Ureteroscopy: Background and Current Controversies



(Images of surgical equipment featured in this article are for patient education only. They are not intended for promotional use or a reflection of personal preference. We accept no fees or other benefits from vendors or their agents.)

Evolution of Technique

The fascinating history of urology with its captivating depictions, texts and stories rivals any other field in medicine. In particular, the ancient past of lithotomy (treatment and removal of urinary stones) dates back to Mesopotamia (3200 BC)and descriptions and treatments for urinary stone disease have been identified from ancient cultures including Hindu, Greek, and Egyptian. The treatment of stones, which at the time most commonly occurred in the bladder, was very dangerous, often lethal.  As such, it led to the development of one of the first medical subspecialists, the lithotomist, who opened the urinary tract and removed stones directly. Recognition of this unique set of skills earned a distinction in the Hippocratic oath, still recited by graduating students: “I will not cut for the stone, but will leave this to be done by practitioners of this work…”

Today, “cutting for stone,” otherwise known as open stone surgery, has been replaced by alternative minimally invasive techniques. Critical to this change has been the introduction of the endoscope. Whereas early pioneers such as Howard Kelly (depicted above in the early 1900’s using a wax tipped catheter in the ureter to detect a ureteral stone) relied heavily on intuition, feel, and clinical suspicion, advances in endoscopy have made it possible to inspect all parts of the urinary tract directly.Screen Shot 2016-01-19 at 1.56.38 PM

The particular endoscope that has revolutionized our ability to treat kidney stones in a minimally invasive fashion is the ureteroscope. Incorporation of its use into urologic practice has led to the development of a unique subspecialty, endourology, that focuses on minimally invasive and endoscopic surgical treatments.

Modern Ureteroscopy

A ureteroscope, as its name implies, is an endoscope designed to visualize and work within the ureter. Other scopes commonly used by urologists and endourologists include the cystoscope (used in the bladder) and the nephroscope (used in the kidney).

Although such scopes now enable modern surgical stone treatment, they have only been routinely utilized for the past several decades. Minimally invasive kidney stone treatment began in the mid-1980’s with shock wave lithotripsy and percutaneous nephrolithotomy. Ureteroscopy for treatment of ureteral stones was not performed routinely until then as well, and it was not until the late 1990’s and early 2000’s that ureteroscopes could routinely access and treat stones in the kidney. In the United States we often take such technologies and treatment options for granted, but open stone surgery is still practiced in many parts of the world where modern technology remains limited.

There are two types of ureteroscopes, rigid and flexible. Rigid ureteroscopes, as their name implies, are firm and preferred for treatment of stones lodged in the lower ureter which can usually be accessed in a straight path. When stones are located in the upper ureter and/or kidney, they often require Screen Shot 2016-01-19 at 2.09.57 PM
flexible ureteroscopes that accommodate to the shape of the ureter and renal collecting system (figure on right).  Though more difficult to maneuver, flexible scopes allow the urologist to inspect nearly the entirety of the inner kidney to find stones, treat them, and remove them using a variety of techniques. Innovation this area is brisk and modern digital ureteroscopes offer increasingly superior image quality, lighting and wide fields of view.

Fiberoptic vs. Digital URS

(Figure – Left ) Ureteroscopic image of the renal collecting system using older generation fiberoptic ureteroscope (left) and newer generation digital ureteroscope (right).  Note the superior image quality, increased light intensity and wider field of view.  Panels A and B feature small stones attached to a renal papilla.  Panels C and D feature the endoscopic appearance of Randall’s plaque.


Irrigation and Access Sheaths

In order visualize anything at all, fluid must run continuously through the scope and into the kidney to wash away blood, debris, and crystals that impair visualization. To accomplish this, the fluid (most commonly saline) is hung from a bag and run through tubing directly into the body of the scope where it comes out the tip and into the kidney.

This inflow is harmless, but excess filling of the kidney because of high pressure inflow or an inability of the fluid to freely exit around the scope can overstretch the kidney and cause fluid absorption, leakage, bleeding, and small tears within the kidney itself, a term we call extravasation.

To prevent this, many urologists use a device called a ureteral access sheath. This can be thought of as a temporary tunnel from the bladder to the kidney which allows any fluid that is irrigated into the kidney to quickly wash out around the scope, optimizing visualization and decreasing the likelihood of extravasation. The scope can be passed back and forth without rubbing against and potentially damaging the lining of the ureter, which is generally around the same small diameter as the scope itself. When used appropriately, temporary sheaths are safe and decrease postoperative infections and sepsis. While the majority of urologists routinely use them during ureteroscopy, debate does exist within the community as to whether or not they are required in every case.

Screen Shot 2016-01-20 at 11.41.49 PM(Figure on Left – Boston Scientific Navigator HD TM, Marlborough, MA)

The concern with routine use of a sheath is trauma and injury to the ureter when the sheath is passed. Larger diameter sheaths are preferable for procedures, but the ureter is quite narrow and often will not accommodate a large sheath and sometimes any sheath at all. In such cases, surgeons have several options.  If they deem a sheath necessary, they can place a temporary ureteral stent that lets the ureter passively dilate and facilitate sheath placement at a later time. Alternatively, they can dilate the ureter during the procedure using either balloon or serial dilators in order to get the sheath up.

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(The ureteral access sheath (white arrow) is passed under fluoroscopic guidance over a wire (black arrow) that is positioned from outside the body and extends through the ureter to the kidney.)

Because the ureter is delicate and easily torn and injured when overstretched, there is risk.  In a recent publication by Traxer et al. that describes 359 consecutive cases of ureteroscopy where a ureteral access sheath was used, nearly half (46.5%) of the patients had some degree of ureteral injury. Most injuries were superficial, but severe injuries were found in 13.3%. The main figure (below) from this paper often presented at society meetings, particularly by those who do not favor sheath use.

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While these images raise concerns, there is no evidence to date that when managed properly with placement of a temporary ureteral stent these injuries produce any long term consequence. For example, there is no published evidence of an association between ureteral access sheath use and ureteral stricture. Most studies have shown that intraoperative complication rates during flexible ureteroscopy are no different with or without an access sheath.

Alternatively, urologists have the option of performing ureteroscopy without using a sheath at all.  One advantage of this approach is that the ureteroscopes themselves are thinner than the sheaths and thus more likely to be able to be passed up the naturally thin ureter without trauma or need for dilation.  This approach does have limitations though including poorer visualization, higher potential for excess intrarenal pressure, and a limited ability to make multiple passes back and forth between the kidney and bladder to remove stones.

Lasers and Baskets

Many instruments, all are extremely thin, can be passed through the small working channel that runs from the back of the ureteroscope outside of the body, to the tip of the scope in the kidney. They are used to fragment and remove stones.

Stone retrieval baskets, pictured below, (Cook Medical, Bloomington, IN) are opened and closed by an assistant to ensnare stones and remove them from the kidney. They come in various shapes, sizes and configurations. When stones are roughly 2-4 mm the basket is able to remove them intact.  When stones are larger, they must be fragmented into smaller pieces in order to be removed or pass.

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The most commonly utilized method to fragment stones during ureteroscopy is laser lithotripsy.  Several lasers exist for the purpose but the most popular one by far is the Holmium laser. The Holmium laser can safely fragment any type of stone. The laser delivers short bursts of light energy through water that destroys the stone’s structure by creating a micro explosion of intense heat, pressure, and cavitation bubbles. Because the laser energy penetrates less than half of a millimeter deep it causes minimal damage to surrounding tissues.

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(Dornier Medtech, Friedrichshafen, Germany)

Ureteroscopic Stone Treatment Techniques

As ureteroscopic technology and familiarity with this approach to treat stones continues to grow, the relative number of stones being treated in this fashion has been growing rapidly as well. The latest estimates of surgical practice from the past decade show that ureteroscopy has replaced shock wave lithotripsy as the most commonly performed treatment of kidney stones, accounting for 54% of upper urinary tract stone procedures. Along with the widespread adoption of this procedure, two main techniques have evolved into practice, the optimal one of which remains unclear.

Active Extraction

Active extraction means to remove every piece of stone from the kidney so that at the end of the procedure there are no remaining stones and patients do not pass any stones postoperatively. Critics raise concerns that this technique requires a ureteral access sheath, an assistant to operate the basket, and potentially increases the operating time. A video description of this technique prepared for this article can be seen below.

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Stone Dusting

Stone dusting is conceptually different from active extraction because the goal of the procedure is not to remove all stones directly but rather fragment them into minute pieces (dust) that can then be passed after the procedure, painlessly and without consequence.

Because his technique needs no access sheath, being performed with single pass of the ureteroscope, it benefits patients with narrow ureters.  The surgeon can dust with only a laser and avoid a basket with its cost of disposable equipment and need for a skilled assistant. Here is a video of the procedure prepared by Lumenis Ltd, Israel.

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Which Technique is Best?

Urologists debate whether active extraction or dusting is the better treatment approach, and both sides have their staunch advocates. As is common, the intensity of debate reflects the paucity of studies that compare the two techniques.

Interim results from an ongoing study by the Endourology Disease Group for Excellence (EDGE) comparing dusting to active extraction (table) indicate that dusting is associated with a shorter operative time (40.5 vs. 59.8 min) despite being used to treat larger stones (113 mm2 vs 81mm2).

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On the other hand, a greater percentage of patients treated with a dusting had residual (leftover) stones after the procedure than those treated using active extraction (39.1% vs 11.1%).

These residual stones were not just dust; 44% of the stones were greater than 4 mm.

Despite the higher rate of residual fragments in the dusting group, only one patient in each arm suffered symptoms from a residual fragment at short term follow-up, raising the question of whether or not small residual stones are clinically significant.

But these clinically insignificant residual fragments (CIRFs)’ may not be clinically insignificant.

In one recent study, the EDGE working group found that 44% of 232 patients who had ureteroscopic stone treatment and were found to have residual fragments experienced a “stone event” (defined as a composite of stone growth (at least 1 mm), stone passage, re-intervention or postoperative complications) at mean follow-up of nearly 17 months. Of these 29% required a surgical intervention.

The likelihood of stone events and reintervention were depended on the size of the residual fragment. Among patients with fragments greater than 4mm, reintervention was required 38% of the time and complications related to the fragment occurred 59% of the time. Second surgical procedures occurred sooner in patients treated with a dusting technique compared to those treated with active extraction but the statistical significance of this difference was uncertain.

Portis et al. found that among 218 patients treated with ureteroscopy and active extraction residual stones predicted need for retreatment. At a median follow-up of 4.1 years, patients with residual fragments less than 2mm in size required retreatment 2.4% of the time, compared to 19% among patients with residual fragments 2 to 4 mm in size, and 46% among patients with residual fragment greater than 4mm. Rebuck et al. found a nearly 20% likelihood of retreatment for residual fragments less than 4 mm after ureteroscopy at a mean of 1.6 years.

All in all, both sides in the debate can find reasons for their position. Active extraction leaves behind fewer fragments, but so far in a head to head trial need for less secondary surgery has not been documented. Dusting avoids the cost and complexity of the basket and the sheath, but in the long term may condemn patients to more followup surgery. Time and trial will tell, ultimately.

Follow-Up After Ureteroscopy

Oftentimes urologists will leave a temporary ureteral stent to prevent swelling of the ureter as a result of the procedure. This use of stents is a source of controversy worthy of a future post.

All agree one needs follow-up imaging of the kidneys to tell whether or not stones have been fully removed and whether or not a ureteral stricture (scar) has caused obstruction and  kidney swelling (hydronephrosis), a complication that occurs 1-4% of the time.

Ultrasound Imaging

Ultrasound is relatively inexpensive, requires no radiation, and offers very detailed images of the kidney to determine whether or not there is hydronephrosis. But it is not very accurate at identifying residual stones, particularly small ones. It is also operator dependent and results can vary based upon the experience of the sonographer performing the examination.

KUB X-Rays

Ultrasounds are commonly combined with a kidney x-ray (commonly referred to as a KUB) which is also inexpensive and better at detecting stones with minimal radiation.The majority of published studies to date that have assessed stone free rate after ureterscopy have used KUB/US to determine the presence of residual fragments. Stone free rates using this imaging endpoint are commonly found to be in the mid 80-90%; even for large stones greater than 2 cm in size.  

CT Scans

CT scans are the best test to identify stones, but are more expensive and are associated with higher degrees of radiation. Those studies that have used postoperative CT scans to identify residual stones demonstrate much lower stone free rates, commonly in the range of 50%.  Interestingly the difference appears to be in the small stones <4 mm more likely to be seen on CT scan over KUB/US. If these stones are not taken into consideration, CT scan follow-up would otherwise be on par with that reported in the KUB/US series.

Although the question of whether KUB/US or CT is a better follow-up test is an important one, the more important question is whether or not routine imaging is being performed after the procedure at all. Despite recommendations by the American Urological Association that all patients should undergo at least a minimum of an ultrasound after ureteroscopy (see figure below) ,a recent study from the Cleveland Clinic found that fewer than half of all urologists routinely obtain any postoperative imaging whatsoever.

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Take Away Messages

The goal of ureteroscopy should be to render the patient stone free 

Regardless of the technique used, the ultimate goal of the procedure should be to leave the patient with no stones. Residual fragments are likely sources of future stone events. Therefore removing all stones should improve long term outcomes.

Urologists should be familiar with all ureteroscopic treatment techniques

Results of studies such as the EDGE group comparing dusting and extraction will determine the gold standard ureteroscopic treatment technique. In all likelihood though, we will come to realize that ureteral anatomy, width, and ability to pass an access sheath as well as the stone themselves will mandate one technique over another for any one patient.

Soft stones, for example, are more likely to fragment to true dust and thus may be more amenable to dusting. Harder stones are more likely to fragment into large pieces and thus benefit from active removal. Infection mandates complete stone removal, potentially harder to achieve with dusting. Alternatively dusting does not require an assistant and thus may be the only feasible option in instances where extra help is not available.

The ureteroscopy should not be the end of the story

Nephrolithiasis often manifests as an acute event ending in ureteroscopy; however, it is increasingly recognized as a chronic condition. As such, it is critical that surgery to remove the stone is not the end of the relationship with the patient.

Residual stones commonly lead to clinical events greater than one year from the time of the initial procedure including growth, passage, and need for retreatment.

Stone disease is chronic and recurrent, and the least desired outcome is formation of new stones after stones have been removed. As many as 50% of first time stone formers will recur within 10 years highlighting the significance and potential benefits to dietary counseling, metabolic testing, surveillance imaging, and other practices to prevent and detect stones over the long-run.

The main thrust of this entire site is toward prevention, before surgery is ever needed and with especial need after a successful surgery so that another need never be performed.

91 Responses to “Ureteroscopy: Background and Current Controversies”

  1. Maegan

    Hello Dr. Coe,
    I am having almost the same problem as Marissa, but for some reason, I am unable to read your response. I went to the ER on February 28 knowing I had a kidney stone. I saw a urologist the next day who scheduled me for a ureteroscopy the following day. I’ve constantly had pain in my right kidney down to my bladder since surgery. I had to make another trip to the ER because the pain was so bad Sunday night. I also still have a lot of blood in my urine. My follow-up appointment was supposed to be for four weeks but now the earliest I can be seen is Wednesday. Any idea what may be causing the pain? Should I still have a lot of blood in my urine? Any suggestions to help deal with this pain?

    • Fredric Coe, MD

      Hi Maegan, If you have pain like this your physician needs to figure out why and fix the problem. It could be retained fragments, as an example. So the appointment is the right idea, as soon as possible. The blood and pain together would be common with fragments of stones. Regards, Fred Coe

  2. Elan

    Hello Dr. Coe,
    I had lithrotripsy for a 5 mm stone Jan 14,2018. Four days later, I reverted to feeling as sick as I was prior to the procedure. I felt that a stone was travelling and then became stuck. My Dr did kub post of 1 week later,and due to MSK he dismissed my condition by telling me I would always have stones. I switched Drs,had a CAT done with findings of another stone in same side at 6mm. Dr wants to do ureteroscopy despite not able to clearly know it’s location in the kidney,if he can get to it or if it’s in the meat of the kidney. I was asymptomatic,and decided to wait. Now I feel that a stone is stuck close to bladder as my labia hurts,pressure,and urgency. When I turn or move gently,I feel a pinch on the treated side near the bladder. No ureteral stones were seen on CT. Could it be a fragment trapped in the juncture? If small,could it be missed on CT? Is ureteroscopy the only way to know?

    • Fredric Coe, MD

      Hi Elan, indeed it could be where you say. The choice of approach is for your surgeon but I imagine he/she will want to do ureteroscopy. Given your many stones, be sure and achieve prevention. Try starting here, as you made no mention of it. Regards, Fred Coe

      • Elan

        Thank you Dr. Coe,
        Yes, I have finally found a Dr that has put me on a stone prevention plan. It has taken 13 years, and for the first time I am feeling hopeful that it is possible. I have taken Jill Harris’s class which was most helpful. As I am a calcium oxalate stone factory from MSK and a pre diabetic, I felt challenged with meal planning. A dietician consult was very helpful with that. Most helpful has been the addition of a nephrologists who is very enthusiastic about stone prevention. He has put me on a low oxalate diet, continued the thiazide,added allapurinol,continued lemon juice in water, and added 325 mg ferrous sulfate at each meal.we will repeat 24 hour urine in 1 month after implementation of these changes. My last collection was : urine volume 2.47 , SS CaOx 10.98 urine calcium 296 urine oxalate 49 urine citrate 538, SS CaP 1.74 , pH 6.266, SS uric acid .53 urine uric acid .856. I do realize now that I’ve been eating all wrong , lots of whole grains and green high oxalate veggies though I was told a few years ago not to eat spinach,rhubarb,and watch sodium. My dietary sodium is good. What would be the reason for the ferrous sulfate other than I have cut my protein down to 5 1/2 oz daily? I understand that the ferrous sulfate helps prevent anemia.

        • Fredric Coe, MD

          Hi Elan, low oxalate diet is always a secondary thing – calcium is the first. Low protein diet is not important, the article is not quite ready but recent excellent research has greatly reduced interest in it. Your urine calcium is quite high and you are taking thiazide, so I suspect your urine sodium is far above ideal of below 100 mEq or better below 65 mEq. As for the iron, I do not know your details, you may have modest anemia or another sign of iron deficiency. Regards, Fred Coe

  3. Sarah Lutz

    I’m a 42 yr. old female. On December 7th, 2017, I had acute abdominal pain which sent me to the doctor on December 8th. The doctor could not figure out what was causing the pain, so I was wheeled down to the ER. In the ER they did an x-ray, and discovered that I had a “complete” Staghorn Calculus in my left kidney. I also had a UTI, of which I had no symptoms previously (which they told me is odd, considering the stone is typically formed by re-occurring UTI’s). I had an abundance of abdominal pain that didn’t make sense, so they did a CT scan as well. I had some ureteral swelling, but nothing else was abnormal. I had no flank pain at the time. I was observed overnight because of the inability to control the pain, and then discharged the following day. A couple days later, I started getting flank pain, and the abdominal pain lessened, other than in the area on front side of my kidney. A subcostal left percutaneous nephrolithotomy was performed on December 28th. The surgery was challenging as my urologist had to enter from the bottom of the kidney because it was impacted and he was unable to get in from the top where he initially made an incision. I knew prior to the surgery that he would most likely need to do a follow up surgery. A post op x-ray, which they did because they made an incision above my lowest rib, showed mild atelectasis in both lobes. I ended up getting a post op infection, was discharged prematurely (after a 4 day stay rather than the 1 day expected), ended up back in the ER the following day with pneumonia. I saw my urologist, had my stent removed, and a follow up surgery was scheduled for February 1, 2018. A urethoscopy with laser lithotripsy was performed on an outpatient basis and I was sent home with a self removable stent, to be taken out on February 5th. Recovery was going as planned, however the stent was much more painful this go around. The stent was removed without any problems, I had quite a bit of pain and cramping for the day that I took pain meds for. That night at 11pm I started getting the chills, took some ibuprofen and went to bed. The following morning I ended up going by ambulance to the ER because my fever was 103.1, I had altered vision, was shaking all over, whole body ached, and I was extremely nauseated. Sat in the ER waiting room for 7 hours (that’s a whole other story), and when I was finally seen I was diagnosed with pyelonephritis and sepsis and was hospitalized for 2 nights (pretty much 3 full days). I was extremely sick. While I was in the ER they did a CT, and is showed residual stone fragments. I was told I would need surgery again, but not immediately as they were not blocking anything. After talking with my urologist, he wants to take a wait and see approach because he says that sometimes the fragments appear bigger than they actually are on a CT because they like to clump together. He is hoping they will pass on their own. He is going to run a complete metabolic test, do ultrasounds, etc for the time being. This whole situation has been one disaster after another. When I left the hospital my symptoms had all subsided, but now the left flank pain is back, along with the nausea and now I’m having chest pain on the left side (which I’ve never had in my entire life). I do have some atelectasis still in my left lung, though it has improved. An ekg and chest x-ray came back normal other than the atelectasis. No fluid around my heart. The chest pain doesn’t correlate with breathing, so we’re not sure what’s causing it. Having surgery again is the last thing I want to do, however I’m concerned that my symptoms are back. What is your opinion of this treatment plan? My doctor is a well regarded stone surgeon and affiliated with a highly respected university hospital.

    • Fredric Coe, MD

      Hi Sarah, you did not say but implied the stone was struvite – made by infection, and your story suggests recurring infection. From this distance I can form no opinion about your proper surgical course as I have not read your CT scans, and know essentially nothing about your situation. If you have surgery no doubt it will be ureteroscopic stone removal. There is a risk of sepsis but given the excellence of your physician and the institution I am sure they can minimize that risk. An alternative is to consult at another center simply to obtain perspective before another surgery. No doubt your physicians will be delighted to help as all university physicians are when so asked and usually make proper referrals to peers. Regards, Fred Coe

  4. Darla Perkins

    Dr. Coe: My daughter, 46, had a kidney stone removed which resulted in damage to the ureter. The Dr. told her about it, apologized, said there could be future complications but suggested nothing further. She HAS had to have several surgeries, the latest taking cheek skin from the inside of her mouth and sewing it on the ureter after laying it open. She was told today that this has also failed and her options would be to POSSIBLY move the kidney or REMOVE the kidney. We need VERY expert advice and information and don’t know where to go or how to go about it. We are in NM but will travel. She is scheduled for March 6th so we have no time to waste. Where would you go for help?

    • Fredric Coe, MD

      Hi Darla, The best surgeon I know for this is Dr James Lingeman at Indiana University in Indianapolis. Call him and see if he can fix it. Please use my name as we are friends and colleagues. We must not lose a kidney. Let me know by email if necessary, Regards, Fred Coe

  5. Stone Patient

    Fantastic Site.

    I’d appreciate your input.

    I was recently diagnosed with a kidney stone; fully obstructing the left kidney; it took 6 months from diagnosis to operation (uteroscopy) (UK NHS) and post op, a stent was inserted for a week after.

    Everything appeared fine, but, a month later, back and abdominal pain (akin to the start of a kidney stone episode), bearable, but, always there. Appears to be compounded by weigh bearing (e.g. walking, standing, etc).
    Are there long term effects from such procedures?
    Clinical team have suggested that kidney function test is pointless, as, what can you do if you find they are not working well…..

    • Fredric Coe, MD

      Hi Brian, I am sorry it took 6 months to cure an obstructing stone. Does that kidney still function? Usually one acts much more rapidly. As for this new pain, it could be just muscular, but given all of what has happened I would advise your physicians might want to do another CT scan and be sure about that kidney. Is it draining? Infected? As for kidney function, I am sure they measure overall function and it is adequate, and reading between the lines I suspect the obstructed kidney may not be so good. Regards, Fred Coe

      • Marissa

        I’m 27 and I had my first kidney stone over the holidays. For the month of December I had lower back pain on my right side, which I ignored until the pain took a very sharp turn that sent me to the emergency room while on vacation. I was diagnosed with a stone, it was surgically removed, and a stent was put in place for about a week. After the stent was removed everything seemed fine; however, the backache that accompanied the earlier stages of my stone resumed a day or two after stent removal. It has now been a couple weeks and the pain is still there – somewhat similar to what the above poster expressed – bearable, but constant. I was very paranoid that I had another stone, the pain was just so similar to those early weeks (before it morphed into the hell that directly preceded my surgery). I’ve seen a urologist for followup and he ordered a CT scan that came back totally normal. I suppose my question is… could this possibly be just residual soreness/pain from the procedure and stent even after a month? My doctor doesn’t think so and at this point we are both at a loss.
        P.S. Thank you so much for this site, it has helped assuage some of my worry. My mom has had an absurd number of stones (like, 30) and I am anxious I will be burdened in a similar fashion.

        • Fredric Coe, MD

          Hi Marissa, Given the family history and yours, I would worry about crystal attacks- pain but nothing seen. You need 24 hour urine and serum measurements, and stone analysis to know exactly what is wrong with you and fashion rational prevention. Here is a good article to help with that. If it is crystals, proper treatment will end them. Regards, Fred Coe

  6. John Hughes

    Dear Dr. Coe,
    As a result of an incident where a significant amount of blood was discovered in my urine (witnessed by me 5am in the morning – about 1pm in the afternoon of the same day when I would urinate) my urologist has recommended a Ureteroscopy be done to more fully reveal an abnormality discovered in a CT scan for my left kidney. After her and two radiologists looked at the scan, it was difficult for them to determine if the abnormality they saw in the scan was simply a cyst or possibly a tumor. For background, in reaching this point, so far I have given urine (normal), a blood panel was done (normal) a CT scan of my bladder, urethra & kidneys (all clear except what I mentioned above) and today a cystoscopy (done today.. all clear). Though I have no detection of kidney stones, does the ureteroscopy seem like a reasonable procedure to have done to help reveal a partial unknown seen in the CT scan of my left kidney? BTW, the visible blood in my urine has not returned except for that one day (about a month ago). About 6 hours prior to the blood being visible, I had exerted myself jogging… not far.. just enough to be winded. Thanks – John H.

    • Fredric Coe, MD

      Hi John, Given unexplained bleeding, URS seems reasonable to look for a cause along the ureter or in the renal pelvis. Your physicians seem eminently reasonable and cautious about an important matter. I would do as they recommend. Regards, Fred Coe

  7. Sherman Hsu

    Hi Dr. Coe
    I’m 53 yo male. Diagnosis showed there’re 3 stones in the right kidney(no symptoms but some blood traces in urine lead to the finding). My Urologist recommended SWL first and performed it on Jan. 2017(maximum force , 1 hr duration) but showed no impact. Prior to this procedure, creatinine is 0.88, eGFAR is 108. Than he recommended Laser lithotripsy and performed on Feb. ( I think he’s using dusting method, it lasted about one hr from the x-ray time stamp). He’s not able to get all stones and some stones moved after break up that he’s not able to catch. Stent being left for 5 days and removed. No follow up image being performed and he refer me to see his colleague who is more stone specialized. 6 weeks after the procedure, my family doctor ordered lab report and showed that the creatinine is 1.48, eGFAR is 55. Further ultra sound showed severe hydronephrosis. ( I felt few times the lower right flank pressure/pain for 2-3 days after the stent removed , the Dr. office stated it’s normal and advised to take Motrin). The colleague Dr. not able to get trough the ureter due to the blockage( he’s not sure it’s stone or scar tissue). He referred me to see local medical school faculty and identified cluster of stones fragments embedded in the ureter and UPJ area. Nuclear image showed 20%/80% split function. I like to know your opinion about how is this possible happened ? Have you seen a clinical case like this ? Thanks. -Sherman

    • Fredric Coe, MD

      Hi Sherman, Of course we all have seen obstruction from stones lead to loss of function of the obstructed kidney and therefore reduced total kidney function. I am sure the university urologists will clear up the obstruction as soon as possible in hopes of preserving that kidney. Unfortunately given what appears to be an interval of many weeks of obstruction that kidney may not regain its original function. Let’s hope for the best possible outcome. Regards, Fred Coe

      • Sherman Hsu

        Hi Dr. Coe
        Thanks for the prompt reply. As you indicated that the university faculty urologist remove a lot of stone fragments from the ureter through PCN back in June. The function stay as it is now from nuclear image and keep monitoring it. The question is how’s that possible of a common laser lithotripsy turned into fragments embedded in the ureter and cluster on UPJ ? If I had known the risk, I’d either go for PCN or leave as it is. Neither able to google out a case like this.
        From the laser lithotripsy to the nuclear image function check is about 14 weeks. Can the kidney function really degrade that much from the obstruction? Odd is that I did not have symptom. If not because of a regular annual physical lab checkup, worse even could happen. Thanks.


        • Fredric Coe, MD

          Hi SHerman, Sometimes fragments occlude the ureter without pain and kidneys are obstructed and lost. You were lucky your physicians found it. Regards, Fred Coe

  8. Charles mozingo

    Five years ago I had lipotripsy which did not break stone small enough to pass. As a result, my urologist had to do uretoscpy surgery, seven times in seven month to retrieve them.
    I now have been informed that that kidney has atropic iced and shrunk in size to the size of
    Of a bean. I am now being told I have stage 3 kidney disease. Do you think all those Ureterscopt surgeries back to back have caused this.

    • Fredric Coe, MD

      Hi Charles, I cannot make any judgement of this without reviewing all of the images and operative reports – that is not possible outside the purview of actual clinical care. But I can say that having one kidney greatly increases the importance of stone prevention, so I would pursue it with vigor. Here is my best suggestions. Regards, Fred Coe


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