Staged transurethral surgery for complete stone clearance in a rare giant infected ureteral stone: a case report

Giant ureteral calculi are uncommon but pose significant management challenges. When associated with infection, they heighten the risk of urosepsis and complicate surgical planning, as conventional single-stage procedures may be hazardous. Optimal treatment for this rare combination remains undefined. We present a case of a giant infection-related ureteral stone successfully managed through a planned staged endourological strategy, achieving complete clearance and preservation of renal function. This report highlights a tailored approach providing a practical staging algorithm based on stone size (9 cm), infection status (Escherichia coli infection), and anatomical factors (stricture).

A 75-year-old female presented with left lower abdominal pain and was found to have a giant left ureteral calculus (maximum diameter of approximately 9 cm) causing hydronephrosis, with urine culture positive for Gram-negative bacilli. Given the large stone burden and active infection, a staged ureteroscopic strategy was employed to achieve complete clearance while minimizing septic risk. Three sequential procedures were performed at 3-week intervals: initial laser lithotripsy and stenting to establish drainage, followed by a time-limited second-stage for definitive stone extraction, and a final flexible ureterorenoscopy to clear residual fragments. At one-year follow-up, the patient was stone-free with preserved renal function.

This case demonstrates that a staged ureteroscopic strategy is safe and effective for rare, infectious giant ureteral calculi. It achieves initial infection control and renal preservation, followed by complete stone clearance while minimizing the risk of urosepsis. This approach offers a strategic solution for this complex clinical scenario.