Management of stones in abnormal situations

Laparoscopy-assisted ultrasound-guiding percutaneous nephrolithotomy for the treatment of stones in pelvic ectopic kidney: A case report

Background

Pelvic ectopic kidney is a kind of congenital malformations of urinary system due to the failure of ascent from the pelvis to the abdomen during development.

Case presentation

A 39-year-old man was referred to the urology department of our hospital for abdominal pain for half a month. Radiographic studies revealed stones in pelvic ectopic left kidney. Laparoscopy-assisted ultrasound-guiding percutaneous nephrolithotomy (PCNL) was performed. Postoperative plain film revealed that the patient achieved a stone-free status.

Conclusions

Laparoscopy-assisted ultrasound-guiding PCNL is a safe alternative for the treatment of stones in pelvic ectopic kidney with a high stone-free clearance.

Is There Still a Place for Percutaneous Nephrolithotomy in Current Times?

Background: Percutaneous nephrolithotomy (PCNL) and its miniaturized modifications are usually considered the standard surgical options for large (>20 mm) staghorn and infected stones. Moreover, PCNL is a viable alternative to retrograde intrarenal surgery (RIRS) for smaller stones (<20 mm) in the presence of anatomical malformations or inaccessible lower pole stones. However, due to the advancements in laser and scope technology, RIRS is expanding its indications with the potential benefits of lower complications and a shorter hospital stay. Methods: A literature search using the PUBMED database from inception to June 2022 was performed to explore the current role of PCNL in endourology. The analysis involved a narrative synthesis. Results: PCNL confirmed its role in the treatment of large and complex stones; moreover, miniaturized PCNL has become more competitive, gaining space among classic indications of flexible ureteroscopy. Conclusions: considering all the evaluated subgroups, we can conclude that PCNL is an old fascinating procedure and is here to stay.

Calyceal Diverticulum: A Case Report

Calyceal diverticulums are often benign and asymptomatic. On the other hand, some interventions are necessary in several symptoms. Radiological imaging is performed to made dianoses, but somehow can pose misinterpretation of radiological imaging results and mistreatment from the urologist. To present a case of a calyceal diverticulum treated with open diverticulectomy. This study reported a case of a calyceal diverticulum in a 30-year-old man with an almost 1-month history of left flank pain. The patient undergone several imaging diagnostics, before finally diagnosed calyceal diverticulum with a stone inside it. The patient had underwent open diverticulectomy. Initially, cystoscopy and insertion of Double J Stent (DJ Stent) were done, and then using the lumbotomy approach the incision that had been made. This case demonstrated the use of imaging combined with urologist interpretation and surgical management which was successfully treated the patient’s clinical problems.

The safety and efficacy of mini-percutaneous nephrolithotomy vs. retrograde intrarenal surgery for treatment of renal lithiasis in pelvic ectopic kidney: an exploratory pilot study

Background

To compare the safety and efficacy of mini-percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) for the treatment of renal lithiasis in patients with pelvic ectopic kidney.

Methods

From January 2015 to October 2017, mini-PCNL and RIRS were performed in ten patients diagnosed with lithiasis in pelvic ectopic kidneys, including three cases under laparoscopy-assisted mini-PCNL. Patient demographics and perioperative characteristics (age, gender, BMI, side of pelvic kidney, stone size, stone number, stone location, special medical history, and ASA physical status classification), and operative and post-operative related details (operation time, hospital stay, blood loss, VAS, analgesic requirement, complications, and stone free outcome) were reviewed.

Results

Although the mean operation time of mini-PCNL (71.3 min) was shorter than RIRS (85.3 min), the mean operation time of laparoscopy assisted mini-PCNL (92 min) was longer than patients without laparoscopy-assisted mini-PCNL (55.8 min). However, the use of mini-PCNL allowed for larger lithiasis to be dealt with (1.9 cm in laparoscopy assisted mini-PCNL and 2.4 cm in mini-PCNL without laparoscopy-assist) compared with RIRS (1.2 cm). In addition, although the mean hospital-stay time, blood loss, and analgesic requirement of patients undergoing RIRS were less than those receiving mini-PCNL, the success rate of RIRS was only 50% (3/6) in comparison to 100% (7/7) for mini-PCNL. Except for pain and urinary tract infection after the operation, there were no significant intraoperative and postoperative complications, and no residual lithiasis were seen in any patient.

Conclusions

Although RIRS was less time-consuming and invasive, mini-PCNL can deal with the bigger lithiasis and more complex situations with a higher success rate. Both mini-PCNL and RIRS are feasible and safe treatments for pelvic ectopic kidney lithiasis with each carrying unique advantages. Hence in practice, an appropriate individualized treatment should be selected depending on patient characteristics.

Laparoscopic and robotic surgery for stone disease

Treatment for stone disease has evolved drastically during the past 3-4 decades. Ureteroscopy, percutaneous nephrolithotomy along with SWL, provides the means to treat practically all urinary tract stones with minimal invasion to the patients. However, for complex stone case scenarios where open surgery is being considered, a less invasive and better tolerated option such as laparoscopy (robot assisted or not) can be performed. The present manuscript reviews role of laparoscopic and robotic surgery in treating urinary tract stones.

Percutaneous Management of Stone Containing Calyceal Diverticula: Associated Factors and Outcomes

PURPOSE

We evaluated the outcomes of percutaneous treatment and metabolic evaluation of calyceal diverticula with associated stones.

MATERIALS AND METHODS

We retrospectively identified 51 patients with a calyceal diverticulum in our prospectively maintained percutaneous nephrolithotomy database. Patients with complete data were separated into 14 with stones isolated to the diverticulum and 15 with renal stones in and outside the diverticulum. A total of 571 patients with renal stones but no diverticulum were used for comparison. Statistical differences were assessed using the chi-square test and the t-test.

RESULTS

Patients with stones isolated to the diverticulum were younger (44 vs 54 years, p = 0.024), had a lower body mass index (23.2 vs 27 kg/m², p = 0.032) and were more often female (71% vs 44%, p = 0.046) compared to patients with renal stones but no diverticulum. Calyceal diverticula were anterior in 19 of 29 cases and in the upper pole in 15. Average diverticular size was 2.5 cm with a 1.5 cm stone burden. Percutaneous treatment was successful in 96% of patients with a 4% complication rate. The diverticular neck was dilated in 22 of 51 patients (43%). During 5-year followup in the 51 patients there was 1 stone recurrence, which was managed by ureteroscopy, while 46 and 5 patients showed complete absence and reduction of the diverticulum, respectively. Of the calyceal diverticular stones 82% contained calcium phosphate compared to only 33% in patients with renal stones but no diverticulum. All patients with a diverticulum had at least 1 metabolic derangement.

CONCLUSIONS

Percutaneous treatment of calyceal diverticula is safe and effective regardless of size or location, including anterior diverticula. Infundibular neck dilation does not appear to be necessary. There are metabolic abnormalities in a significant proportion of patients with a calyceal diverticulum.

Stones in special situations

There are several special situations in which urinary lithiasis presents management challenges to the urologist. An in-depth knowledge of the pathophysiology, unique anatomy, and treatment options is crucial in order to maintain good health in these patients. In this review, we summarize the current literature on the management of the following scenarios: bladder stones, stones in bowel disease, during pregnancy, in association with renal anomalies, with skeletal deformities, in urinary diversions, and in children.

Percutaneous nephrolithotomy in pelvic kidneys: is the ultrasound-guided puncture safe?

OBJECTIVE

To demonstrate our experience with the use of ultrasound (USG) for puncture guidance while performing percutaneous nephrolithotomy in ectopic pelvic kidneys.

METHODS

From January 1990 to December 2013, we have performed percutaneous nephrolithotomy in 26 patients with USG-guided punctures. The stones were solitary in 15 patients (58%) and multiple in 11 patients (42%). The mean stone size was 22 mm (range, 10-50 mm), including 3 staghorn calculi. All procedures were performed in an oblique-supine position, and the intraoperative complications as the postoperative outcome were reviewed.

RESULTS

The mean operative time was 93 minutes, achieving complete stone clearance in 22 (88%) of the patients. One of the patients had urine leakage after removing nephrostomy, needing postoperative double J stenting. One patient had significant intraoperative bleeding requiring staging of the procedure and blood transfusion. No bowel injuries were identified. Mean hospitalization time was 5.6 days.

CONCLUSION

USG-guided puncture is a safe and effective approach to the collecting system even in renal anomalies like in pelvic ectopic kidneys when performed in experienced hands.