Presentation
Right loin pain. History of recurrent right renal colic and passing stones.
Patient Data
Moderate right hydronephrosis with dilated right ureter due to distal 3 cm stricture containing a 5 mm stone.
Large left renal stag-horn stone casting its pelvicalyceal system with no pelvicalyceal dilatation.
Moderate right hydroureteronephrosis with delayed contrast excretion up to 1 hour due to distal ureteric obstruction.
Dilated tortous right ureter. The right ureter reaches 14 mm in diameter at the lower third prior to the obstruction. Smooth tapering of the lower third of the right ureter ending into a very thin segment till vesicoureteric junction reflecting stricture. The stricture is measuring 30 mm in length.
The left kidney shows a large stag-horn stone casting its pelvicalyceal system. Normal adequate excretion of contrast after 5 minutes excluding obstruction. Normal caliber of the left ureter.
Adequate filling of the urinary bladder and normal evacuation on delayed postvoiding film.
Case Discussion
Regarding the patient's history of recurrent stone passages, appearances mostly represent stone-induced distal ureteral stricture. This is supported by the appearance of stricture in intravenous pyrography, which shows smooth tapering of the transition zone before the stricture and the presence of impacted stone in the middle of the stricture. Despite the ureteric stone being small in size, it may need ureteroscopic extraction as the stricture will decrease its chance to pass easily.
Ureteric strictures can also be a sign of underlying malignancy and care should be given not to miss this diagnosis. So, ureteroscopy and retrograde ureterography is a preferred option for management of suspected ureteric strictures as imaging and tissue sampling can be done at the same time.
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