V6-08: Simultaneous Robotic Pyelolithotomy, Ureterolithotomy, and Vesicolithotomy for a Severely Encrusted Retained Ureteral Stent
Retained ureteral stents can be prone to encrustation and in extreme cases can form large renal, ureteral and bladder calculi. These are challenging to manage endoscopically and often require several treatments and multiple anesthetic sessions. There is no consensus on the best way to approach this complex problem. Here we present an interesting case of a right ureteral stent that was retained for seven years with subsequent right renal calculi, ureteric calculi and large bladder calculus and describe our experience with simultaneous pyelolithotomy, ureterolithotomy, and vesicolithotomy in order to treat the stone burden in a single session.
A 28 year old male presented from an outside hospital with an elevated creatinine of 2.4 and leukocytosis of 26,000/µL. A non-contrast CT of the abdomen and pelvis was obtained revealing a retained right ureteral stent significant for a 1.7 cm calculus and 6 mm calculus in the right renal pelvis, multiple large stones filling and distending the ureter, the largest 4.8 cm long, and a 5 cm calculus at the distal portion of the stent in the bladder. Due to the large stone burden and the lack of follow up, the patient decided to undergo simultaneous robotic pyelolithotomy, ureterolithotomy, and vesicolithotomy. Our technique is unique because we attempted stone removal in a single session rather than undergoing multiple percutaneous and endoscopic techniques. We were also able to utilize our third robotic arm to aid in exposure for our various dissections.
Operative time was 441 minutes. Estimated blood loss was 100 cc. There were no immediate post-op complications. The patient was discharged home on hospital day 3. Creatinine nadired at 1.3. Pathologic analysis of the stone showed 45% calcium phosphate, 55% struvite mixed with other stone types. Stone culture was significant for methicillin resistant staphylococcus aureus. The patient did not return until 3 months after surgery for retrograde pyelogram and stent removal. We have planned for metabolic evaluation and 24 hour urine collection.
Simultaneous robotic pyelolithotomy, ureterolithotomy, and vesicolithotomy for retained ureteral stent with a significant stone burden is an effective and reasonable approach to treat patients presenting with a large stone burden that would otherwise require multiple percutaneous and endoscopic procedures.