Bilateral ureteric calculi

   September 7, 2020  Posted in Genitourinary system

Case contribution: Dr Radhiana Hassan

Clinical:

  • A 70 years old man
  • Underlying DM, HPT and Gout
  • CKD for last 3 years, not on dialysis
  • Presented with lumbar pain and hematuria
Ultrasound KUB

Ultrasound findings:

  • Right kidney is larger than the left side. Bipolar length: Right: 11.4cm, Left: 8.7cm.
  • Gross hydronephrosis of right kidney. No calculus seen.
  • Unable to trace the right ureter distally due to obscuration by bowel gas.
  • Solitary cyst seen at midpole of right kidney measures 4.5cm x 6.1cm x 5.3cm (APxWxCC).
  • Urinary bladder bladder is partially distended filled with clear urine. No focal lesion or calculus seen.
  • Prostate is heterogenous and enlarged measures 4.4cm x 5.4cm x 5.0cm (APxWxCC). Foci of calcification noted.
CT scan of abdomen; upper row non-contrast and lower row at delayed phase
CT scan abdomen non-contrast soft tissue window in coronal planes

CT scan findings:

  • A calculus at proximal right ureter (yellow arrows) causing moderate right hydronephrosis (blue arrows) and proximal hydroureter
  • Another smaller ureteric calculus at left distal ureter (red arrows) not causing any obstruction to left collecting system
  • A renal cyst at right midpole (white arrows) as seen on ultrasound

Diagnosis: Bilateral ureteric calculi with obstructive uropathy on the right side.

Discussion:

  • Ureteric calculi are stones lying within the ureter at any point from the ureteropelvic junction (PUJ) to the vesicoureteric junction (VUJ)
  • The prevalence is high, about 12% of men and 7% of women
  • Most patients present between ages 30-60 years
  • The risk increased with past history of ureteric calculus and with positive family history.
  • Other risk factors include low fluid intake, frequent UTI and medications that may crystallize within the urine
  • Plain radiograph can identify large radiopaque calculi.
  • Small calculi and radiolucent stones may go undetected.
  • Non-contrast CT scan (CT KUB) is the gold standard for ureteric stone. On CT scan, 99% seen as hyperdense focus. Stones >1mm are visualized, specificity as high as 100%.
  • Ultrasound is helpful as initial screening. It may avoid unnecessary CT scan in certain cases.
  • Ultrasound features include echogenic foci, acoustic shadowing, assessment of hydronephrosis or pyonephrosis.

Progress of patient:

  • Bilateral retrograde ureteric stenting done
  • DTPA scan shows severe reduced right kidney function with mild reduced left kidney function

 

Author: radhianahassan