A 46-year-old male patient visited the hospital with severe flank pain caused by a urinary stone. He had initially visited another clinic due to left-sided flank pain and was diagnosed with a large radiolucent stone in the upper ureter. Radiolucent stones are not visible on standard X-ray imaging, which can make certain treatments more challenging. Because of this characteristic, endoscopic surgery is often considered when treating such stones.
The patient first underwent extracorporeal shock wave lithotripsy (ESWL), a common noninvasive treatment for urinary stones. However, the procedure failed to remove the stone. He was then advised to undergo endoscopic surgery and visited our hospital for further treatment.
The patient had a history of recurrent urinary stones. Further evaluation revealed a 17 mm stone located in the upper left ureter, along with hydronephrosis, a condition in which the kidney becomes swollen due to blocked urine flow. Surgery was performed using both rigid and flexible ureteroscopes. During the procedure, a laser was used to fragment the stone into smaller pieces that could pass naturally through the urinary tract. After fragmentation, a ureteral stent was inserted to maintain urine flow and support healing. Follow-up ultrasound confirmed that both the stone and hydronephrosis had resolved, and the ureteral stent was subsequently removed.
This case illustrates an important point: when extracorporeal shock wave lithotripsy is unlikely to effectively remove a stone, ureteroscopic endoscopic surgery should be considered as an alternative treatment option.
Urinary stones, also known as urolithiasis, refer to stones that form anywhere within the urinary system. Most stones originate in the kidneys and may move through the ureter, bladder, and urethra. As they travel through the urinary tract, they can obstruct urine flow and cause severe pain. In some cases, complications such as urinary tract infection, hydronephrosis, or even kidney failure may develop.
When urinary stones are diagnosed, extracorporeal shock wave lithotripsy is usually considered as the first-line treatment. One of its advantages is that it does not typically require hospitalization or anesthesia, and patients can often return to normal daily activities within about one hour after treatment. However, ESWL is not suitable for every type of stone.
There are several situations in which ureteroscopic stone removal may be a more appropriate treatment.
First, ureteroscopic surgery should be considered when complications such as kidney failure, hydronephrosis, or urinary tract infection are present. ESWL works by breaking stones into smaller fragments that are then naturally passed through urine. However, when kidney function is already impaired, urine flow may be insufficient to allow fragments to pass effectively. In addition, if a urinary tract infection is present, removing the stone promptly through endoscopic surgery can prevent the infection from worsening.
Second, ureteroscopic surgery is recommended for certain types of stones, including radiolucent stones, bilateral ureteral stones, and multiple stones within the ureter. Radiolucent stones cannot be visualized on X-ray imaging, which makes ESWL guidance difficult. In cases where stones are blocking both ureters simultaneously, urine flow from both kidneys may be obstructed, creating a potentially dangerous situation that can lead to acute kidney failure. Waiting for multiple ESWL sessions in such cases may not be safe. Similarly, when multiple stones are present in a single ureter, breaking only one stone may still leave other stones blocking urine flow. In these cases, ureteroscopic stone removal can be a more effective approach.
Third, ureteroscopic surgery is often recommended when the stone is larger than 1 cm. Large stones are less likely to be successfully fragmented with a single session of shock wave lithotripsy. Multiple treatment sessions may be required, usually spaced five to seven days apart to allow the body to recover from the shock waves. During this extended treatment period, the large stone may continue to block the ureter, causing ongoing pain and potentially worsening kidney function. For this reason, removing a large stone through ureteroscopic surgery in a single procedure may be faster and more effective.
According to data from the Health Insurance Review and Assessment Service (HIRA) in Korea, the number of patients with urinary stones has increased by approximately 13.9% over the past five years. Changes in dietary patterns, particularly increased consumption of animal protein and sodium, are believed to be contributing factors.
Urinary stones are known to cause pain that can be as severe as childbirth. Therefore, when extracorporeal shock wave lithotripsy does not successfully remove the stone, ureteroscopic stone removal should be considered as a definitive treatment option. Advances in surgical equipment—including both rigid and flexible ureteroscopes—have made these procedures safer and more effective than ever before.
If a patient’s condition resembles the case described above, consulting with a urology specialist to discuss the most appropriate treatment approach is strongly recommended.
As people age, various urologic conditions can begin to interfere with daily life. Providing objective and practical information about urologic health can help individuals maintain a healthier and more comfortable life during middle age and beyond.