Neoinfundibulotomy For The Management Of Symptomatic Caliceal Diverticula

Creation of a neoinfundibulum and serial balloon dilations for the treatment of the excluded calyx: Two cases describing a novel technique

An excluded calyx is a rare, acquired urologic condition where there is discontinuity between a portion of the renal collecting system with the remainder of the collecting system. Re-establishment of reliable long-term communication between the excluded calyx and the remaining collecting system is crucial for preservation of renal function and possible relief of symptoms. In this manuscript, we discuss two such cases where a previously undescribed novel procedure is used for treatment of this uncommon condition, where percutaneous antegrade transcatheter techniques were used to establish long-term urinary drainage. The first case discusses an excluded calyx in a 17-year-old male who suffered left renal injury after a high speed motor vehicle accident, where the kidney was divided by the injury and subsequently required creation of a neoinfundibulum in order to maintain continuity of the collecting system. The second case involves a 39-year-old female who underwent resection of a renal cell carcinoma, later developing an excluded calyx where radiofrequency wire recanalization was performed and the neoinfundibular track underwent serial retrograde balloon dilation, resulting in a continuous collecting system. Both patients have done well for more than 2 years after neoinfundibulum creation, showing that this novel technique should be considered a viable and safe procedure in the treatment of this rare condition.

Retrospective Analysis of Ultrasound-guided Flexible Ureteroscopy in the Management of Calyceal Diverticular Calculi

Background:

Percutaneous nephrolithotomy (PCNL) is the most widely recommended treatment for calyceal diverticular calculi, providing excellent stone-free results. However, its invasiveness is not negligible considering its major complication rates. Flexible ureteroscopy (FURS) is currently used to treat calyceal diverticula. However, the greatest drawback of FURS is locating the diverticulum since its neck is narrow and concealed. In such a case, the FURS procedure must be converted to PCNL. The aim of this study was to evaluate ultrasound-guided flexible ureteroscopy (UFURS) identifying diverticulum and the management of calyceal diverticular calculi.

Methods:

A retrospective analysis was conducted on 24 patients who had calyceal diverticular calculi. In all 12 patients in the UFURS group, direct FURS failed to find evidence of calyceal diverticula but were confirmed with imaging. The other 12 patients in the PCNL group received PCNL plus fulguration of the diverticular walls.

Results:

Puncture of calyceal diverticulum was successful in all 12 UFURS patients. Two patients in this group had postoperative residual calculi and two patients developed fever. In the PCNL group, percutaneous renal access and lithotomy were successful in all 12 patients. One patient in this group had residual calculi, one had perirenal hematoma, and two patients developed fever. No significant difference was found in the operating time (UFURS vs. PCNL, 91.8 ± 24.2 vs. 86.3 ± 18.7 min), stone-free rate (UFURS vs. PCNL, 9/12 vs. 10/12), and rate of successful lithotripsy (UFURS vs. PCNL, 10/12 vs. 11/12) between the two groups (all P > 0.05). Postoperative pain scores in the FURS group were significantly lower than that in the PCNL group (2.7 ± 1.2 vs. 6.2 ± 1.5, P < 0.05). Hospital stay in the UFURS group was significantly shorter than that in the PCNL group (3.4 ± 0.8 vs. 5.4 ± 1.0 days, P < 0.05). All patients were symptom-free following surgery (UFURS vs. PCNL, 10/10 vs. 12/12).

Conclusion:

Ultrasound-guided puncture facilitates identification of calyceal diverticula during FURS and improves the success rate of FURS surgery.

Anatomy and Physiology of the Urinary Tract: Relation to Host Defense and Microbial Infection

The urinary tract exits to a body surface area that is densely populated by a wide range of microbes. Yet, under most normal circumstances, it is typically considered sterile, i.e., devoid of microbes, a stark contrast to the gastrointestinal and upper respiratory tracts where many commensal and pathogenic microbes call home. Not surprisingly, infection of the urinary tract over a healthy person's lifetime is relatively infrequent, occurring once or twice or not at all for most people. For those who do experience an initial infection, the great majority (70% to 80%) thankfully do not go on to suffer from multiple episodes. This is a far cry from the upper respiratory tract infections, which can afflict an otherwise healthy individual countless times. The fact that urinary tract infections are hard to elicit in experimental animals except with inoculum 3-5 orders of magnitude greater than the colony counts that define an acute urinary infection in humans (105 cfu/ml), also speaks to the robustness of the urinary tract defense. How can the urinary tract be so effective in fending off harmful microbes despite its orifice in a close vicinity to that of the microbe-laden gastrointestinal tract? While a complete picture is still evolving, the general consensus is that the anatomical and physiological integrity of the urinary tract is of paramount importance in maintaining a healthy urinary tract. When this integrity is breached, however, the urinary tract can be at a heightened risk or even recurrent episodes of microbial infections. In fact, recurrent urinary tract infections are a significant cause of morbidity and time lost from work and a major challenge to manage clinically. Additionally, infections of the upper urinary tract often require hospitalization and prolonged antibiotic therapy. In this chapter, we provide an overview of the basic anatomy and physiology of the urinary tract with an emphasis on their specific roles in host defense. We also highlight the important structural and functional abnormalities that predispose the urinary tract to microbial infections.

Is retrograde flexible nephrolithotripsy feasible for calyceal diverticular stone?

The aim of this study is to manage the calyceal diverticular (CD) stone, several treatment options were applied but it is still a challenging condition of endourology. In this retrospective study, we aim to report the results of our patients with CD stones treated with retrograde flexible nephrolithotripsy (RFNL). A total of 47 patients (55 procedures) who underwent RFNL by a single surgeon for CD stones from January 2004 to March 2013 were evaluated retrospectively. The demographic properties and initial complaints of those patients have been recorded along with their comorbidities and previous history of stone management. Moreover, the size and number of the stones, the duration of the surgery, fluoroscopy time, stone-free rate (SFR) and postoperative complications of the patients have been evaluated. The mean age was 41.8 years (range 16-71). Of the study population, 31 (65.9%) were male. Mean stone size was 21.1 (7-52) mm whereas in 3 (6.4%) of the cases the stones could not be reached. Mean duration of the surgery was 92.8 (57-163) min whereas mean fluoroscopy time was 35.9 (14-103) s. After 3 months of follow-up period, the SFR was 85.1%. No major complications occurred. RFNL with holmium laser and nitinol basket catheter application is a feasible and successful procedure in the management of CD stones. With its high success rates, low incidence of complications and minimal morbidity when compared with other treatment options, RFNL has the potential of becoming the preferred treatment option in the minimally invasive management of patients with CD stones.

Percutaneous nephroscopic surgery

With the development of techniques for percutaneous access and equipment to disintegrate calculi, percutaneous nephroscopic surgery is currently used by many urologists and is the procedure of choice for the removal of large renal calculi and the management of diverticula, intrarenal strictures, and urothelial cancer. Although it is more invasive than shock wave lithotripsy and retrograde ureteroscopic surgery, percutaneous nephroscopic surgery has been successfully performed with high efficiency and low morbidity in difficult renal anatomies and patient conditions. These advantages of minimal invasiveness were rapidly perceived and applied to the management of ureteropelvic junction obstruction, calyceal diverticulum, infundibular stenosis, and urothelial cancer. The basic principle of endopyelotomy is a full-thickness incision of the narrow segment followed by prolonged stenting and drainage to allow regeneration of an adequate caliber ureter. The preferred technique for a calyceal diverticulum continues to be debated. Excellent long-term success has been reported with percutaneous, ureteroscopic, and laparoscopic techniques. Each approach is based on the location and size of the diverticulum. So far, percutaneous ablation of the calyceal diverticulum is the most established minimally invasive technique. Infundibular stenosis is an acquired condition usually associated with inflammation or stones. Reported series of percutaneously treated infundibular stenosis are few. In contrast with a calyceal diverticulum, infundibular stenosis is a more difficult entity to treat with only a 50-76% success rate by percutaneous techniques. Currently, percutaneous nephroscopic resection of transitional cell carcinoma in the renal calyx can be applied in indicated cases.

Percutaneous balloon dilatation of stenotic calyceal diverticular infundibula in patients with recurrent urinary tract infections

AIM

Renal calyceal diverticula are usually detected as incidental findings on intravenous pyelograms (IVPs) and rarely manifest any clinical signs or symptoms. However, they can interfere with patient's quality of life in a number of instances causing pain, recurrent urinary tract infections (UTIs), abscess, systemic sepsis and calculus formation. The purpose of this study was to review the clinical indications, procedure technique and clinical outcome in all patients referred to Interventional Radiology for the percutaneous management of renal calyceal diverticula.

MATERIALS AND METHODS

A retrospective review of all patients treated with percutaneous balloon dilatation of calyceal diverticular infundibula in the Interventional Radiology Department over a 10-year period was performed. Data collected included clinical details, laboratory indices, IVP and CT findings, procedure details and clinical outcome.

RESULTS

A total of three patients were treated over the course of the study period. All patients were young females who presented as a result of recurrent urinary tract infections. The calyceal diverticula were diagnosed incidentally on routine IVPs, with CT eloquently confirming the plain film findings in two cases. Technical procedure success was achieved in all cases, avoiding surgical intervention. Clinical follow-up revealed no further UTIs following dilatation.

CONCLUSION

Fluoroscopic guided percutaneous balloon dilatation of renal calyceal diverticular infundibula following direct diverticular puncture is a safe and well tolerated method to reduce UTI and potentially avoid future stone formation.

Techniques for fluoroscopic percutaneous renal access

PURPOSE

Percutaneous nephrolithotomy has undergone considerable evolution since its introduction in the 1970s, which has been driven by advances in access techniques, instrumentation and endoscopic technology. Recent reports suggest an increase in the number of percutaneous stone treatments being performed. However, despite the increasing use of percutaneous nephrolithotomy a minority of urologists obtain their own access. We reviewed the techniques for performing safe and effective percutaneous renal access.

MATERIALS AND METHODS

A literature search using Entrez PubMed was performed. All relevant literature concerning techniques for fluoroscopic percutaneous renal access published within the last 20 years was reviewed.

RESULTS

The success of percutaneous nephrolithotomy is critically dependent on achieving suitable percutaneous access. The ideal site of percutaneous puncture should be selected to maximize the use of rigid instruments, minimize the risk of complications and attain stone-free status. Familiarity with basic renal anatomy is essential to obtain access safely. Adherence to basic principles allows the establishment of percutaneous access in a straightforward and efficient manner. Certain clinical situations may require special access techniques.

CONCLUSIONS

Percutaneous nephrolithotomy is the treatment of choice for complex stone disease. While the efficacy of percutaneous nephrolithotomy relies on the establishment of effective percutaneous access, there are considerable advantages for the urologist able to achieve access.

Endourological re-establishment of a disrupted infundibulum after renal laceration

We report a case of severe urinary extravasation after renal contusion and its successful management by endoscopic creation of a neoinfundibulum. When the stenotic infundibulum cannot be traversed with a guide wire, creation of a new infundibulum will offer a secure alternative for accessing the collecting system.

Ureteroscopy for Symptomatic Hydrocalices: A Case Series

BACKGROUND

Hydrocalix is an uncommon condition that typically is treated with percutaneous dilation of the stenotic infundibulum. Ureteroscopy has the advantage of minimizing invasiveness.

METHODS

We reviewed our experience with 12 retrograde ureteroscopies for hydrocalix in 10 patients.

RESULTS

Access to the hydrocalix could not be achieved in one. Of the remaining 11, the original infundibulum was dilated in all but one, in whom neoinfundibulotomy was performed with a laser. The laser was used in eight cases, balloon dilation with cautery in two, and cautery alone in one. Of the seven hydrocalices bearing stones, four were rendered stone free. Immediate symptomatic success was achieved after 6 of the 11 evaluable procedures (one patient was lost to follow-up after a technically successful procedure). Of the five symptomatic failures, three went on to additional treatment (one ureteroscopy and two percutaneous), one elected against treatment despite recurrence of stenosis, and one had persistent pain owing to stones even though the hydrocalix was cured. Of the six symptomatic successes, three were without symptoms at a mean 25 months of follow-up, two have had recurrences necessitating additional treatment (both percutaneous) a mean of 51 months later, and one did not have adequate imaging follow-up.

CONCLUSION

Ureteroscopy for hydrocalix achieved technical success in most patients, but relief of symptoms followed only about half of the procedures. A trial of ureteroscopy does not preclude subsequent success with a percutaneous approach. Ureteroscopy is a reasonable option for hydrocalix for patients who wish to avoid percutaneous surgery.

PERCUTANEOUS NEPHROLITHOTOMY FOR CALICEAL DIVERTICULAR CALCULI: A NOVEL SINGLE STAGE APPROACH

PURPOSE

Current percutaneous treatment of symptomatic caliceal diverticular calculi involves renal access, stone removal, dilation of the diverticular communication, fulguration of the cavity and placement of a nephrostomy tube. We reviewed the outcomes of patients undergoing a novel single stage percutaneous nephrolithotomy technique for radiopaque caliceal diverticular stones that eliminates ureteral catheterization and entry into the renal collecting system.

MATERIALS AND METHODS

A total of 21 patients (8 male and 13 female including 1 bilateral) with a mean age of 42.4 years underwent percutaneous nephrolithotomy for caliceal diverticular stones from February 2001 to May 2003. Of the diverticula 12 were upper pole, 4 were interpolar and 6 were lower pole. Infracostal access was established by the urologist directly onto the radiopaque stones without the aid of a ureteral catheter. After balloon tract dilation a 30Fr Amplatz sheath was placed and following stone removal the diverticulum was fulgurated. The infundibulum was neither cannulated nor dilated. A 20Fr red rubber catheter or an 8.5Fr Cope loop was placed into the diverticulum. Stone-free status was assessed by noncontrast computerized tomography on postoperative day 1 (POD1). The drainage tube was removed if there was no urine drainage and the kidney was stone-free. Excretory urography was performed at 3 months to evaluate diverticular resolution.

RESULTS

Of 21 patients 20 were discharged home tubeless on POD1 and 18 of 21 (85.7%) renal units were stone- free on POD1 noncontrast computerized tomography. Mean operative time was 58.5 minutes and mean stone burden was 138.9 mm. Mean stone diameter was 11.6 mm and mean diverticular diameter was 15.3 mm. Of 22 renal units 16 had followup excretory urography. All diverticula decreased in size and 14 (87.5%) had complete resolution.

CONCLUSIONS

In patients with symptomatic radiopaque caliceal diverticular stones, a single stage procedure without the need for ureteral catheterization combined with direct infracostal diverticular puncture allows for a rapid procedure with little morbidity.

Retroperitoneoscopic management of caliceal diverticular calculi

INTRODUCTION

The management of caliceal diverticular calculi has changed from an open surgical approach to endoscopic management.

TECHNICAL CONSIDERATIONS

Different minimally invasive treatment modalities, such as extracorporeal shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, laparoscopy, and retroperitoneoscopy, can be offered to the patient. We report on a retroperitoneoscopic operative technique using endosonography for location and performing nephrotomy with complete excision of the caliceal diverticulum and ligation of the diverticular neck with an Endo-loop.

CONCLUSIONS

The advantages of this minimally invasive technique include total excision of the diverticulum with no risk of recurrence and easy and complete closure of the diverticular neck.

Endoscopic surgery for renal calculi

PURPOSE OF REVIEW

Endoscopic surgery plays an important role in the treatment of renal calculi, especially for the more complex cases. Recent advancements have improved the efficacy of procedures, and increasing surgeon experience is associated with low complication rates. This article will review recent literature pertinent to endoscopic surgery for renal calculi.

RECENT FINDINGS

Endoscopic renal calculus removal is associated with up to >90% calculus clearance rates. This is true for both retrograde and percutaneous approaches. The added utility of flexible instrumentation and holmium laser therapy have contributed greatly to improving surgical success. With increased experience in endoscopic techniques, major complications occur in approximately 1% of patients. Most procedures are performed on an outpatient (retrograde) basis or a <23 h inpatient (percutaneous) basis.

SUMMARY

Endoscopic surgery is safe, and the most efficacious therapy with low morbidity for renal calculi.

Percutaneous nephrolithotomy: an update

PURPOSE OF REVIEW

Percutaneous nephrolithotomy has undergone an evolution in technique and in equipment since its introduction in the late 1970s. This evolution continues today and is evidenced by the numerous publications about the technique. This review summarizes some of the important articles over the past year.

RECENT FINDINGS

Although ureteroscopy and shock wave lithotripsy predominate in the treatment of urolithiasis, percutaneous nephrolithotomy continues to play an important role. Percutaneous nephrolithotomy is advantageous as it causes minimal renal injury and maximizes stone clearance, especially in patients with complex stone disease. Although nephrostomy drainage tubes have always been placed after percutaneous nephrolithotomy, there may be specific indications for tubeless percutaneous nephrolithotomy.

SUMMARY

Percutaneous nephrolithotomy continues to be an important part of the urologist's armamentarium. Recent studies have redefined the role of percutaneous nephrolithotomy and future studies will further delineate the importance of this procedure in the treatment of urolithiasis.

Surgical management of the calyceal diverticulum

PURPOSE OF REVIEW

The management of calyceal diverticulum has evolved from an open surgical approach to a minimally invasive approach. Currently, the percutaneous, ureteroscopic and laparoscopic techniques are recommended by individual investigators. Recent studies have helped establish patient selection criteria for each of the above procedures. This review will discuss technique and results and suggest a treatment algorithm for the patient with a symptomatic calyceal diverticulum.

RECENT FINDINGS

Excellent long-term success has been reported with all three minimally invasive modalities. Percutaneous ablation of the calyceal diverticulum is the most established minimally invasive technique for this disorder. A direct puncture into the calyceal diverticulum is recommended. Limitations exist primarily for an anteriorly located diverticulum. In this situation, if the diverticulum is in a superior anterior calyx, a ureteroscopic approach is recommended while if the diverticulum is in a middle or lower pole calyx, a laparoscopic approach is recommended.

SUMMARY

This review suggests that experience and expertise in percutaneous, ureteroscopic and laparoscopic techniques provide the urologist with the best opportunity to individualize treatment approach based on location and size of the diverticulum. A treatment algorithm based on these parameters may be helpful in patient counseling and decision-making.

Surgical management of urolithiasis

The surgical management of urinary calculus disease has changed dramatically in the past two decades. Minimally invasive options have made open stone surgery nearly obsolete. The development of shock wave lithotripsy, percutaneous nephrostolithotomy techniques and intracorporeal lithotripsy devices has conferred unprecedented management tools for upper tract stones. Moreover, transfusion rates, hospital costs, and convalescence periods have been markedly reduced when compared to open surgery. Likewise, the advent of fiberoptic technology has resulted in miniaturization of ureteroscopes making access to the entire collecting system possible from either a retrograde or antegrade approach. With experience, successful stone retrieval has occurred in upwards of 90% of cases, again with minimal complications. The subspecialty of Endourology has emerged over the past 20 years and significantly changed the management of urinary tract calculi within this short period of time. Further advancements in shock wave and laser technology, training modules and the development of more durable endoscopes may prove beneficial in providing even better stone treatments with a reduction in morbidity.