Challenging Ureteroscopy in Complex Anatomy: A Case Report

Ureteroscopy is a well-established minimally invasive modality for the management of ureteric calculi; however, technical difficulty may arise in the presence of impacted stones and distorted urinary tract anatomy. We present a case of challenging ureteroscopic lithotripsy in a 24-year-old man with a symptomatic impacted distal ureteric calculus measuring approximately 9 × 8 × 10 mm, associated with hydroureteronephrosis and markedly altered pelvic orientation due to kyphoscoliosis. The patient also had underlying metabolic bone disease with renal osteodystrophy, which further complicated perioperative positioning and anesthetic management. Preoperative imaging demonstrated distorted pelvic anatomy, an abnormal ureteral course, and a high-density distal ureteric stone. During surgery, spinal deformity and pelvic tilt created a highly angulated ureteral path, reducing ureteroscopic maneuverability and increasing resistance to advancement. The stone was fragmented using a combined pneumatic and laser lithotripsy approach, and a double-J ureteral stent was placed to facilitate drainage and ureteral healing. The postoperative course was uneventful, with complete stone clearance and preservation of renal function. This case highlights the importance of recognizing anatomical distortion, skeletal comorbidity, and stone-related factors as causes of difficult ureteroscopy and underscores the value of careful preoperative imaging, individualized planning, and intraoperative adaptability in complex endourological cases.