Successful Management of Complete Ureteral Stenosis Complication following

Ureteroscopic Lithotripsy (URS) using Resection and Ureteroureterostomy

Anastomosis Repair: A Case Report
Ilham Bagas Setyawan1,2, Hermawan Pramudya1,3
1
General Practitioner, dr. Mintohardjo Naval General Hospital, Jakarta, Indonesia
2
Faculty of Medicine, Universitas Padjadjaran
3
Faculty of Medicine, Universitas Indonesia

Introduction

Ureteroscopic lithotripsy (URS) is a procedure done to break up kidney stones with high success
rates and low complication rates. Complete ureteral stenosis following the URS procedure may
present as a late and serious complication that can further lead to hydronephrosis, acute renal
injury, and more severe kidney injury. The specific incidence rate is unknown, but literatures
reported that the incidence rates range between 0,2%-24%. The pathogenesis of ureteral
stenosis is not fully understood. We present a case of complete ureteral stenosis following the
URS procedure that was successfully managed using resection and end-to-end anastomosis
repair.

Case description

A 57-year-old woman was admitted to the ED with the chief complaint of right back pain since
two weeks prior to admission and was diagnosed as hypertensive emergency, acute kidney
injury, and anemia. The patient had URS procedure done two years ago and did not follow up to
the urologist routinely. After the patient was admitted, the patient was consulted to our
urologist and a renal ultrasound was planned. The result of the ultrasound showed moderate
left hydronephrosis, mild right hydronephrosis, and chronic kidney disease. The patient then
underwent a non-contrast urological CT scan and it revealed ureteral stricture. The patient was
re-evaluated using retrograde pyelography (RPG) and it revealed total stenosis of the left ureter
at S1-2 level. Our urologist performed percutaneous nephrostomy and definitive treatment was
taken, which was resection and anastomosis repair with left Double J (DJ) stent insertion.
Discussion

The mechanism of ureteral stenosis following URS is multifactorial and is not fully understood.
The risk factors include: impacted calculi, stone size dan location, intraoperative ureteral injury,
and prolonged inflammatory reaction caused by the stones. Our patient was suspected of
ureteral stenosis and was then evaluated with RPG. The evaluation revealed that the patient
had total left ureteral stenosis as high as S1-2. Our urologist chose percutaneous nephrostomy
followed by resection and end-to-end anastomosis repair with left Double J (DJ) stent insertion
as the definitive treatment. The urologist performed a flank incision and exploration to identify
the location of ureteral stenosis and resected the stenosis. The distal and proximal ureters were
debrided and spatulated, and then left Double J (DJ) stent inserted. Lastly, end-to-end
ureteroureterostomy anastomosis at S1-S2 level was performed.

Conclusion

With recent advances in technology, URS has a good outcome, but late and silent complications
may still occur. There is currently no guideline on the management of ureteral stenosis
following URS procedure. Therefore, treatment decisions are multidisciplinary, involving
patients, families, and teams of doctors. Based on our case, we present that resection and
anastomosis repair is a safe and effective treatment for complete ureteral stenosis following
URS. In this case, the hydronephrosis didn’t recur when the patient was evaluated three
months post-surgery.