Case Overview

A 54-year-old male patient presented with low back pain and oliguria one month prior. Examinations revealed bilateral hydronephrosis with ureteral stenosis. A left ureteral stent placement was performed, but post-operative renal function showed poor recovery, progressing to anuria. Subsequently, a right percutaneous nephrostomy (PCN) was performed, yet renal function showed minimal improvement. A CT scan indicated worsening left-sided hydronephrosis. A left PCN was therefore performed half a month ago. Past medical history included hypertension for 9 years, coronary heart disease, and regular post-operative chemotherapy for colorectal malignancy. Cystoscopy pathology indicated a poorly differentiated adenocarcinoma of intestinal origin. Serum creatinine level was elevated to 1019 µmol/L.

Current Diagnoses

1. Bilateral Ureteral Stenosis with Bilateral Hydronephrosis

2. Acute Renal Insufficiency

Surgical Procedure

Dual-Endoscopy Assisted Right Covered Stent Placement

• Endoscopy & Stenosis Localization: Under general anesthesia, the patient was placed in a prone position. A guidewire was inserted. Initial dual-endoscopy (combined ureteroscopy and nephroscopy) on the right side was performed to visually confirm the location of the ureteral stenosis.

• Sheath Dilation: The stenotic segment was dilated using a 12/14Fr ureteral access sheath.

• Stent Positioning & Deployment: After observing adequate dilation of the stenotic segment, an EVT ureteral stent system was deployed antegradely over the guidewire under direct vision until the stent fully covered the stenotic area. The stent was slowly released by unscrewing the deployment handle and withdrawing the pull wire. After allowing approximately 3 minutes for full stent expansion, the delivery system was withdrawn, completing the stent placement.

• Post-placement Inspection: A flexible ureteroscope was inserted to inspect the stent position. A drainage tube was placed, the percutaneous sheath was peeled away, and the guidewire was removed.

Dual-Endoscopy Assisted Left Covered Stent Placement

For the left side, dual-endoscopy was again used for direct visual confirmation of the stenosis. Considering the presence of multiple stenotic segments on the left, after dilation, two EVT ureteral stent systems were deployed in a tandem (series) configuration. Following stent release, a flexible ureteroscope was used to inspect the placement. A drainage tube was inserted, concluding the procedure.

Surgical Outcome

For both sides, the dual-endoscopy technique was successfully employed without the need for fluoroscopy, and the EVT ureteral stent systems were implanted successfully. Post-operative X-ray confirmed ideal stent positioning and restored urinary tract patency.

Follow-up Results

An 18-day post-operative follow-up ultrasound revealed: The right kidney showed normal morphology, intact capsule, and no pelvicalyceal separation. Mild dilation of the right proximal ureter was noted, indicating resolution of right hydronephrosis. The left kidney exhibited normal morphology and intact capsule, with slight dilation of the left renal pelvis. No significant dilation of the left proximal ureter was observed, indicating alleviation of left hydronephrosis.