Renal calculi in patients with ureteropelvic junction obstruction (UPJO) present a therapeutic challenge, as both conditions must be addressed when selecting an appropriate surgical intervention. In cases of recurrent UPJO following dismembered pyeloplasty, an endoscopic approach may be preferable due to potential difficulty in dissecting fibrotic tissue from previous surgery. Moreover, endoscopic techniques allow for simultaneous treatment of both renal calculi and recurrent obstruction in a single procedure. Miniature Endoscopic Combined Intrarenal Surgery (mini-ECIRS) has emerged as a transformative technique for managing complex renal stones and concomitant UPJO. By combining percutaneous and retrograde endoscopic access, this dual approach provides enhanced visualization, facilitates complete stone clearance, and enables precise endopyelotomy for recurrent UPJO under direct vision from both antegrade and retrograde perspectives. The Thulium Fiber Laser (TFL) offers superior precision, minimal collateral thermal damage, and efficient tissue ablation. Compared to holmium:YAG lasers, TFL operates at lower energy levels, enabling fine dusting of calculi and more controlled tissue incision during endopyelotomy. The integration of mini-ECIRS with TFL optimizes stone clearance and ensures accurate UPJ incision, making it an ideal option for patients with recurrent UPJO and associated renal calculi. This case highlights the effectiveness of this minimally invasive combined approach in achieving favorable clinical outcomes.

CASE PRESENTATION : A 51-year-old female with a history of left ureteropelvic junction obstruction (UPJO) underwent laparoscopic dismembered pyeloplasty in 2014. During routine follow-up imaging in 2024, a computed tomography (CT) scan revealed severe left hydronephrosis due to recurrent UPJO, along with two non-obstructing renal pelvic stones measuring 1.0 cm and 0.7 cm. The patient subsequently underwent mini-Endoscopic Combined Intrarenal Surgery (ECIRS) for lithotripsy of the renal calculi, combined with retrograde endopyelotomy under direct vision using a Thulium Fiber Laser (TFL), setting 1J 2Hz. At the end of the procedure, a double-J (DJ) stent was placed, and no nephrostomy tube was required.

The patient was discharged on postoperative day one without complications. Follow-up imaging confirmed complete stone clearance.

This case highlights the successful management of recurrent ureteropelvic junction obstruction (UPJO) and concomitant renal calculi using Endoscopic Combined Intrarenal Surgery (ECIRS) and retrograde endopyelotomy with a Thulium Fiber Laser (TFL). The combination of these minimally invasive techniques allowed for effective stone fragmentation and accurate UPJ incision. This approach demonstrates the potential for improved patient outcomes in the treatment of recurrent UPJO with renal calculi. Further studies are warranted to assess long-term efficacy and recurrence rates.