X-Ray-Free Endoscopic Combined Intrarenal Surgery for Complex Proximal Ureteral Stone: A Case Report.

X-ray-free endoscopic combined intra renal surgery (ECIRS) is a feasible alternative to avoid radiation exposure to both surgical teams and patients, but has not been reported prior. The aim of this report is to present our first-hand experience of performing X-ray-free ECIRS for complex ureteral stone. A 57-year-old female presented with right flank pain, fever, dysuria, and leukocytosis. The computed tomography scan showed right impacted proximal ureteral stone sized 33 ´17 mm and grade IV hydronephrosis. Percutaneous nephrostomy was performed immediately. With improvement of clinical symptoms two days after nephrostomy, X-ray-free ECIRS was performed. The patient was placed in a Galdakao-modified supine position. During ureteroscopy (URS), there was noted right ureteral stenosis in the distal part of the stone, which could be passed. However, the stone was impacted and the semi-rigid URS was not able to push it. Therefore, antegrade approach with percutaneous nephrolithotomy was performed. Previous nephrostomy tract was used as percutaneous access. Tract dilatation was performed under direct visualization from the URS. The 28 Fr rigid nephroscope was used during the ECIRS procedure. The stone was fragmented using shock-pulse lithotripters. There was no residual stone or infundibular laceration after the procedure. A 6 Fr double J stent was inserted retrogradely due to ureteral stenosis. There was no complication during and after the procedure. The patient was discharged on post-operative day three. X-ray free ECIRS for complex proximal ureteral stone was possible and showed good results.