Kidney Stone Treatment & Bladder Cancer Care | Dr. Sun Ying (Urology) | CMCS Shanghai

About Dr. Sun Ying

Dr. Sun Ying is a urologist at Renji Hospital, Shanghai Jiao Tong University School of Medicine — one of China's leading centres for urological oncology and minimally invasive stone surgery. She specialises in urological oncology, complex kidney stone management, and minimally invasive bladder surgery, with extensive experience in mini-PCNL, flexible ureteroscopy, and en-bloc transurethral resection for bladder cancer. Dr. Sun is recognised for her patient-centred communication approach and strong outcomes with international patients, and her team has established bilingual follow-up protocols specifically designed for patients returning to their home countries after treatment in Shanghai.

Case Overview

Mr. Robert King, a 58-year-old British senior director in London's financial district, presented with 2 months of left flank pain and macroscopic haematuria, and 1 week of fever. CT urography demonstrated a complete left staghorn calculus (4.5 x 3.0 cm, filling the entire renal pelvis and calyces) with left hydronephrosis and superimposed infection, and a 3 x 2 cm sessile bladder trigone mass. Cystoscopic biopsy confirmed high-grade urothelial carcinoma invading the superficial muscle layer (cT2aN0M0). Critically, the right kidney — previously operated for stone disease 20 years earlier — was atrophic and non-functional: the left kidney was his sole functioning kidney. Serum creatinine was 130 μmol/L. Conventional management — radical cystectomy with ileal conduit diversion — would have condemned this patient to a permanent urostomy bag, and any left renal injury during stone surgery risked immediate dialysis dependence. Dr. Sun Ying designed an integrated kidney-sparing and bladder-sparing strategy: percutaneous nephrostomy drainage to control infection and recover renal function; two cycles of gemcitabine-cisplatin chemotherapy combined with PD-1 immunotherapy (toripalimab) as neoadjuvant treatment; mini-PCNL (14F) for stone clearance; and en-bloc thulium laser TURBT with intraoperative hyperthermic mitomycin C instillation for bladder tumour resection. Pathological complete response (pCR) was achieved. Creatinine stabilised at 85 μmol/L. The patient was discharged on day 7 and returned to London for work, with a bilingual follow-up protocol established between Dr. Sun's team and his London GP.

Patient Background

• Name / Nationality: Mr. Robert King (pseudonym) — British
• Age / Sex: 58-year-old male
• Occupation: Senior director, City of London financial institution — high quality-of-life expectations; international travel essential
• Chief Complaint: Left flank pain with macroscopic haematuria for 2 months; fever for 1 week
• Surgical History: Right open nephrolithotomy 20 years prior; right kidney now atrophic and non-functional
• Medical History: Long-term low-dose aspirin (discontinued 1 week pre-presentation)
• Physical Examination: Left renal angle tenderness positive; no lymphadenopathy
• Laboratory Results: Creatinine 130 μmol/L (impaired); urine culture: Escherichia coli positive; NSE mildly elevated; CEA normal

Imaging and Diagnosis

CT Urography (CTU)

• Left kidney: Complete staghorn calculus 4.5 x 3.0 cm — filling the renal pelvis and all major calyces; left hydronephrosis; perinephric stranding consistent with superimposed infection
• Bladder: Sessile papillary mass 3 x 2 cm at the bladder trigone — broad base, irregular surface

Enhanced CT / MRI

• Bladder tumour invading the superficial muscle layer (T2a); no pelvic lymph node enlargement; no distant metastasis

Cystoscopy and Biopsy

• High-grade urothelial carcinoma invading the muscularis propria confirmed on histology

Clinical Diagnosis

• Left complete staghorn calculus with superimposed infection and renal impairment
• Muscle-invasive bladder cancer — cT2aN0M0
• Solitary functioning kidney (right kidney atrophic and non-functional)

Clinical Decision Making

Two simultaneous life-threatening problems in a patient with a single functioning kidney created a treatment dilemma of exceptional complexity:

• Stone disease: Conventional staghorn calculus management by open surgery or large-channel PCNL carried high haemorrhage risk and renal parenchymal loss — unacceptable in a solitary kidney with already impaired function
• Bladder cancer: The international standard of care for muscle-invasive bladder cancer — radical cystectomy with ileal conduit urinary diversion — would condemn this patient to a permanent urostomy bag, with catastrophic quality-of-life consequences for an active international executive; furthermore, any surgical complication affecting the left ureter or kidney would precipitate immediate dialysis dependence
• The dilemma: Prioritising stone treatment risked tumour progression; prioritising bladder cancer surgery risked renal failure; conventional radical cystectomy was functionally unacceptable to the patient

Dr. Sun Ying's integrated kidney-sparing and bladder-sparing strategy: This patient has one kidney and one bladder — and he intends to keep both. Radical cystectomy is the textbook answer for T2 bladder cancer, but it is not the only answer, and for this patient it is not the right answer. Neoadjuvant immunotherapy combined with chemotherapy has demonstrated pathological complete response rates of 30–40% in muscle-invasive bladder cancer — meaning that in a significant proportion of patients, the tumour is eradicated before any surgical resection. If we achieve pCR, en-bloc TURBT with hyperthermic chemotherapy instillation is a curative bladder-sparing option. Simultaneously, mini-PCNL with a 14F channel will clear the staghorn calculus with minimal renal parenchymal trauma. Our goal: tumour eradication, stone clearance, kidney preserved, bladder preserved, patient back in London.

Treatment Process

Phase 1 — Infection Control and Renal Recovery

Percutaneous nephrostomy drainage of the obstructed left kidney was performed under ultrasound guidance, decompressing the collecting system and initiating antibiotic therapy for the E. coli infection. Within 2 weeks, creatinine had fallen from 130 to 90 μmol/L — establishing adequate renal reserve for cisplatin-based chemotherapy.

Phase 2 — Neoadjuvant Immunochemotherapy

Two cycles of gemcitabine plus cisplatin (GC regimen) combined with toripalimab (PD-1 immune checkpoint inhibitor) were administered. Post-treatment MRI demonstrated 60% reduction in bladder tumour volume; haematuria resolved; the patient's general condition improved substantially. Left hydronephrosis also partially resolved as the stone burden's inflammatory contribution diminished.

Phase 3 — Mini-PCNL Stone Clearance

Approach: Ultrasound-guided left mini-PCNL
Channel size: 14F (half the diameter of conventional PCNL channels)
Operative time: 70 minutes
Blood loss: Less than 50 mL

Under ultrasound guidance, a 14F access sheath was established into the left renal collecting system — without muscle dilation, eliminating the haemorrhage risk of conventional large-channel PCNL. The staghorn calculus was fragmented using a combined ultrasonic and pneumatic lithotripsy system and aspirated through the sheath. A flexible ureteroscope was passed through the access sheath to inspect all calyceal groups, confirming complete stone clearance and collecting system integrity. A double-J ureteric stent was placed; no nephrostomy tube was left (tubeless PCNL technique), minimising post-operative discomfort and accelerating recovery.

Dr. Sun's operative note: In a solitary kidney with impaired function, the channel size is not a technical preference — it is a renal survival decision. Every millimetre of additional channel diameter increases the risk of parenchymal haemorrhage and post-operative renal scarring. The 14F mini-PCNL channel achieves the same stone clearance as a 24F conventional channel with a fraction of the renal trauma. For this patient, that difference is the difference between preserved renal function and dialysis.

Phase 4 — En-bloc TURBT with Hyperthermic Chemotherapy

Approach: Blue-light cystoscopy-guided en-bloc thulium laser TURBT + intraoperative hyperthermic mitomycin C instillation
Anaesthesia: Spinal anaesthesia
Operative time: 45 minutes

Under blue-light (narrow-band imaging) cystoscopy, the tumour margins were precisely delineated — identifying satellite lesions invisible under white light. Rather than conventional piecemeal resection, Dr. Sun employed thulium laser en-bloc resection: the tumour was excised as a single intact specimen including its base and a margin of underlying muscle, providing the pathologist with an architecturally intact specimen for accurate depth-of-invasion assessment and margin evaluation.

Immediately following resection, hyperthermic mitomycin C (42°C) was instilled into the bladder for 60 minutes — destroying any residual circulating tumour cells and reducing the risk of implantation recurrence.

Final pathology: resection margins negative; no viable tumour cells identified in the resected specimen — pathological complete response (pCR) confirmed.

Dr. Sun's operative note: En-bloc resection is not simply a technical refinement of conventional TURBT — it is a fundamentally different oncological operation. Conventional piecemeal resection fragments the tumour, obscures the depth of invasion, and risks intravesical tumour cell dissemination. En-bloc resection removes the tumour as a single intact unit, provides the pathologist with an accurate specimen, and eliminates the risk of resection-related tumour seeding. Combined with hyperthermic chemotherapy instillation, it is the most complete bladder-sparing treatment we can offer for T2 disease that has responded to neoadjuvant therapy.

Post-operative Recovery and Follow-up

ERAS Protocol

• Day 1: Mobilised; liquid diet commenced
• Day 3: Urinary catheter removed (en-bloc resection creates a clean wound margin that heals rapidly)
• Day 5: Discharged (total hospitalisation 7 days — compared with 2 weeks for conventional open surgery)

Renal Function

• 1-month creatinine: 85 μmol/L — stable and improved from pre-treatment baseline; left kidney GFR within normal range

Oncological Follow-up

• 3-month cystoscopy: Normal bladder capacity; no recurrence; surgical scar only
• Voiding function: Normal urinary flow; no incontinence; sexual function fully preserved
• Ongoing treatment: Maintenance PD-1 immunotherapy for 1 year

International Patient Care

Dr. Sun's team established a bilingual (English and Chinese) follow-up record for Mr. King, with direct WeChat communication between the Renji Hospital urology team and his London GP — ensuring continuity of oncological surveillance across time zones and healthcare systems.

Extended Case: Solitary Kidney Cast Stone with Renal Failure

Dr. Sun Ying's expertise in complex stone management extends to the most challenging scenario in nephrolithiasis: complete cast calculus in a solitary kidney with pre-dialysis renal failure.

A 50-year-old woman with a prior right nephrectomy presented with a complete cast calculus filling the entire left renal collecting system and creatinine of 200 μmol/L. Dr. Sun performed multi-channel mini-PCNL combined with flexible ureteroscopy — the sandwich technique: two micro-access channels established at the upper and lower poles for direct stone fragmentation, with the mid-zone managed by flexible ureteroscope passed through the access sheath. Stone-free rate: 100%. Post-operative creatinine: 110 μmol/L — dialysis avoided. This case was enrolled in the CROES PCNL Global Study database as a representative example of Chinese minimally invasive stone surgery technique.

Expert Commentary — Dr. Sun Ying

1. Minimally Invasive Surgery Means Organ Function Preservation

For patients with a solitary kidney or impaired renal function, kidney preservation is the absolute first principle — superseding all other surgical considerations. Mini-PCNL and flexible ureteroscopy achieve equivalent stone clearance to conventional large-channel PCNL with a fraction of the renal parenchymal trauma. In this case, conventional open surgery or large-channel PCNL would have risked haemorrhage requiring nephrectomy — and immediate dialysis. The 14F channel is not a compromise. It is the correct operation for this patient.

2. Immunotherapy Has Transformed Bladder Cancer Management

Muscle-invasive bladder cancer was once a binary choice: radical cystectomy or palliation. Neoadjuvant immunotherapy combined with chemotherapy has fundamentally changed this landscape. Pathological complete response rates of 30–40% mean that a substantial proportion of patients can achieve tumour eradication before any surgical resection — enabling bladder-sparing consolidation with en-bloc TURBT rather than cystectomy. For patients who achieve pCR, the oncological outcomes of bladder-sparing treatment are equivalent to radical cystectomy, with dramatically superior quality of life. This is now an international guideline-endorsed option, and it is our standard approach for eligible patients.

3. En-bloc Resection: The Oncological Standard for TURBT

Conventional piecemeal TURBT has three fundamental limitations: it fragments the tumour specimen, making accurate pathological staging impossible; it risks intravesical tumour cell dissemination during resection; and it leaves uncertain resection margins. En-bloc resection eliminates all three. The tumour is removed as a single intact unit, the pathologist receives an architecturally preserved specimen with clear margins, and the risk of resection-related seeding is eliminated. Combined with hyperthermic chemotherapy instillation, en-bloc TURBT is the most complete bladder-sparing procedure available. It is our routine technique — not a specialised option reserved for selected cases.

4. Communication Is the Core of International Medical Care

International patients arrive carrying anxiety, language barriers, and the weight of diagnoses they may not fully understand. Technical excellence is necessary but not sufficient. We must explain the disease, the treatment options, and the realistic outcomes in language the patient can understand — and we must continue that communication after they return home. The bilingual follow-up protocol we established for Mr. King — connecting our team directly with his London GP — is not a courtesy. It is a clinical necessity. Oncological surveillance cannot have a gap at the international border.

How CMCS Shanghai Coordinated This Case

China Medical Concierge Shanghai (CMCS) supported Mr. King's care pathway from initial overseas inquiry through 1-year oncological follow-up. Our coordination included:

• Pre-arrival review of CT imaging, prior operative records, and renal function history; specialist referral to Dr. Sun Ying's urology team at Renji Hospital, Shanghai Jiao Tong University
• Arrangement of CT urography, enhanced MRI bladder staging, cystoscopic biopsy, and renal function panel for complete pre-treatment assessment
• Bilingual interpretation during the multidisciplinary treatment planning consultation, including detailed explanation of the staged treatment strategy, neoadjuvant immunotherapy rationale, mini-PCNL technique, en-bloc TURBT approach, and realistic quality-of-life outcomes compared with radical cystectomy
• Coordination of percutaneous nephrostomy drainage: interventional radiology scheduling, drain management guidance, and serial creatinine monitoring until chemotherapy eligibility was confirmed
• Neoadjuvant treatment coordination: oncology referral for GC plus toripalimab regimen initiation, cycle scheduling, toxicity monitoring, and interim MRI response assessment
• Surgical admission logistics for both mini-PCNL and TURBT procedures: hospital registration, operative suite scheduling, and accommodation support for accompanying family
• On-site medical interpretation throughout both hospitalisations, including ERAS protocol guidance, catheter management, and discharge planning
• Establishment of bilingual follow-up protocol: English-language summary records prepared for Mr. King's London GP; direct communication channel between Dr. Sun's team and the GP for ongoing surveillance coordination
• 3-month cystoscopy coordination: scheduling, results translation, and communication to the London oncology team
• Maintenance immunotherapy coordination: toripalimab cycle scheduling, toxicity monitoring, and 1-year surveillance planning

For international patients facing the combination of complex urological stone disease and bladder cancer — particularly those with a solitary functioning kidney, or those who have been told that radical cystectomy with permanent urostomy is their only option — the combination of mini-PCNL expertise, neoadjuvant immunotherapy capability, and en-bloc bladder-sparing surgery at Shanghai's leading urology centres represents a pathway to treatment that preserves both life and quality of life. CMCS exists to connect patients with that pathway: ensuring every organ-sparing option is evaluated, every treatment decision is explained in their language, and every step from pre-operative drainage to long-term oncological surveillance is coordinated across borders with precision and care.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.