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There arevariousguidelines thatsuggests SWL as the treatment choice for kidney stones with sizes less than 2 cm and treatment of larger stones with PCNL. The lower pole stone results are poor with other modalities so primary PCNL might be justified for stones larger than 1. Till now flexible URS has not been mentioned by most guidelines. Very few dataare available on the use of flexible URS for lower polar Kidney stones. The latest ureterenoscopes allow access to almost all calices and, together with laser lithotripsy, ureteral access sheaths and vide variety of baskets and retrieval devices, allows the removal of most calculi  Initially variousauthors reportedRIRS in patients with large stone burden who were either unfit for surgery or combined this procedure with other procedure such as SWL.
In their study, the mean calculated stone surface area was mm2 Range 58 mm mm2. In another study Grasso, et al. Prabhakar reported30 cases of upper ureteric and renal stones 1. They reported that26 patients out of 30 The stone free rate in RIRS is Another study was done at our centre on 94 patients who underwent RIRS in whom stone size was 2.
Stone free rate was In eight patients 8. We concluded that RIRS and laser lithotripsy can be performed safely and effectively in patients with renal stones more than 2 cm which were previously managed by other more invasive techniques.
Further prospective randomised trials are needed for this subset of patient . They found complete stone-free rates were The respective complication rates evaluated using the Clavien system were Prospective randomized controlled trials are needed to confirm these findings 2.
With the advent of flexible URS, however, the treatment of such renal stones became an attractive option. Managing asymptomatic renal stones at the time of URS for symptomatic ureteral stones significantly prolongs surgery duration but does not lengthen hospital stay, increase complications, or lower success rates.
This combined approach reduces the need for future procedures and is probably more cost effectiveOther authors have also studied Concomitant renal and ureteric stones safely removed by RIRS in a single session. This combined approach is expected to reduce the need for future procedures and seems to be more cost-effective . InChon et al. Bilateral single-session RIRS and laser lithotripsy can be performed safely and effectively with a high success rate and low complication rate in patients with bilateral renal stones.
In one studytotal of 42 patients 28 male, 14 female were studied. The mean stone size was We did a study on 74 patients in whommean stone size was The stone-free rates were In eight patients We Concluded that in patients with bilateral renal stones up to 1.
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Until now, the ureteroscopic procedure including RIRS has shown its safety in patients with bleeding disorders with an acceptable level of increase in complications[23,24]. Renal Stones inAnomalous Kidneys Due to the presence of structural and anatomical differences that accompany anomalous kidneys, currently available endourological modalities such as SWL and PNL may be insufficient, or additional laparoscopic assistance may be required. Many Authors have evaluated the efficacy and safety of retrograde flexible ureterorenoscopic stone treatment in patients with kidney anomalies.
Their patientshad an average preoperative stone size of1. Six patients had complete clearance of the stone on postoperative imaging. No patients required additional surgical intervention . Twenty-five patients with renal anomaly wereevaluated in another study which consisted of3 horseshoe kidneys 1 cross-fused ectopic kidney,13 ectopic kidneys [6 pelvicand 7 lumbar kidneys], four renal malrotations and four duplicate ureters.
These patients were treated by flexible Ureterorenoscopy and laser lithotripsy. Seven of the patients with residual stones underwent a second session and the remaining three patients were subsequently treated with SWL. The authors concluded that Flexible Ureterorenoscopy with holmium laser lithotripsy is a safe option for the treatment of renal stones in anomalous kidneys with satisfactory success rates .
The stone-free rate in their study was Similarly, Atis, et al. Comparing with PNL, RIRS harbor advantages such as less invasiveness, no need for blood transfusion, shorter hospital stays and fewer contraindications  Jie Ding, etal. Ten patients obtained stone-free status with one session while four obtained stone-free status after two sessions.
Single session stone-free rate was Two patients had small residual stones in the lower pole Since last sevenyears an increasing number of successful reports on using Flexible URS in treating HSK urolithiasis are reported, we started to perform F-URS on Horse shoe kidney patients with renal stones.
Recently we evaluated the files of 9 patients 7 men and 2 women who underwent RIRS for the treatment of lower calyceal stones in a HSK between April and December at our tertiary centre for stone diseases. Total, 12 renal units with lower calyceal stones were treated, as 3 patients had stones in both kidneys. Discussion The first description of a retrocaval ureter was made by Hochstetter in Initially, it was thought to be an anomaly of ureteral development.
However, advances in embryology studies have shown that it is abnormal development of the IVC. Postulated by Shulman inthe most accepted theory today suggests the persistence of the subcardinal vein which regresses during normal development as the IVC, crossing the middle portion of the ureter thereby placing it in a retrocaval position.
Other authors suggest the persistence of the posterior cardinal veins as the inferior cava vein. In both theories, failure of the development of the supracardial vein as the infra-renal IVC is common sense 13.
Patients generally present symptoms in the third or fourth decade of life, especially symptoms related to ureteral obstruction and hydronephrosis, such as right flank pain, repetitive urinary infections and nephrolithiasis; patients may complain of hematuria 4.
Excretory urography was a commonly used method to diagnose the circumcaval ureter, showing dilation of the renal calyces, the renal pelvis and of the proximal ureter above the obstruction. Typically, contrast may fail to fill the posterior portion of the IVC, reinforcing the diagnostic hypothesis 5. More recently, computed tomography has been considered the gold standard in the diagnosis of this pathology, since it is noninvasive and accurately determines the anatomical relationships between the ureter and the IVC, thereby helping in the differential diagnoses, especially of retroperitoneal masses that can cause extrinsic compression and of retroperitoneal fibrosis 4.
Conclusions Similar to this case report, most cases described in the literature involve the right ureter. Only patients who are symptomatic or those who have complications related to ureteral compression should be treated surgically. However, attention should be paid during surgical procedures for other comorbidities in these patients, since anatomical variations may lead to unintentional lesions.
To date, the patient remains asymptomatic and she is monitored in the outpatient clinic. Acknowledgements Footnote Conflicts of Interest: The authors have no conflicts of interest to declare.
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Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Veia cava inferior pre-ureteral: Acta Pediatr Port ; Indian J Surg ; Retrocaval ureter and associated abnormalities. Int Urol Nephrol ;