Infundibulopelvic stenosis: a long-term followup

Endo-infundibulotomy of a hydrocalyx, mysterious pains after percutaneous nephrolithotomy: A case report

Hydrocalyx is a dilated renal calyx due to obstruction of the infundibulum and a rare complication after percutaneous nephrolithotomy. We present a 22-year-old girl with hydrocalyx who had following percutaneous nephrolithotomy and its management. A 22-year-old female with recurrent right flank pain underwent percutaneous nephrolithotomy for a kidney stone. Despite interventions such as endoscopic infundibulotomy and double J stenting, the patient experienced persistent symptoms. Laparoscopy ultimately led to improvement. Hydrocalyx is a rare but significant complication post-percutaneous nephrolithotomy. Minimally invasive procedures and endoscopic interventions are the primary treatment options. Laparoscopy may be considered if initial interventions fail. Formation of hydrocalyx after percutaneous nephrolithotomy is a rare yet considerable complication and there are only a few articles in this field available to our knowledge.

Congenital infundibulopelvic stenosis: Indications for intervention, surgical technique, and review of literature

INTRODUCTION

Congenital infundibulopelvic stenosis (IFPS) is a rare renal dysmorphism marked by dilated calyces proximal to diminutive infundibulum and renal pelvises. The entity is theorized to exist on the spectrum of congenital obstructive renal diseases between ureteropelvic junction obstruction and multicystic dysplasia.

OBJECTIVE

This case series sought to review and present the surgical management of three cases of IFPS with progressive renal insufficiency.

MATERIALS AND METHODS

After Institute Review Board approval, we reviewed three cases of IFPS treated by a single surgeon over a 20-year period. All cases displayed evidence of progressive renal decline. The first case of a 16-year-old female had IFPS in a solitary kidney, with previous contralateral nephrectomy of a multicystic dysplastic kidney. The second case, a 17-year-old male, presented after blunt trauma to the ipsilateral flank. The third case of a 10-year-old female presented with microhematuria, mild azotemia and bilateral IFPS.

RESULTS

Our current surgical management has evolved from renal sinus exposure and multiple infundibuloplasties in the first case to preoperative three-dimensional mapping of the dilated calyceal system with intraoperative ultrasonography for selective calicocalicostomies draining to a lower pole ureterocalicostomy in the third case. Our first case, treated with multiple infundibuloplasties experienced slow renal decline into her 20s, and the later cases, treated with calicocalicostomies, have experienced stable to mild loss of renal function with ongoing nephrological follow-up.

DISCUSSION

IFPS is a complex pediatric urology problem without a clear treatment algorithm. The goal of surgical intervention is to offer an opportunity to halt or reduce progressive renal insufficiency. Our current surgical approach utilizes preoperative three-dimensional modeling via magnetic resonance urography to guide placement of multiple calicocalicostomies draining to a lower pole ureterocalicostomy.

CONCLUSIONS

Not all cases of IFPS require surgical intervention. We have intervened in cases of IFPS with progressive hydronephrosis or worsening renal insufficiency with acceptable results.

Symptomatic Infundibulopelvic Dysgenesis in an Adolescent

Infundibulopelvic dysgenesis is a rare condition characterized by congenital malformation of the pelvicalyceal system. We present the case of an 18-year-old boy with chronic intermittent right flank pain and cystic dilation with parenchymal thinning on ultrasonography. The left kidney was normal. The patient denied dysuria, constipation, and history of UTIs or renal calculi. Cystoscopy with retrograde pyelogram showed marked stenosis of the right pelvicalyceal system and anatomy unfavorable to stenting. The patient's symptoms were unresponsive to conservative management. Reconstruction of the right collecting system was unsuccessful and a simple nephrectomy was performed, which led to complete resolution of his symptoms.

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.

Bilateral infundibulopelvic stenosis without renal insufficiency: is surgery necessary?

The following case describes the clinical course of a patient with bilateral infundibulopelvic stenosis from her initial presentation at age 2 through the age of 14 years. This condition is associated with hypoplasia of segments of the upper collecting system and is characterized by dilated calyces that drain through stenotic infundibulae. Our patient is unique in that, although her renal function has slowly deteriorated with time, she has a persistently non-obstructive pattern on dynamic imaging studies. Only a minority of patients reported in the literature with this condition progress to renal insufficiency or failure. Although some patients have undergone surgery for presumed obstruction, surgical intervention has no proven benefit. Patients are at risk for hyperfiltration injury and should be followed for the development of hypertension, proteinuria and renal insufficiency. Without evidence of obstruction, medical management remains the cornerstone of treatment.

Renal hypertrophic infundibular stenosis

Bilateral hydrocalycosis secondary to radiographically demonstrated bilateral infundibular stenosis required a left nephrectomy in an 18-year-old young man. The infundibular narrowing was due to marked hyperplasia of the submucosal smooth muscle. Scattered within the hypertrophic smooth muscle were rare spindled CD117-positive interstitial cells, similar to the cells responsible for peristaltic pacemaker activity within the gastrointestinal tract. The admixture of CD117 cells suggests this is a true muscular hyperplasia rather than a leiomyomatosis. The stimulus to the hyperplasia is unknown.

Childhood infundibular stenosis

Infundibular stenosis is a rare condition marked by dilation of one or more calices proximal to a stenotic infundibulum. Contrary to older reports, more recent information suggests that progressive renal dysfunction occurs in a significant number of these patients. We present a case of incidentally discovered infundibular stenosis. On the basis of the existing published reports, we make several recommendations. Close monitoring for a decline in renal function secondary to hyperfiltration injury is essential, and a worsening should prompt referral to a pediatric nephrologist. Progressive hydronephrosis should be corrected surgically, although proof of effect on the disease process is lacking in the evidence-based reports.

Use of ureteroscopy and holmium:yttrium-aluminum-garnet laser in the treatment of an infundibular stenosis

An infundibular stenosis is defined by a dilated calyx draining through a narrowed infundibulum into a nondistended renal pelvis. We describe the use of ureteroscopy and the holmium:yttrium-aluminum-garnet (YAG) laser to successfully treat an infundibular stenosis in a 27-year-old woman who presented with left flank pain. The holmium:YAG laser is well suited for this application. It can be applied with precise control of the direction and depth of the cut. The retrograde approach avoids the morbidity of a percutaneous nephrostomy and is well suited for treating an anterior infundibular stenosis.