⚠️ Teaching Case Note: This case has been de-identified and reconstructed for educational purposes. Clinical details reflect real surgical decision-making and outcomes. Patient identity is fully protected.
One Session. Stone-Free. Back to Work.
For two years, a 52-year-old internet architect had been living with recurring right flank pain and intermittent blood in his urine. He managed it, adapted around it, and kept working. Then the episodes intensified — low-grade fever, worsening pain, three months of escalation. When imaging finally revealed the full picture, it was clear this was not a simple stone.
A partial staghorn calculus measuring 4.2 cm, CT density averaging 1,150 Hounsfield units — high-hardness calcium oxalate with uric acid components. A subclinical infection layered on top. For a professional whose career demands sustained cognitive performance and rapid physical recovery, the stakes of getting this right were high.
The urology team at Changhai Hospital, Naval Medical University, took the case.
The Diagnosis: Complex Stone, Compounded Risk
Non-contrast CT confirmed the staghorn morphology with mild pelvicalyceal dilation and preserved cortical thickness. CT urography showed an infundibulopelvic angle (IPA) of approximately 72° — favorable geometry for antegrade puncture. eGFR was 96 mL/min/1.73m², kidney function intact. Urine culture grew E. coli, sensitive to ceftriaxone and levofloxacin. Twenty-four-hour urine metabolic workup revealed low citraturia and hyperuricosuria — the underlying metabolic drivers of stone formation.
The multidisciplinary team — urology, infectious disease, radiology, anesthesia, and nutrition — reviewed the options systematically. Extracorporeal shockwave lithotripsy (ESWL) was contraindicated given stone size and density. Staged retrograde intrarenal surgery (RIRS) alone carried high risk given the stone burden. Standard PCNL offered acceptable clearance but with elevated bleeding and collecting system injury risk for this anatomy.
The consensus: Endoscopic Combined Intrarenal Surgery (ECIRS) — simultaneous antegrade and retrograde access in a single session — with strict infection control and ERAS-linked post-operative metabolic intervention.
The Surgery: Two Approaches, One Session, 75 Minutes
Pre-operatively, targeted oral antibiotics were administered for three days based on culture sensitivity. Two weeks prior, a 6Fr double-J stent was placed retrogradely to passively dilate the ureter, reducing post-operative edema and stricture risk.
The patient was positioned in the Galdakao-modified supine Valdivia position — a key technical choice. This allows simultaneous antegrade (percutaneous) and retrograde (transurethral) access without repositioning, while maintaining favorable hemodynamic and respiratory conditions compared to prone positioning.
The retrograde approach came first. A 12/14Fr ureteral access sheath was placed cystoscopically to the renal pelvis. Flexible ureteroscopy mapped the stone distribution. Holmium laser pulverization (0.5 J / 20 Hz) was applied to the lower pole fragments — converting them to dust and clearing space for the antegrade channel.
Simultaneously, the percutaneous channel was established under combined ultrasound and fluoroscopic guidance, targeting the lower calyx. Sequential dilation to 16Fr mini-PCNL, Amplatz sheath placed. Rigid nephroscopy entered the collecting system. A dual-modality lithotripsy strategy followed: holmium laser core fragmentation (1.0 J / 30 Hz) for the central stone mass, combined with pneumatic ballistic clearance for rapid fragment removal. Irrigation pressure was maintained at 20–30 cmH₂O throughout — low-pressure lavage to prevent pyelovenous backflow and urosepsis.
Flexible ureteroscopy performed a second-look sweep of all calyces: no residual fragments greater than 2 mm. A 14Fr nephrostomy tube was placed antegradely; the double-J stent was exchanged retrogradely. Total operative time: 75 minutes. Blood loss: approximately 40 mL. Hemoglobin drop less than 10 g/L. No transfusion.
Recovery: Three Days to Discharge, Six Months to Full Function
At 24 hours post-operatively, temperature was normal, pain score (VAS) was 2, and nephrostomy drainage was clear. Early ambulation was initiated per the ERAS protocol.
At 48 hours, the nephrostomy tube was clamped. Ultrasound confirmed no perirenal fluid collection. The tube was removed. Semi-liquid diet resumed.
On day 3, he was discharged. A personalized stone prevention protocol was initiated: allopurinol for uric acid reduction, potassium citrate for urine alkalinization and citrate supplementation, and a daily fluid intake target above 2.5 liters.
At one month: non-contrast CT confirmed 100% stone-free rate. The double-J stent was removed cystoscopically. Serum creatinine had improved to 82 μmol/L.
At six months: 24-hour urine metabolic indices had normalized. No recurrence. He had returned to full-time work and resumed light aerobic exercise.
His own words: “From recurring colic and hospital admissions, to one minimally invasive session — precision endoscopy and evidence-based prevention gave me back control of my own rhythm.”
About Professor Sun Yinghao
Professor Sun Yinghao is former Director of Urology at Changhai Hospital, Naval Medical University, Shanghai. A pioneer of laparoscopic and endoscopic urological surgery in China, he served as President of the Chinese Urological Association and has trained a generation of urologists nationwide. His department is one of China’s leading centers for complex stone management and minimally invasive urological reconstruction.
How CMCS Supported This Patient
China Medical Concierge – Shanghai (CMCS) coordinated the full care pathway: case review and specialist matching at Changhai Hospital, MDT scheduling, pre-operative urine culture and metabolic workup logistics, on-site Mandarin-English interpretation for all consultations and consent discussions, accommodation near the hospital, and post-operative follow-up coordination including stone prevention protocol management and stent removal scheduling.
For international patients managing complex urological conditions in China, CMCS provides end-to-end support — from first inquiry to long-term metabolic surveillance.
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