combining Retroperitoneal Laparoscopic Ureterolithotomy and Flexible Ureteroscopy for Effective Removal of a Large Ureteral Stone: A Case Report

BACKGROUND Large ureteral stones (LUSs) pose significant health risks, including chronic obstruction and renal impairment. Timely intervention is critical to preserve kidney function. While the optimal treatment for LUS is debated, retroperitoneal laparoscopic ureterolithotomy (RLU) is often preferred over percutaneous nephrolithotomy (PCNL), ureteroscopy, or extracorporeal shockwave lithotripsy due to its effectiveness. Combining RLU with antegrade flexible ureteroscopy (aFURS) can enhance stone clearance rates, addressing the challenges of intrarenal access and guidewire passage. CASE REPORT We report the case of a 65-year-old woman with a large proximal left ureteral stone (15×15×42 mm), renal atrophy, and severe hydronephrosis, presenting with persistent lumbar pain and intermittent hematuria. An urgent percutaneous nephrostomy (PCN) improved her renal function, yet left renal GFR was low at 10.62 ml/min. Forty-seven days post-PCN, she underwent a combined procedure of RPLU and aFURS through the PCN tract. This approach ensured complete stone removal while minimizing ureteral trauma. The stone was successfully fragmented and removed, followed by antegrade double-J stenting. The patient experienced an uneventful recovery and was symptom-free at the 3-month follow-up. Imaging confirmed the absence of residual stones and strictures. CONCLUSIONS This case underscores the effectiveness and safety of combining RPLU and aFURS for large ureteral stone removal in a single session. It highlights the importance of a multidisciplinary approach and surgical expertise in managing complex stone cases, offering insights into optimizing patient outcomes and minimizing complications.