the authors present a case of giant ureteric calculus highlighting the importance of plain film radiograph in the assessment of children with suspected renal tract calculi .
ultrasonography demonstrated left hydronephrosis and a 2 cm echogenic area with acoustic shadow in the proximal ureter , consistent with a ureteric calculus .
plain radiography astonishingly revealed a large 7 cm radio - opaque shadow in the line of the left ureter extending from the left pelvi - ureteric junction to the mid - ureter , and a second 4 cm opacity in the left distal ureter ( fig 1 ) .
plain abdominal radiograph demonstrating large opacity extending from the left pelvi - ureteric junction to the mid ureter , and a smaller opacity in the distal ureter .
a dmsa scan showed split renal function of 30% on the left side and 70% on the right .
the left distal ureter was identified using an extraperitoneal approach through a left iliac fossa incision .
the distal calculus was extracted through a longitudinal ureteric incision . as it was not possible to retrieve the proximal stone through this incision
the proximal ureteric calculus measured 6.5 x 1.8 cm and weighed 7991 milligrams ( fig 2 ) .
ureteric calculi removed from the proximal ( left ) and distal ( right ) ureter .
it was composed of 85% magnesium ammonium phosphate ( struvite ) and 15% carbonate apatite .
the uk incidence of urolithiasis in children has been estimated to be two per million per annum ( 1 ) .
giant. renal tract calculi commonly present with renal colic , haematuria , urinary tract infections or lower urinary tract symptoms .
giant ureteric calculi have been reported to present with urinary tract infection and retention of urine ( 2,3 ) .
they can however be asymptomatic and progress silently , as was characterised by our case , where the giant calculus was discovered incidentally .
current practice reflects evidence that ultrasonography is more sensitive than plain radiography in detecting renal tract calculi in children ( 4,5 ) .
however , ultrasonography is less sensitive in detecting and characterising ureteric stones than plain radiography .
a combination of ultrasonography and plain radiography has therefore been recommended as the standard assessment .
ultrasonography does not always accurately characterise ureteric calculi and if a plain radiograph had not been performed , the extent of the calculus would not have been appreciated and a different course of management may have been undertaken .
the management of giant ureteric calculi entails removal of the calculus or nephroureterectomy depending on kidney function .
the authors wish to emphasise the importance of including a plain abdominal radiography in the pre - operative assessment of ureteric calculus in children .
 giant ureteric calculi are extremely rare in children . 
 we present a case of a child who was originally admitted for observation following non - accidental injury and had an episode of painless haematuria as an inpatient . 
 ultrasonography demonstrated left hydronephrosis and a 2 cm echogenic area in the proximal ureter . 
 a plain abdominal radiograph surprisingly revealed two left ureteric calculi , one 7 cm and the other 4 cm in length . 
 stone extraction was achieved using an open left ureterolithotomy and pyelolithotomy . 
INTRODUCTION
CASE PRESENTATION
DISCUSSION