Linear relationship between absorbed radiation dose and pulse rate during fluoroscopy.

PURPOSE: To identify the relationship between fluoroscopy pulse rate and absorbed radiation dose. We compared absorbed radiation dose with common proxy measurements such as fluoroscopy time and C-arm reported dose. METHODS: Using a simulated patient model, 60 s fluoroscopy exposures were performed using pulse rates of 30, 8, 4, 2, and 1 pulse(s) per second. Each experiment was performed with both standard and low-dose settings using a GE OEC 9800 plus C-arm. Landauer nanoDot™ OSL dosimeters were used to measure the absorbed radiation dose. RESULTS: Fluoroscopy pulse rate and absorbed radiation dose demonstrated a linear correlation for both standard (R2 = 0.995, p < 0.001) and low-dose (R2 = 0.998, p < 0.001) settings. For any given pulse rate, using the low-dose setting reduced absorbed radiation dose by 58 ± 2.8%. Fluoroscopy time demonstrated a linear relationship with absorbed radiation dose for both standard (R2 = 0.996, p < 0.001) and low-dose (R2 = 0.991, p < 0.001) settings, but did not change with use of the low-dose setting. C-arm reported radiation dose correlated linearly with absorbed dose (R2 = 0.999) but consistently under-estimated measured values by an average of 49 ± 3.5%. Using a combination of 1 pulse-per-second and low-dose fluoroscopy, absorbed dose was reduced by 97.7 ± 0.1% compared to standard dose and 30 pulse-per-second settings. CONCLUSION: Absorbed radiation dose decreases linearly with fluoroscopy pulse rate during equivalent exposure times. Adjusting fluoroscopy pulse rate and utilizing low-dose settings significantly reduces overall absorbed radiation exposure by up to 98%.

Interdisciplinary planning improves radiologist obtained access for percutaneous nephrolithotomy.

INTRODUCTION: Proper antegrade access for percutaneous nephrolithotomy (PCNL) is essential for success but can be challenging. Previous work evaluating access obtained by interventional radiology (IR), largely in the emergent setting, has shown high rates of additional access at the time of PCNL. We hypothesize that efforts to improve pre-procedural communication between urology and IR can impact the utility of the access for subsequent PCNL. MATERIAL AND METHODS: We conducted a retrospective review of patients undergoing PCNL at a single hospital from January 2011 to December 2022. Adult patients undergoing PCNL with established preoperative access were included. RESULTS: A total of 141 cases were identified with preoperative access. A total of 111 patients had evidence of planning with IR prior to antegrade access. There were high rates of anatomic abnormality (50%) and staghorn calculus (53%). Patients with planned access had higher body mass index (BMI). While preoperative access was initially utilized in 97% of cases, 6% required additional access to be obtained intraoperatively; this included a low rate of new access in those that were previously discussed with IR (4% vs. 17%, p = 0.02). Overall stone free rates (91%), rates of second stage procedures (55%) and complications (14%) were similar between planned and unplanned groups. CONCLUSION: In this retrospective study of complex patients with large stone burden presenting for PCNL with preoperative antegrade access obtained by IR, the rate of new access was far lower than prior reports. This was likely influenced by urologist involvement in planning access.

Defining 24-hour urine parameters and kidney stone risk of student athletes.

PURPOSE: Dehydration is a risk factor for kidney stone formation. Studying populations that may experience dehydration without a known increased incidence of stone formation may help understand stone formation and prevention. High-caliber athletes represent such a population. We characterized the urinary environment of high-caliber athletes utilizing 24-hour urine collections with comparison to non-athlete controls. MATERIALS AND METHODS: After Institutional Review Board (IRB) and National Collegiate Athletic Association (NCAA) compliance officer approval, 74 college-student athletes and 20 non-athletes were enrolled. Demographics, medical history, and sport of participation were recorded. Participants were asked to provide 24-hour urine collections as well as diet and activity logs at the time of urine collection. Standard stone risk parameters were assessed and compared to litholink reference standards. RESULTS: 34 athletes and 10 non-athletes provided at least one 24-hour urine specimen for evaluation. Athletes had a high prevalence of urinary risks for stone formation including low volume (median 1.46 L), low citrate, high sodium, high calcium (females), and high uric acid (males). However, athletes also had a high prevalence of known stone-protective factors such as high urine magnesium. Athletes had a lower urine pH but high supersaturation of uric acid and calcium oxalate compared to non-athletes. CONCLUSION: Student athletes appear to have a high prevalence of urinary risk factors for stone formation such as dehydration, high calcium, high uric acid, high sodium, and low citrate. Overall stone risk in this population may be offset by increased levels of stone-protective factors such as magnesium. Further study of this population may help generate hypotheses for effective stone prevention strategies in the general population.

Subcapsular hematoma in a solitary kidney: successful conservative management.

Subcapsular renal hematoma (SRH) is an infrequent complication of urologic interventions but can lead to serious consequences in patients with a solitary kidney. We present our experience with conservative management of a patient with a solitary kidney and multiple medical comorbidities who developed a SRH and subsequent renal failure after nephroureteral catheter placement. Literature on the management of this unique clinical scenario is limited. Herein, we share our experience with supportive care and temporary dialysis in a medically complex patient whose outcome is complete renal recovery.

Prospective randomized trial of 2 versus 12-weeks of postoperative antibiotics after percutaneous nephrolithotomy in complex patients with infection-related kidney stones.

PURPOSE: Treatment of struvite kidney stones requires complete surgical stone removal combined with antibiotic therapy to eliminate urinary tract infections and preventive measures to reduce stone recurrence. The optimal duration of antibiotic therapy is unknown. We sought to determine if 2- or 12-weeks of antibiotics post percutaneous nephrolithotomy (PNL) for infection stones resulted in better outcomes for stone recurrence and positive urine cultures. MATERIAL AND METHODS: This multi-center, prospective randomized trial evaluated patients with the clinical diagnosis of infection stones. Patients were randomized to 2- or 12-weeks of postoperative oral antibiotics (nitrofurantoin or culture-specific antibiotic) and included if residual fragments were ≤4 mm on computed tomography imaging after PNL. Imaging and urine analyses were performed at 3-, 6-, and 12-months post-procedure. RESULTS: Thirty-eight patients were enrolled and randomized to either 2-weeks (n = 20) or 12-weeks (n = 18) of antibiotic therapy post-PNL. Eleven patients were excluded due to residual fragments >4 mm, and 3 patients were lost to follow-up. The primary outcome was the stone-free rate (SFR) at 6 months post-PNL. At 3-, 6-, and 12-months follow-up, SFRs were 72.7% versus 80.0%, 70.0% versus 57.1%, 80.0% versus 57.1% (p = ns), between 2- and 12-week-groups, respectively. At 3-, 6-, and 12-months follow-up, positive urine cultures were 50.0% versus 37.5%, 50.0% versus 83.3%, and 37.5% versus 100% between 2- and 12-week groups, respectively (p = ns). CONCLUSIONS: For patients with stone removal following PNL, neither 2-weeks nor 12-weeks of postoperative oral antibiotics is superior to prevent stones and recurrent positive urine cultures.

Minimizing radiation dose in management of stone disease: how to achieve 'ALARA'.

PURPOSE OF REVIEW: Exposure to radiation is known to have adverse effects such as secondary malignancies. Patients with nephrolithiasis are exposed to radiation in the workup and treatment of their condition. Furthermore, exposure to radiation is often repeated due to the high recurrence rate of nephrolithiasis. RECENT FINDINGS: We discuss practices inside and outside of the operating room to strive to keep radiation exposure as low as reasonably achievable (ALARA) for patients being treated for nephrolithiasis. These efforts include reduced dose computed tomography scans, fluoroless surgical techniques and new alternative technologies. SUMMARY: Maintaining radiation exposure ALARA for our patients is increasingly practical. The urologist must make every effort to adhere to ALARA principles to protect patients from the stochastic effects of radiation.

Endoscopic diagnosis of renal pseudoaneurysm following ureteroscopy.

Renal pseudoaneurysm following ureteroscopy is a rare cause of hematuria usually diagnosed and treated with angiography and embolization. Here we present a case of a small pseudoaneurysm causing intermittent flank pain and gross hematuria associated with clot retention initially diagnosed during ureteroscopy and subsequently treated with a combined endourologic and endovascular approach.

Trends in renal calculus composition and 24-hour urine analyses in patients with neurologically derived musculoskeletal deficiencies.

PURPOSE: To better characterize metabolic stone risk in patients with neurologically derived musculoskeletal deficiencies (NDMD) by determining how patient characteristics relate to renal calculus composition and 24-hour urine parameters. MATERIALS AND METHODS: We performed a retrospective cohort study of adult patients with neurologically derived musculoskeletal deficiencies presenting to our multidisciplinary Kidney Stone Clinic. Patients with a diagnosis of NDMD, at least one 24-hour urine collection, and one chemical stone analysis were included in the analysis. Calculi were classified as primarily metabolic or elevated pH. We assessed in clinical factors, demographics, and urine metabolites for differences between patients who formed primarily metabolic or elevated pH stones. RESULTS: Over a 16-year period, 100 patients with NDMD and nephrolithiasis were identified and 41 met inclusion criteria. Thirty percent (12 / 41) of patients had purely metabolic calculi. Patients with metabolic calculi were significantly more likely to be obese (median body mass index 30.3kg / m2 versus 25.9kg / m2), void spontaneously (75% vs. 6.9%), and have low urine volumes (100% vs. 69%). Patients who formed elevated pH stones were more likely to have positive preoperative urine cultures with urease splitting organisms (58.6% vs. 16.7%) and be hyperoxaluric and hypocitraturic on 24-hour urine analysis (37mg / day and 265mg / day versus 29mg / day and 523mg / day). CONCLUSIONS: Among patients with NDMD, metabolic factors may play a more significant role in renal calculus formation than previously believed. There is still a high incidence of carbonate apatite calculi, which could be attributed to bacteriuria. However, obesity, low urine volumes, hypocitraturia, and hyperoxaluria suggest an underrecognized metabolic contribution to stone formation in this population.

Identifying and managing the risks of medical ionizing radiation in endourology.

INTRODUCTION: The risks of exposure to medical ionizing radiation is of increasing concern both among medical professionals and the general public. Patients with nephrolithiasis are exposed to high levels of ionizing radiation through both diagnostic and therapeutic modalities. Endourologists who perform a high-volume of fluoroscopy guided procedures are also exposed to significant quantities of ionizing radiation. The combination of judicious use of radiation-based imaging modalities, application of new imaging techniques such as ultra-low dose computed tomography (CT) scan, and modifying use of current technology such as increasing ultrasound and pulsed fluoroscopy utilization offers the possibility of significantly reducing radiation exposure. We present a review of the literature regarding the risks of medical ionizing radiation to patients and surgeons as it pertains to the field of endourology and interventions that can be performed to limit this exposure. MATERIALS AND METHODS: A review of the current state of the literature was performed using MEDLINE and PubMed. Interventions designed to limit patient and surgeon radiation exposure were identified and analyzed. Summaries of the data were compiled and synthesized in the body of the text. RESULTS: While no level 1 evidence exists demonstrating the risk of secondary malignancy with radiation exposure, the preponderance of evidence suggests a dose and age dependent increase in malignancy risk from ionizing radiation. Patients with nephrolithiasis were exposed to an average effective dose of 37mSv over a 2 year period. Multiple evidence-based interventions to limit patient and surgeon radiation exposure and associated risk were identified. CONCLUSION: Current evidence suggest an age and dose dependent risk of secondary malignancy from ionizing radiation. Urologists must act in accordance with ALARA principles to safely manage nephrolithiasis while minimizing radiation exposure.

Vitamin D Repletion in Kidney Stone Formers: A Randomized Controlled Trial.

PURPOSE: Vitamin D deficiency is often detected during metabolic evaluation in the nephrolithiasis population. Multiple vitamin D repletion protocols exist, although their differing impact on urinary stone formation risk factors is unclear. MATERIALS AND METHODS: Patients with a history of calcium stones and vitamin D deficiency (less than 30 ng/ml) were randomized to receive either 1,000 IU daily or 50,000 IU weekly of vitamin D supplementation for 6 weeks. Patients completed a pretreatment and posttreatment serum vitamin D level evaluation and 24-hour urine collections to assess the response and any changes in urine stone formation risk parameters. RESULTS: A total of 21 patients completed the study, including 8 who received 1,000 IU daily and 13 who received 50,000 IU weekly. The 50,000 IU weekly group showed a significant increase in median serum vitamin D levels of 23 ng/ml (135%, p <0.01), while the 1,000 IU daily group showed a nonsignificant median increase of 9 ng/ml (49%, p = 0.12). Post-repletion 24-hour urine analysis demonstrated no significant change in urine calcium between the groups, including a median change of -11 mg (IQR -143-29) in patients receiving 1,000 IU and -16 mg (IQR -42-66) in those receiving 50,000 IU. Between the groups there was no significant difference in the supersaturation of calcium oxalate or calcium phosphate. CONCLUSIONS: High dose and low dose vitamin D repletion had no effect on urine calcium excretion or the supersaturation of calcium salts in known stone formers. The higher dosing regimen, which had superior repletion, may be the optimal protocol in patients with vitamin D deficiency.

A prospective, multi-institutional study of flexible ureteroscopy for proximal ureteral stones smaller than 2 cm.

PURPOSE: Flexible ureteroscopy is rapidly becoming a first line therapy for many patients with renal and ureteral stones. However, current understanding of treatment outcomes in patients with isolated proximal ureteral stones is limited. Therefore, we performed a prospective, multi-institutional study of ureteroscopic management of proximal ureteral stones smaller than 2 cm to better define clinical outcomes associated with this approach. MATERIALS AND METHODS: Adult patients with proximal ureteral calculi smaller than 2 cm were prospectively identified. Patients with concomitant ipsilateral renal calculi or prior ureteral stenting were excluded from study. Flexible ureteroscopy, holmium laser lithotripsy and ureteral stent placement was performed. Ureteral access sheath use, laser settings and other details of perioperative and postoperative management were based on individual surgeon preference. Stone clearance was determined by the results of renal ultrasound and plain x-ray of the kidneys, ureters and bladder 4 to 6 weeks postoperatively. RESULTS: Of 71 patients 44 (62%) were male and 27 (38%) were female. Mean age was 48.2 years. ASA(®) score was 1 in 12 cases (16%), 2 in 41 (58%), 3 in 16 (23%) and 4 in 2 (3%). Mean body mass index was 31.8 kg/m(2), mean stone size was 7.4 mm (range 5 to 15) and mean operative time was 60.3 minutes (range 15 to 148). Intraoperative complications occurred in 2 patients (2.8%), including mild ureteral trauma. Postoperative complications developed in 6 patients (8.7%), including urinary tract infection in 3, urinary retention in 2 and flash pulmonary edema in 1. The stone-free rate was 95% and for stones smaller than 1 cm it was 100%. CONCLUSIONS: Flexible ureteroscopy is associated with excellent clinical outcomes and acceptable morbidity when applied to patients with proximal ureteral stones smaller than 2 cm.

Acute renal vein thrombus and renal atrophy following shock wave lithotripsy: a unique complication.

Serious complications of shock wave lithotripsy (SWL) are rare, but can have significant long term effects. We present a case of acute renal vein thrombus following SWL leading to subsequent renal atrophy and loss of renal function. To our knowledge this is a newly reported complication of SWL.

Accuracy of Radiology Reports for Obstructing Ureteral Stone Size in the Emergency Department.

OBJECTIVE: To evaluate the number of dimensions of obstructing ureteral stones in the emergency department (ED) described in present-day radiology computed tomography reports and assess for measurement discrepancies between radiologist and urologist review. METHODS: We conducted a single-center retrospective study of patients who presented to the ED with unilateral, solitary, obstructing ureteral stones from March 2018 to March 2021. Stone size in each reported dimension recorded by the radiologist was extracted from the chart and then compared to size independently measured by one of our urologists for all 3 stone dimensions. Our primary outcome was the number of stone dimensions included in the radiology report. RESULTS: In total, 181 patients were included for analysis. 82.3% of radiology reports described the stone in one dimension, 15% in two dimensions, and 2.7% in three dimensions. There was a significant difference in median maximal stone size between radiologist and urologist measurement (5.5 vs 6.5 mm, respectively, P < .001). One hundred fourteen stones (62%) had the maximal measurement recorded in the craniocaudal (CC) dimension by urologist review. Only 26% of radiology reports had the CC measurement included in the radiology report. CONCLUSION: Ureteral stone size in a present-day ED cohort is still frequently measured in only 1 or 2 dimensions. In many cases, this is associated with an absence of a reported CC measurement. Inadequate characterization of stone size may affect acute management. This study hopes to encourage reporting of all three dimensions of obstructing ureteral stones in the ED setting for improvements in patient management.

Urinary Metabolic Disturbances During Topiramate Use and their Reversibility Following Drug Cessation.

OBJECTIVE: To understand the metabolic disturbances of stone formers currently taking topiramate and to examine the reversibility of these disturbances with cessation of the medication. MATERIALS AND METHODS: All progress notes written by 5 endourologists from a single academic center were retrospectively reviewed from January 2010 to July 2020 containing the words "topiramate" or "topamax." Inclusion criteria were age >18 and presence of either a 24-hour urine sample or stone analysis while on topiramate. In addition, a subgroup of 18 patients with 24-hour urine samples before and after stopping topiramate were identified. RESULTS: A total of 93 patients were identified and included for final analysis. Twenty-four hour urine samples were available in 67 patients and showed mean citrate excretion of 331 ± 322 mg/d, mean pH of 6.6 ± 0.5, and mean calcium phosphate supersaturation of 1.9 ± 1.1. In the subgroup analysis urinary citrate excretion increased from 225 mg/d to 614 mg/d (P <.01) and pH decreased from 6.59 ± 0.54 to 6.33 ± 0.47 (P = .06) after stopping topiramate. In addition, 114 stone events occurred in 73 distinct patients, with 50% of stones either pure or majority (≥50%) calcium phosphate by composition. CONCLUSION: Hypocitraturia and elevated pH is seen during topiramate use with resultant higher rate of calcium phosphate stone formation compared to the general population. Stopping topiramate leads to significant increase in citrate excretion and normalization of pH. These metabolic disturbances appear to be reversible with medication cessation.

International Alliance of Urolithiasis (IAU) guidelines on the metabolic evaluation and medical management of urolithiasis.

The aim of this study was to construct the fourth in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis (IAU) that by providing a clinical framework for the metabolic evaluation, prevention, and follow-up of patients with urolithiasis based on the best available published literature. All recommendations were summarized following a systematic review and assessment of the literature in the PubMed database from January 1976 to June 2022. Each generated recommendation was graded using a modified GRADE methodology. Guideline recommendations were developed that addressed the following topics: initial evaluation, metabolic testing, dietary measures, medical management, and follow-up of recurrent stone formers. It was emphasized by the Panel that prevention of new stone formation is as important as the surgical removal of the stones. Although general preventive measures may be effective in reducing stone recurrence rates in some patients, specific medical and dietary management should be well considered and eventually applied in an individualized manner based on the outcomes of metabolic work-up, stone analysis and some certain patient related factors. A detailed follow-up of each case is essential depending on the metabolic activity of each individual patient.

Safety During Ureteroscopy: Radiation, Eyes, and Ergonomics.

It is known that urologic surgeons are at risk of work-place injury due to the physical requirements of operating and exposure to hazards. These hazards include radiation, exposure to body fluids, use of laser energy, and orthopedic injury due to the physical nature of operating. The risks that these hazards present can be mitigated by implementing several evidence-based safety measures. The methods to protect against radiation exposure include keeping radiation usage in the operating room as low as reasonably achievable, donning lead aprons, and wearing protective glasses. Additionally, protective glasses decrease the risk of eye injury from laser injury and exposure to body fluids. Finally, practicing sound surgical ergonomics is essential to minimize the risk of orthopedic injury and promote career longevity. The interventions discussed herein are simple and easy to implement in one's daily practice of urology.

Validity of administrative coding in identifying patients with upper urinary tract calculi.

PURPOSE: Administrative databases are increasingly used for epidemiological investigations. We performed a study to assess the validity of ICD-9 codes for upper urinary tract stone disease in an administrative database. MATERIALS AND METHODS: We retrieved the records of all inpatients and outpatients at Johns Hopkins Hospital between November 2007 and October 2008 with an ICD-9 code of 592, 592.0, 592.1 or 592.9 as one of the first 3 diagnosis codes. A random number generator selected 100 encounters for further review. We considered a patient to have a true diagnosis of an upper tract stone if the medical records specifically referenced a kidney stone event, or included current or past treatment for a kidney stone. Descriptive and comparative analyses were performed. RESULTS: A total of 8,245 encounters coded as upper tract calculus were identified and 100 were randomly selected for review. Two patients could not be identified within the electronic medical record and were excluded from the study. The positive predictive value of using all ICD-9 codes for an upper tract calculus (592, 592.0, 592.1) to identify subjects with renal or ureteral stones was 95.9%. For 592.0 only the positive predictive value was 85%. However, although the positive predictive value for 592.1 only was 100%, 26 subjects (76%) with a ureteral stone were not appropriately billed with this code. CONCLUSIONS: ICD-9 coding for urinary calculi is likely to be sufficiently valid to be useful in studies using administrative data to analyze stone disease. However, ICD-9 coding is not a reliable means to distinguish between subjects with renal and ureteral calculi.

The association of increasing body mass index and kidney stone disease.

PURPOSE: Previous epidemiological works have reported that obesity is a risk factor for kidney stone disease. However, the effect of increasing degrees of obesity on stone formation has yet to be defined. To address this question we examined how an increasing body mass index affects the risk of kidney stone disease. MATERIALS AND METHODS: We evaluated claims from a 5-year period (2002 to 2006) in a national private insurance database to identify subjects diagnosed with or treated for kidney stones. From a data set of 95,598 patients, subjects were identified by ICD-9 or CPT codes specific to kidney stone disease. Descriptive analyses were performed and odds ratios were calculated. RESULTS: Gender distribution of the 3,257 stone formers was 42.9% male and 57.1% female. Obesity (body mass index greater than 30 kg/m(2)) was associated with a significantly greater likelihood of being diagnosed with a kidney stone. However, when obese patients were stratified by body mass index there were no significant differences in the likelihood of a kidney stone diagnosis, suggesting a stabilization of risk once body mass index increased above 30 kg/m(2). The association of body mass index and a stone removal procedure was significant only for men and women with a body mass index between 30 and 45 kg/m(2) relative to a body mass index less than 25 kg/m(2) (p <0.001). CONCLUSIONS: An obese body mass index is associated with an increased risk of kidney stone disease. However, the magnitude of this risk appears to be stable in the morbidly obese population. Once body mass index is greater than 30 kg/m(2), further increases do not appear to significantly increase the risk of stone disease.

Management of stone disease in pregnancy.

PURPOSE OF REVIEW: Nephrolithiasis is a not infrequent complication of pregnancy. The occurrence of a stone event in a pregnant woman is a complex situation. Therefore, a clear understanding of the management options available and their relative advantages and disadvantages for this unique population is important. RECENT FINDINGS: When initial, conservative measures have failed in the treatment of a pregnant woman suffering from an acute stone event, management options have historically been of a temporizing nature: generally, either ureteral stent placement or nephrostomy drainage. However, with recent advances in surgical technology and surgeon technique, a more definitive approach to these patients has become more widely adopted. Indeed, several recent case series have reported the complication rate for ureteroscopy during pregnancy to be low. Furthermore, a meta-analysis of case series of ureteroscopy during pregnancy suggests definitive endoscopic treatment is well tolerated in this patient population. SUMMARY: In a pregnant patient without contraindications to ureteroscopy, the definitive endoscopic treatment of an acute stone event is a reasonable management strategy, should conservative measures fail. Although further investigation with randomized control trials is ideally needed to confirm these results, at present, the published case series and meta-analysis confirm the safety of ureteroscopy in pregnant patients in the appropriate setting. A multidisciplinary approach is key to the successful management of this complex patient population.

Unconventional Use of the Lithoclast to Aid in the Treatment of Large Distal Ureteral Stone Burden in a Patient With a Ureterocele.

INTRODUCTION: Large ureteral stone burden can present significant challenges for the urologist to treat. Here we present the retrograde use of the Lithoclast Select, in a dilated distal ureter after incision of a ureterocele. METHODS: The patient is a 64 year-old female with large distal ureteral stone burden, with approximately 15 1-2 cm stones. She presented with significant right flank pain, urinary urgency, frequency, dysuria, and recurrent urinary tract infections. RESULTS: A 22-French rigid cystoscope was inserted into the bladder. Urethral outlet was normal. Patient was noted to have 2 right-sided ureteral orifices, consistent with a completely duplex system. At the medial right ureteral orifice a very large ureterocele was noted. The lower pole system was scoped and stone free. The ureter to the upper pole moiety was scoped and a large stone burden within the distal ureter was visualized. The Plasmacise Gyrus was used to incise the anterior part of the ureter by inserting the Plasmacise into the ureteral orifice and tenting it anteriorly. The 24-French nephroscope was then inserted into the distal ureter. Graspers were used to extract many fragments however several were unable to be extracted from the distal ureter due to their size and thus were fragmented and evacuated with the ultrasonic lithoclast within the distal ureter. A 365-µ laser fiber was also used to fragment some of the stones. There were no complications. CT Scan 4 months post operatively was negative for stone recurrence. Last follow up was 15 months postprocedure where the patient was doing well. CONCLUSIONS: Utilization of the rigid nephroscope and ultrasonic lithotripter in a female patient with a dilated distal ureter with a capacious or incised ureterocele is safe and effective, allowing for treatment of greater than 15 cm total distal ureteral stone burden.