Procedure: Urethral dilation, cystoscopy, right retrograde pyelogram, right ureteral dilation, right rigid ureteroscopy, right flexible digital ureteral pyeloscopy, laser lithotripsy of ureteral and renal calculi, placement of right double-J stent 6 x 26.

A 22-French cystoscope was then used to evaluate the patient. The patient was noted to have meatal stenosis. He underwent dilation of the fossa navicularis with Van Buren sounds up to 24-French.
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A 22-French cystoscope was then used to evaluate the patient. The anterior urethra was normal in appearance without any evidence of stricture. His urethrovesical anastomosis was intact. Upon entering the bladder, both ureteral orifices were identified, appeared to be in orthotopic position with clear
efflux of urine. Systematic evaluation of the bladder with a 30- and 70-degree angle lens demonstrated no gross intravesical pathology. Specifically, no gross inflammation, tumor, or calculi.
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A right retrograde pyelogram was performed. This demonstrated what appeared to be a stone near the iliac vessels. There was also evidence of calcification in the lower pole of the right kidney. The ureteral orifice was dilated with a Nottingham dilator. The cystoscope was then withdrawn.
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A 6.9-French semi-rigid ureteroscope was then used to evaluate the patient. The distal ureter was normal in appearance up to the iliac vessels. The stone appeared to be proximal to the iliac vessels, but unfortunately, I was unable to navigate the semi-rigid ureteroscope proximal to the iliac vessels. At this point, an additional wire was then placed through the working port of the semi-rigid ureteroscope and the ureteroscope was withdrawn.
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The digital ureteroscope was then advanced over the wire. We were able to identify the stone just proximal to the iliac vessels. Using the holmium laser, the stone was then dusted into multiple small fragments. The ureteroscope was then advanced at this point and a wire was placed through the digital ureteroscope and the ureteroscope was withdrawn. An 11 x 13 x 44 ureteral access sheath was then advanced. I was unable to advance the
ureteral access sheath proximal to the iliac vessels. Given this finding, I did place an additional wire, then advanced the ureteral scope into the right renal pelvis. The patient’s major stone burden was in the lower pole of the right kidney. The stone was then broken up into multiple small fragments. These fragments were too small to engage in a Nitinol basket. Systematic evaluation on remainder of the calyces demonstrated no evidence of any significant residual stone burden. At this point, then a retrograde pyelogram was performed through the scope. There did not appear to be any evidence of extravasation nor residual stone burden. The ureter was then examined as the ureteral scope was withdrawn. A 6 x 26 double-J stent was then placed into the right renal pelvis in a retrograde fashion under fluoroscopic guidance. The bladder was drained. The cystoscope was withdrawn. Please note, there was 1 stone fragment, which was retained, which will be sent for analysis. The patient tolerated the procedure well and was taken to the recovery room postoperatively. We will arrange for patient be discharged home with prescriptions for ciprofloxacin, Norco, and Ditropan. Mid-
level follow up in 1 week with KUB.