Introduction: Urolithiasis is of high prevalence in clinical practice. Recurrent urolithiasis constitutes a challenge for the Urologist.

Case Report: We present the case of a 53-year-old male patient, with prior history of urolithiasis, who had already been submited to endoscopic treatment in three different moments, medical treatment after metabolic study and a laparoscopic left pyeloureterolithotomy, with extraction of 3 stones, with the post-operative computed tomography showing a stone free kidney and ureter. Six months after the last surgery, he had a bilateral obstructive pyelonephritis, with the abdomino-pelvic computed tomography revealing three stones in the proximal left ureter of 13, 14 and 21 mm and a 8 mm stone in the lumbar right ureter. Bilateral double J stents were placed. Three months later he underwent a new laparoscopic left pyeloureterolithotomy, that we present on this video. The patient was placed in right lateral decubitus. Four trocars were placed (2 of 12 mm and 2 of 5 mm). The first step was the identification of the kidney. Inflammatory changes were identified in the peripyelic and periureteral zone, consistent with previous surgery and the recent pyelonephritis. Then the pyeloureteral junction was approached, where the bigger stone was placed. The three stones were extracted intact, and sent for biochemical analysis. The double J stent, which was calcified, was also extracted. A new double J stent was placed anterogradely. The pyeloureteral junction was closed with a running suture of a 3/0 absorbable suture (Vycril ®). An aspirative drain was placed. Surgical time: 130 minutes. Blood loss: 50 mL. The post operative period was uneventful, with the vesical catheterization being removed on the first day and the drain on the third. An abdomino-pelvic computed tomography was performed after one month, revealing a stone free kidney and ureter on the left side. The stent was extracted at the sixth postoperative week.

Conclusion: Our case demonstrates that despite the various developments in endoscopic technologies, there is an important role for laparoscopic and even open surgery for the management of giant ureteric stones in order to achieve the best results and a stone free patient.