0022-534 7/92/1483-0861$03.00/0 Vol. 148, 861~862, September 1992
THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL AssOC[ATlON, ]NC.
Printed in U.S A.
Case Reports GIANT URETERAL STONE R. B. SABNIS, R. M. DESAI, A. M. BRADOO, S. V. PUNEKAR
S. D. BAPAT
AND
From the Department of Urology, L. T. M. G. Hospital and Medical College, Sion, Bombay, India
ABSTRACT
A 58-year-old man presented with left flank pain and a high grade fever. Investigations revealed left pyonephrosis with a left renal stone and a giant left ureteral stone. Nephroureterectomy was performed. The ureteral stone measured 13 cm. long and weighed 90 gm. KEY WORDS:
ureteral calculi, urinary calculi, pyelonephritis, kidney calculi
The majority of ureteral calculi are single and less than 2 cm. in size. Occasionally, they are multiple and can be as large as 5 cm. Ureteral stones larger than 10 cm. and weighing more than 50 gm. are extremely rare. We report a case of a giant ureteral stone. CASE REPORT
A 58-year-old man presented with a high grade fever and throbbing pain in the left flank 15 days in duration. History suggested intermittent left ureteral colic for the last 14 years. He had undergone suprapubic cystolithotomy 14 years previously for a large bladder stone. During that period a left renal stone was diagnosed. The patient had good functioning kidneys bilaterally and he refused left pyelolithotomy at that time. He was subsequently lost to followup. At examination the patient was febrile and had tachycardia. The left kidney was palpable and severely tender. Urine showed severe pyuria and culture yielded significant colonies of Escherichia coli and Klebsiella. The serum creatinine level was 1.5 mg. %. A plain abdominal film revealed opacities suggestive of a left renal stone and a giant left ureteral stone (fig. 1, A). Excretory urography showed a normal right kidney and nonopacification of the left kidney even after 24 hours. Ultrasonography revealed left pyonephrosis. Left percutaneous nephrostomy drained 400 cc pus. A nephrostomogram 10 days later showed an enlarged left kidney with a stone in the lower calix and a markedly dilated, tortuous ureter with a stone in the lower half (fig. 1, B). Nephroureterectomy was performed. The kidney was flabby and pyonephrotic. The ureter was dilated and was as large as the colon. The ureteral wall was thin _and friable. The complete lower half of the ureter was occupied by a stone. The ureter was dissected distal to the stone and up to the vesicoureteral junction. The specimen was removed en masse. Convalescence was uneventful. Histology showed pyelonephritis with no evidence of malignancy anywhere. The ureteral stone measured 13 cm. long, weighed 90 gm. (fig. 2), and consisted of calcium oxalates and phosphates.
FIG. 1. A, plain abdominal x-ray shows giant ureteral stone. B, nephrostomogram reveals dilated tortuous ureter with stone in lower half.
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ems
DISCUSSION
The majority of ureteral calculi originate in the renal pelvis and then descend to the ureter. Ureteral stones less than 4 mm. in diameter are more likely to be passed. 1 However, stones more than 1 cm. in diameter or that weigh more than 0.1 gm. are less likely to be passed. 2 A calculus recently expelled from the
kidney is usually round or ovoid. However, after the stone has resided in the ureter for some time the longitudinal diameter becomes greater than the transverse diameter and, thus, the shape becomes elongated. 3
Accepted for publication February 14, 1992.
861
862
SABNIS AND ASSOCIATES
Most ureteral calculi are less than 2 cm. Sometimes ureteral stones are multiple and can be up to 5 cm. However, giant ureteral calculi (more than 10 cm. long and weighing 50 gm.) are extremely rare. Giant ureteral stones are generally formed in patients who have refused treatment for many years. Our patient neglected symptoms for 14 years, and presented when the kidney became pyonephrotic and nonfunctioning. Giant ureteral stones have been reported in the earlier twentieth century. In 1922 Heath found a 65.8 gm. ureteral stone,4 whereas in 1924 Tennant reported a 66 gm. stone. 5 In our report the ureteral stone measured 13 cm. long and weighed 90 gm., which to our knowledge represents the largest calculus reported.
REFERENCES
1. Drach, G. W.: Transurethral ureteral stone manipulation. Urol.
Clin. N. Amer., 10: 709, 1983. 2. Sutor, D. J. and Wooley, S. E.: Some data on urinary stones which were passed. Brit. J. Urol., 47: 131, 1975. 3. Drach, G. W.: Urinary lithiasis. In: Campbell's Urology, 5th ed. Edited by P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T. A. Stamey. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 25, pp. 1094-1190, 1986. 4. Heath, P. M.: Large ureteral calculus. Brit. J. Surg., 10: 153, 1922. 5. Tennant, C. E.: Ureteral stone of unusual size. J.A.M.A., 82: 1122, 1924.
THE JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL AssOC[ATlON, ]NC.
Printed in U.S A.
Case Reports GIANT URETERAL STONE R. B. SABNIS, R. M. DESAI, A. M. BRADOO, S. V. PUNEKAR
S. D. BAPAT
AND
From the Department of Urology, L. T. M. G. Hospital and Medical College, Sion, Bombay, India
ABSTRACT
A 58-year-old man presented with left flank pain and a high grade fever. Investigations revealed left pyonephrosis with a left renal stone and a giant left ureteral stone. Nephroureterectomy was performed. The ureteral stone measured 13 cm. long and weighed 90 gm. KEY WORDS:
ureteral calculi, urinary calculi, pyelonephritis, kidney calculi
The majority of ureteral calculi are single and less than 2 cm. in size. Occasionally, they are multiple and can be as large as 5 cm. Ureteral stones larger than 10 cm. and weighing more than 50 gm. are extremely rare. We report a case of a giant ureteral stone. CASE REPORT
A 58-year-old man presented with a high grade fever and throbbing pain in the left flank 15 days in duration. History suggested intermittent left ureteral colic for the last 14 years. He had undergone suprapubic cystolithotomy 14 years previously for a large bladder stone. During that period a left renal stone was diagnosed. The patient had good functioning kidneys bilaterally and he refused left pyelolithotomy at that time. He was subsequently lost to followup. At examination the patient was febrile and had tachycardia. The left kidney was palpable and severely tender. Urine showed severe pyuria and culture yielded significant colonies of Escherichia coli and Klebsiella. The serum creatinine level was 1.5 mg. %. A plain abdominal film revealed opacities suggestive of a left renal stone and a giant left ureteral stone (fig. 1, A). Excretory urography showed a normal right kidney and nonopacification of the left kidney even after 24 hours. Ultrasonography revealed left pyonephrosis. Left percutaneous nephrostomy drained 400 cc pus. A nephrostomogram 10 days later showed an enlarged left kidney with a stone in the lower calix and a markedly dilated, tortuous ureter with a stone in the lower half (fig. 1, B). Nephroureterectomy was performed. The kidney was flabby and pyonephrotic. The ureter was dilated and was as large as the colon. The ureteral wall was thin _and friable. The complete lower half of the ureter was occupied by a stone. The ureter was dissected distal to the stone and up to the vesicoureteral junction. The specimen was removed en masse. Convalescence was uneventful. Histology showed pyelonephritis with no evidence of malignancy anywhere. The ureteral stone measured 13 cm. long, weighed 90 gm. (fig. 2), and consisted of calcium oxalates and phosphates.
FIG. 1. A, plain abdominal x-ray shows giant ureteral stone. B, nephrostomogram reveals dilated tortuous ureter with stone in lower half.
jl 111lllillllli!!llllll11!1111jllll!lll!jllll!lll!jlllljlll1Jll!l!lllljlliljlll1jlllljllllj1111!1111\lllljlllljlll!llllljllll!ll!ljlll1J
0
1
2
3
4
5
6
7
8
9
10
11
12
13
ems
DISCUSSION
The majority of ureteral calculi originate in the renal pelvis and then descend to the ureter. Ureteral stones less than 4 mm. in diameter are more likely to be passed. 1 However, stones more than 1 cm. in diameter or that weigh more than 0.1 gm. are less likely to be passed. 2 A calculus recently expelled from the
kidney is usually round or ovoid. However, after the stone has resided in the ureter for some time the longitudinal diameter becomes greater than the transverse diameter and, thus, the shape becomes elongated. 3
Accepted for publication February 14, 1992.
861
862
SABNIS AND ASSOCIATES
Most ureteral calculi are less than 2 cm. Sometimes ureteral stones are multiple and can be up to 5 cm. However, giant ureteral calculi (more than 10 cm. long and weighing 50 gm.) are extremely rare. Giant ureteral stones are generally formed in patients who have refused treatment for many years. Our patient neglected symptoms for 14 years, and presented when the kidney became pyonephrotic and nonfunctioning. Giant ureteral stones have been reported in the earlier twentieth century. In 1922 Heath found a 65.8 gm. ureteral stone,4 whereas in 1924 Tennant reported a 66 gm. stone. 5 In our report the ureteral stone measured 13 cm. long and weighed 90 gm., which to our knowledge represents the largest calculus reported.
REFERENCES
1. Drach, G. W.: Transurethral ureteral stone manipulation. Urol.
Clin. N. Amer., 10: 709, 1983. 2. Sutor, D. J. and Wooley, S. E.: Some data on urinary stones which were passed. Brit. J. Urol., 47: 131, 1975. 3. Drach, G. W.: Urinary lithiasis. In: Campbell's Urology, 5th ed. Edited by P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T. A. Stamey. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 25, pp. 1094-1190, 1986. 4. Heath, P. M.: Large ureteral calculus. Brit. J. Surg., 10: 153, 1922. 5. Tennant, C. E.: Ureteral stone of unusual size. J.A.M.A., 82: 1122, 1924.
