case_images: PMC7338919_01
case_images: Initial computed tomography (CT) urography.. The first CT Urography of the patient shows right staghorn stone with grade 3 hydronephrosis and left kidney cyst.
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case_images: Computed tomography (CT) urography at the previous hospital showed a staghorn stone at the right inferior calyx with a size of 45.7 x 59.3 x 27.5 mm (stone hardness in Hounsfield unit was not available) with a grade 3 right-side hydronephrosis and left kidney cyst. ( Figure 1).
case_images: Steinstrasse formation.. Immediate (
  a) and one-month (April 2016) (
  b) Kidney-Ureter-Bladder imaging following retrograde intrarenal surgery shows the right urinary system with multiple tiny stones.
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case_images: Post-RIRS imaging showed a double J (DJ) stent with multiple tiny stones from the right pelvio-calyces to vesicoureteral junction ( Figure 2a). A month later, when the patient came to our hospital for a second opinion, his kidney-ureter-bladder (KUB) imaging result had not changed ( Figure 2b).
case_images: Sequential imaging photos.. Imaging after right ureterorenoscopy, right nephrostomy, and right percutaneous nephrolithotomy in April 2016 (
  a), imaging after ureterorenoscopy and percutaneous nephrolithotomy in June 2016 (
  b), imaging after the second extracorporeal shock wave lithotripsy in June 2016 (
  c), imaging after the third extracorporeal shock wave lithotripsy in July 2016 (
  d), imaging after right laser ureterorenoscopy and replacement of right double J stent in July 2016 (
  e), imaging after extracorporeal shock wave lithotripsy in October 2016 (
  f), imaging after double J stent removal in October 2016 (
  g), imaging as a routine control in January 2018 (
  h &
  i), imaging after retrograde intrarenal surgery which shows no residual stone in June 2019 (
  j).
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case_images: Right ureteroscopy (URS), right nephrostomy, and right PCNL were performed and post-operative KUB imaging was conducted ( Figure 3a). Another right URS was performed two weeks later, showing the remaining 8-mm stone at the ureter-pelvic junction (UPJ; Figure 3b). Extracorporeal shock wave lithotripsy (ESWL) had been performed twice in June 2016, resulting in a decrease stone size to 6 mm. ( Figure 3c). Another ESWL was performed the next month ( Figure 3d). In July 2016, the patient underwent a right laser URS followed by replacement of the DJ stent ( Figure 3e). Three months later, another ESWL was performed ( Figure 3f). KUB imaging still showed residual right nephrolithiasis. ( Figure 3g). Almost two years later (January 2018), routine KUB imaging and CT urography showed no change in his right nephrolithiasis ( Figure 3h, i). In June 2019, he was persuaded by his family to re-try stone management and had the final RIRS at another hospital, with successful complete removal of the remaining stone( Figure 3j).