Difficult DJ stenting: a severely kinked ureter and a hydronephrotic kidney

A 50-year-old woman visited my hospital after she heard of the presence of hydronephrotic kidney in the left side. She already underwent a ureteroscopic exam in the regional hospital to find a pathologic lesion in the left ureter, but the physician could not identify anything distal to the severely kinked ureteral site. He couldn't see the proximal part. He wrote that there must be obstruction in the left ureter in the referral sheet.

When she visited my hospital, I performed the percutaneous nephrostomy first to relieve the hydronephrosis in the left kidney. And then I decided to perform antegrade and retrograde approaches simultaneously.

There was no obstruction because we can see the blue indigocarmine dye in the ureter. Instead, we can see a narrowed ureteral lesion in the L3 level in the left side and a severely kinked ureter in the distal part. What would be the appropriate treatment? Do you agree that the patient needs a urinary diversion? DJ catheter is better than an indwelling PCN?

First I tried to insert a DJ catheter by using a flexible cystoscope. But the DJ catheter was sticked to the level of the kinked ureter and it did not move anymore. What is your plan?

Then I tried to an antegrade approach. I used an access sheath and a flexible URS. I pull the sticked ureter to the renal pelvis with a stone basket. It was a success.