Value of laparoscopy in the management of calculi complicating renal malformations

A rare case of a combination of ectopic kidney and medial arcuate ligament syndrome: a case report

BACKGROUND

Ectopic kidney and median arcuate ligament syndrome are both rare conditions. The clinical presentation and diagnosis of these conditions are not well studied. There are no reports on the combination of these two rare conditions.

CASE PRESENTATION

We report a 24-year-old woman with fever, dysuria, urinary frequency and left flank pain for two days. The primary diagnoses in the clinic were left acute pyelonephritis and left hydronephrosis due to throbbing pain in the left costovertebral angle and pyuria. However, further computed tomography showed right ectopic pelvic kidney, left renal pelvis dilatation without definite ureteral lesion, good bilateral renal contrast enhancement, and compression of the celiac axis due to obstruction by the median arcuate ligament. Chronic abdominal symptoms were reported by the patient after repeat history taking. The patient's condition was fully explained and discussed with her and her family, but they refused further therapy. After the acute pyelonephritis began improving, the patient was discharged for follow-up at our outpatient clinic.

CONCLUSION

We present an extremely rare case of a combination of two rare conditions: ectopic kidney and median arcuate ligament syndrome. No study to date has reported on the relationship between the two diseases. Given the rarity of the two conditions, no evidence or even a hypothesis exists to explain the possible etiology of their combination. More reports are required to enhance the understanding of these rare conditions.

Unfavorable factors in accessing the pelvicalyceal system during retrograde flexible ureteroscopy (fURS)

Flexible ureteroscopy (fURS) is a well-established procedure for treating multiple upper-urinary tract pathologies, particularly renoureteral lithiasis. Endoscopes have undergone significant advancements, including miniaturization, improved optics, and increased maneuverability. In addition, advancements in accessory instruments, such as the performance of laser fibers, guidewires, and extraction probes, have played a significant role in improving the overall performance of flexible ureteroscopy procedures. However, despite these advancements, unique circumstances can make achieving optimum results during flexible ureteroscopy challenging. These include congenital renal anomalies (horseshoe kidneys, ectopic kidneys, rotation anomalies), as well as the unique intrarenal anatomy (infundibulopelvic angle, infundibular length) or the specifications of the endoscope in terms of maneuverability (active and passive deflection). This review explored challenging scenarios during flexible ureteroscopy procedures in the pyelocaliceal system.

Robotic pyelolithotomy in a solitary pelvic kidney complicated with fulminant Clostridium difficile: a case report

Background

Robotic-assisted surgeries have gradually become the standard of care for many procedures, especially in the field of urology. Despite the widespread use of robotic assistance in surgeries, data on its postoperative complications are extremely limited. We detail a rare presentation of fulminant Clostridium difficile colitis requiring surgical intervention in a patient with a solitary ectopic pelvic kidney who underwent a robotic-assisted pyelolithotomy. Highlights of the most recent management recommendations for C. difficile infection are also presented.

Case presentation

A 26-year-old Caucasian woman who underwent a robot-assisted pyelolithotomy of a pelvic kidney developed tachycardia, leukocytosis, and severe diarrhea 2 days following surgery. Because of her long history of antibiotic use, her severe symptoms were concerning for C. difficile colitis. This was confirmed by a C. difficile toxin test and a computed tomography scan. She was given recommended antibiotics, but her condition progressively deteriorated. The patient developed fulminant colitis and toxic megacolon, for which she underwent an exploratory laparotomy with subtotal abdominal colectomy and ileostomy creation on the twelfth day of her hospitalization. She fully recovered and was discharged 3 weeks after her subtotal colectomy.

Conclusion

Although robotic surgeries have been shown to have several advantages, risk of postsurgical complications remains. We present a rare case of fulminant C. difficile colitis that complicated a robotic-assisted pyelolithotomy. Active prevention, early detection, and optimization of management are essential to preventing unfavorable outcomes.

Rare complication of ureteral double-J stenting after ureteroscopy: pelvic ectopic renal parenchymal perforation

Scarce data are available on pelvic ectopic renal parenchymal perforation. However, this complication might lead to serious consequences. Clinicians should pay attention to the early identification and treatment of this complication. We herein report the first case of pelvic ectopic renal parenchymal perforation caused by a double-J stent after ureteroscopy. Compared with previously reported cases of renal parenchymal perforation not involving an ectopic kidney, our case involved no renal capsule hematoma and no other serious complications. Our primary management strategy was to review relevant examinations and tests, perform close monitoring, and instruct the patient to stay in bed. The patient recovered smoothly after the ureteral stent was removed 1 month postoperatively.

Laparoscopic assisted mini-ECIRS for ectopic kidney lithiasis: A case report and literature review

INTRODUCTION

Ectopic kidney is a rare anatomic variant with an incidence of about 1 in 900. Renal stones can pose a challenge when a standard approach is not possible. Laparoscopic-assisted endourologic procedure can be a feasible and safe choice.

CASE REPORT AND LITERATURE REVIEW

We present a case of 32 years old man with spastic quadriplegia, megacolon and pelvic kidney undergoing intervention of laparoscopic-assisted Mini ECIRS for staghorn stone of the left pelvic kidney. To the best of our knowledge, only 59 cases are reported in the literature concerning laparoscopically assisted encdourologic treatment which seems a feasible, safe and adaptable technique in selected complex cases.

CONCLUSION

Laparoscopic-assisted mini ECIRS is a viable option for the treatment of ectopic kidney stones. This technique should be considered when anatomical anomalies are encountered, to avoid puncture-related complications.

Open Pyelolithotomy in a Pelvic Ectopic Kidney: Case Report and Current Literature Review

BACKGROUND: Advances in urology have significantly reduced the indications for open surgery to treat staghorn kidney stones. Nevertheless, according to our experience, open surgery is still the preferred treatment for rare cases of the ectopic pelvic kidney. CASE PRESENTATION: A 49-year-old man complained about pain in the lower umbilical region for five months. The pain drastically changed into a sharp pain two months before. The vital sign is normal; on physical examination, the palpation of the suprapubic area elicits pain when pressed, no mass is detected. The abdominal computed tomography without contrast showed a right ectopic kidney located anteriorly of the fifth lumbar to the second sacrum. There was also mild hydronephrosis (grade I) and staghorn stones measuring 4 cm x 2.3 cm. The stone was surgically treated with open pyelolithotomy through a midline infra umbilical incision. The patient was discharged five days postoperatively without distinct complications. CONCLUSION: Open surgery can represent a valid alternative in the treatment of kidney stones of very selected cases, including anomalous kidneys, in a setting where resources are limited.

Single-use ureteroscopes in ectopic pelvic kidney stones

We analyzed the results of single-use flexible ureteroscopy (su-fURS) with the holmium laser in treating renal stones associated with ectopic pelvic kidney (EPK). The study retrospectively analyzed data of 11 patients diagnosed with EPK and stone disease who underwent su-fURS between May 2017 and November 2019. The analyzed surgical data included the mean operation time, stone-free and complication rates, as well as hospitalization period. Disposable digital flexible ureteroscopes were exclusively used. The mean age was 55, with a 1.2:1 male to female ratio. The mean stone burden was 30±9 mm (ranging from 17 to 49 mm). The mean calculi digitized surface area (DSA) was 299±56 mm² (ranging from 170 to 597 mm²). A ureteral access sheath was used in all 11 patients, and holmium laser lithotripsy was performed (dusting mode parameters: low energy – 0.5J, high frequency – 50 Hz, long pulse; pop-corn mode: high energy >1 J, medium frequency– 10–50 Hz, long pulse; fragmenting mode: high energy >1 J, low frequency <10 Hz, short pulse). The average operative time was 78±19 minutes (ranging from 68 to 144 minutes). The stone-free status (residual fragments <3 mm) after one session was 60.1%, 84.1% after the second session, and 94.4% after the third session. The hospitalization period was 29 hours (ranging from 17 to 39 hours). The overall complications rate (according to the Clavien-Dindo system) was 19.7%. Therefore, su-fURS represents an effective therapeutic approach characterized by a remarkably high stone-free rate and few complications in EPK-associated calculi.

Laparoscopic pyelolithotomy in pelvic ectopic kidney: Case report and literature review

INTRODUCTION

Pelvic kidney is a rare congenital anomaly. The ectopic kidney is more susceptible to developing lithiasis. The management of this type of lithiasis is a challenge. The objective of this paper was to conduct a review of available literature on the treatment of stone in ectopic kidney.

MATERIAL AND METHODS

Description of a case of transperitoneal laparoscopic pyelolithotomy for the treatment of inferior calyceal lithiasis in a right pelvic kidney. A literature review was performed by using Pubmed. The following terms and combination terms were searched: "pelvic ectopic kidney", "ureterorenoscopy", "extracorporeal lithotripsy", "PCNL", "pyelolithotomy". We incluyed original articles, meta-analysis, review and case reports.

RESULTS

130 articles were excluded by title or duplication. 62 abstracts articles and them 50 full text articles were evaluated. Stone free rate were 75% (SLW), 85% (URSf), 85%-90% (PCNL) and 100% (laparoscopic pyelolithotomy). The literature on treatment on pelvic kidney is poor.

CONCLUSION

Factors such stone size, density and location, and upper urinary tract abnormalities, influence the choice of therapeutic approach (retrograde, percutaneous and/or laparoscopic/robotic). Laparoscopic pyelolithotomy is a safe and minimally invasive treatment option for large kidney stones with unfavorable anatomy for the endoscopic approach.

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 pyelolithotomy in pelvic ectopic kidney: Case report and literature review

INTRODUCTION

Pelvic kidney is a rare congenital anomaly. The ectopic kidney is more susceptible to developing lithiasis. The management of this type of lithiasis is a challenge. The objective of this paper was to conduct a review of available literature on the treatment of stone in ectopic kidney.

MATERIAL AND METHODS

Description of a case of transperitoneal laparoscopic pyelolithotomy for the treatment of inferior calyceal lithiasis in a right pelvic kidney. A literature review was performed by using Pubmed. The following terms and combination terms were searched: «pelvic ectopic kidney», «ureterorenoscopy», «extracorporeal lithotripsy», «PCNL», «pyelolithotomy». We included original articles, meta-analysis, review and case reports.

RESULTS

130 articles were excluded by title or duplication. 62 abstracts articles and them 50 full text articles were evaluated. Stone free rate were 75% (SLW), 85% (URSf), 85-90% (PCNL) and 100% (laparoscopic pyelolithotomy). The literature on treatment on pelvic kidney is poor.

CONCLUSION

Factors such stone size, density and location, and upper urinary tract abnormalities, influence the choice of therapeutic approach (retrograde, percutaneous and/or laparoscopic/robotic). Laparoscopic pyelolithotomy is a safe and minimally invasive treatment option for large kidney stones with unfavorable anatomy for the endoscopic approach.

Long-term outcomes after pyeloplasty for pelvi-ureteric junction obstruction in adults associated with renal congenital anomalies: Age, sex and renal function matched analysis

Objective: To assess the long-term outcomes after pyeloplasty for pelvi-ureteric junction obstruction (PUJO) associated with renal anomalies.

Patients and methods: Data were collected for patients after pyeloplasty for PUJO associated with renal anomalies and analysed retrospectively. Long-term functional success was evaluated by comparing the renographic split renal function (SRF) and glomerular filtration rate (GFR) at last follow-up with baseline values. A change of 5% in SRF was considered significant. Factors affecting functional outcome were assessed. The outcomes were compared to an age, sex and renal function matched group with PUJO in otherwise normal kidneys (Group 2) to evaluate the pattern of difference in functional recoverability in both groups. This was assessed using repeated-measures analysis of variance.

Results: The study initially included 70 adult patients, with a mean age of 31.8 years. At a median of 44 months, 55 patients completed follow-up (Group 1) and no statistically significant changes in GFR (P = 0.7) and SRF (P = 0.06) were found. In all, 17, four and 34 patients showed a decrease, increase and static SRF (functional success rate was 69%). Higher preoperative SRF (P = 0.02) and Anderson–Hynes (A–H) pyeloplasty (P = 0.003) were associated with functional preservation. In the comparison with the other matched group (Group 2), the patients in Group 2 had better functional recoverability after pyeloplasty than patients with associated anomalies [GFR (P = 0.001), SRF (P = 0.002) and functional success (P = 0.001)].

Conclusion: Functional preservation after pyeloplasty in associated renal anomalies could be achieved in 69% of patients, which was significantly lower than those with otherwise normal kidneys. A–H pyeloplasty and higher preoperative SRF were associated with better functional outcomes.

Abbreviations: A–H: Anderson–Hynes; HSK: horseshoe kidneys; OR: odds ratio; PUJO: PUJ obstruction; SRF: split renal function; T_1/2, half-time

Bilateral, fused pelvic, ectopic, laterally rotated kidneys: A case report

Bilateral fused ectopic pelvic kidneys with lateral rotation abnormality in both kidneys is a fortuitous developmental renal anomaly that to the best of our knowledge this is the first report of this rare anomaly in English literature. Due to the morphologic appearance of this anomaly it is likely it could contribute to the individual remaining asymptomatic therefore discovered incidentally. We present a 42-year-old male who presented with acute unilateral flank pain and incidentally discovered this rare renal anomaly which is an important diagnosis for management by both radiologists and urologists.

Management of staghorn stones in special situations

Staghorn stones have always been a challenge for urologists, especially in some special situations, such as horseshoe kidney, ectopic kidney, paediatric kidney, and solitary kidney. The treatment of these staghorn stones must be aggressive because they can lead to renal function loss and serious complications. The gold-standard management for staghorn stones is surgical treatment with the aim of clearing the stones and preserving renal function. Treatment methods for staghorn stones have developed rapidly, such as extracorporeal shock wave lithotripsy, retrograde intrarenal surgery, percutaneous nephrolithotomy and laparoscopy and open surgery. Whether the standard procedures for staghorn stones can also apply to these stones in special situations is still not agreed upon. The decision should be made individually according to the circumstances of the patient. In this review, we evaluates the previous studies and comments on the management of staghorn stones under special situations in the hope of guiding the optimal choice for urologists.

Minimally invasive treatment of an ectopic kidney stone: a case report and literature review

An ectopic pelvic kidney is a rare congenital anomaly with a high incidence of complications such as reflux, hydronephrosis, nephrolithiasis, and even renal failure. We herein report a case of transperitoneal laparoscopic pyelolithotomy for treatment of a left pelvic kidney stone and discuss various surgical procedures based on the published literature. A 64-year-old woman presented to our hospital with generalized weakness and occasional nonspecific waist pain in October 2017. Computed tomography showed a 2.6-cm renal pelvis stone located in the left ectopic pelvic kidney with severe hydronephrosis. The patient underwent transperitoneal laparoscopic pyelolithotomy and was discharged 7 days after surgery. Various treatment procedures are available for ectopic kidney stones. Proper preoperative assessment and selection of the most suitable surgical procedure play critical roles in successful treatment.

[A CASE REPORT: LITHIASIS OF THE LEFT ECTOPIC PELVIC KIDNEY]

We report a case of lithiasis of the left ectopic pelvic kidney. A 70-year-old man was admitted to our department for left lower back pain. He has been aware of gross hematuria since three or four years before. Computed tomography demonstrated the left ectopic pelvic kidney with a 16-mm stone and a 5-mm stone in the renal pelvis which was accompanied by hydronephrosis. Ten days later, the renal pelvic stones moved to the renal calices and the symptoms disappeared. Though a pyeloureteral junction obstruction was not evident, renogram showed a obstruction pattern of the left kidney. He had been followed up for six years, then the stone was impacted in the renal pelvis and hydronephrosis worsened. Open pyelolithotomy was performed. His clinical course was uneventful and no evidence of recurrence has been observed.

Assessment of Congenital Vascular and Organ Anomalies in Subjects With Thalidomide Embryopathy Using Non-Contrast Magnetic Resonance Angiography

BACKGROUND

To determine the type and frequency of vascular and organ malformations in adults with thalidomide embryopathy (TE) using non-contrast magnetic resonance angiography (MRA) and to assess the effect of the observed malformations on renal function. Methods and Results: The institutional ethics committee approved this prospective study and written informed consent was given by all 78 subjects (50 females) with TE (mean age: 55±1.1 years), who were examined by non-contrast MRA at 3T. ECG-triggered balanced turbo field echo images of the chest, abdomen and pelvis were obtained in coronal and sagittal orientations. Two observers assessed the frequency of vascular and organ malformations. Serum creatinine and estimated glomerular filtration rate (eGFR) were obtained to assess renal function. In 58 subjects, 99 vascular anomalies were observed, including 68 arterial (69%) and 31 venous anomalies (31%); 15 patients had 16 abdominal organ malformations including 12 kidney anomalies and 4 cases of gallbladder agenesis. Most vascular anomalies affected the renal vessels (n=66, 67%) or supraaortic arteries (n=28, 28%). Serum creatinine and eGFR revealed normal renal function in all subjects.

CONCLUSIONS

Vascular and organ anomalies occurred in a high number of subjects with TE without evidence of renal dysfunction. Information about the presence of malformations may be important for future surgical interventions in subjects with TE.

Middle calyx ureterocalicostomy in ectopic pelvic kidney with ureteropelvic junction obstruction: Only alternative for renal salvage

Anomalous kidneys are mostly asymptomatic and are often found incidentally during physical or radiological investigations for urological or other medical complaints. The associated genital anomalies ranges from 15% to 45%. Females are associated with bicornuate or unicornuate uterus, rudimentary or absent uterus while males have undescended testes, duplication of the urethra, and hypospadias. A 21 year old married female presented with on and off lower abdomen pain for the past one year with history of primary amenorrhea. On examination an ill defined tender lump palpated in the lower abdomen. USG showed left ectopic pelvic kidney with gross hydronephrosis. The computed tomography confirmed hydronephrotic left ectopic pelvic kidney in front of the sacrum with anteriorly directed renal pelvis with ureter located posteriorly. There was delayed excretion from the ectopic kidney but right kidney was in normal position and function. The diethylene triamine pentaacetic acid (DTPA) scan showed 33% function of the ectopic kidney. On diagnostic laparoscopy, the uterus was small hypoplastic with bilateral ovaries appearing normal. The patient was taken for open pyeloplasty where the ureter was transected below PUJ but for a dependent drainage, the middle calyx as was the most dependent calyx as seen on the CT-scan. So a middle calyx ureterocalicostomy was performed calyx with excellent outcome. The ectopic kidney always remains a challenge because of complex neurovascular anatomy, presence of viscera and associated UPJO, but for a dependent drainage, middle calyx ureterocalicostomy is a feasible option with excellent outcome as was in our case.

Laparoscopic-assisted mini percutaneous nephrolithotomy in the ectopic pelvic kidney: Outcomes with the laser dusting technique

Introduction:

The treatment of renal lithiasis has undergone a sea change with the advent of extracorporeal shock wave lithotripsy (ESWL) and endourological procedures such as percutaneous nephrolithotomy (PCNL), ureterorenoscopy and retrograde intrarenal surgery (RIRS). The presence of anatomical anomalies, such as ectopic pelvic kidney, imposes limitations to such therapeutic procedures. This study is aimed to find a simple and effective way to treat the stones in ectopic kidney.

Materials and Methods:

From 2010 to 2014, nine patients underwent laparoscopic-assisted mini PCNL with Laser dusting for calculi in ectopic pelvic kidneys at our hospital. Retrograde pyelography was done to locate the kidney. Laparoscopy was performed and after mobilizing the bowel and peritoneum, the puncture was made in the kidney and using rigid mini nephroscope, and stones were dusted with Laser.

Results:

The median interquartile range (IQR) stone size was 18 (6.5) mm. Median (IQR) duration of the procedure was 90 (40) min. The median (IQR) duration of postoperative hospital stay was 4 (2) days. The stone clearance in our series was 88.9%, with only one patient having a residual stone. No intra- or post-operative complications were encountered.

Conclusion:

Laparoscopy-assisted mini PCNL with Laser dusting offers advantages in ectopic pelvic kidneys in achieving good stone clearance, especially in patients with a large stone burden or failed ESWL or RIRS.

Direct pelvic access percutaneous nephrolithotomy in management of ectopic kidney stone: a case report and literature review

Percutaneous nephrolithotomy (PNL) is an effective procedure for the treatment of patients with large or complex stones. PNL is challenging in anomalous kidneys, certain patients, such as those with renal ectopia. It is unable to undergo PNL in conventional technique safely in these cases. We presented a case report of laparoscopic-assisted PNL via direct pelvic puncture in a pelvic kidney stone and discussed previous published literature. A 49-year-old man presented with right lower quadrant pain and hematuria. Intravenous pyelography and three-dimensional computerized tomography revealed an opaque 2.7 × 1.7 cm pelvis renalis stone in a right side ectopic pelvic kidney with grade III hydronephrosis. Laparoscopic-assisted tubeless PNL was performed to remove the calculus. Laparoscopic-assisted PNL as a minimally invasive therapy in ectopic kidney has many advantages. Our case showed that, in pelvic ectopic kidney with pelvic stones greater than 1.5 cm in size, laparoscopic-assisted PNL via direct pelvis puncture is a safe and effective technique.

Retroperitoneal laparoscopic pyelolithotomy in an ectopic pelvic kidney

BACKGROUND AND OBJECTIVES

Retroperitoneal laparoscopic pyelolithotomy was performed in an ectopic pelvic kidney with renal pelvis calculi.

METHODS AND RESULTS

Laparoscopic pyelolithotomy was successfully performed in an ectopic pelvic kidney by using the retroperitoneal route. The total operation time was 130 minutes, and the estimated blood loss was < 50 mL. The patient was discharged on the second postoperative day without any complications.

CONCLUSION

Laparoscopic pyelolithotomy is an effective treatment option for management of stones in the pelvis of an ectopic pelvic kidney. The retroperitoneal route may help to avoid intraoperative and postoperative complications.

Management of stones in abnormal situations

Stones in abnormal situations present a management conundrum to the urologist. Many of these situations are relatively rare and literature is scanty on the appropriate management. We review the current literature on the management of stones in the setting of pregnancy, calyceal diverticulum, urinary diversions, pelvic kidneys, transplant kidneys, autosomal dominant polycystic kidney disease, horseshoe kidneys, and other renal anomalies. The aims of treatment are complete stone-free status. The modality of treatment should be individualized to the size and location of stone and type of abnormal situation confronted.

Laparoscopic-assisted "microperc" of a stone in a pelvic kidney of a 3-year-old girl

Treatment of kidney stones in pelvic ectopic kidneys of children is a challenging procedure for urologists. Herein we report a case of laparoscopy-assisted "microperc" in a 3-year-old girl with a stone in her pelvic ectopic kidney. This micro-optical system is helpful in confirming the percutaneous access and provides the possibility of fragmenting the stone without the necessity of dilating the tract.

Critical analysis of outcome after open dismembered pyeloplasty in ectopic pelvic kidneys in a pediatric cohort

OBJECTIVE

To evaluate the functional and morphologic outcome after open pyeloplasty for ureteropelvic junction obstruction (UPJO) in ectopic pelvic kidneys.

MATERIALS AND METHODS

A retrospective review of all patients who underwent open pyeloplasty in ectopic pelvic kidneys was conducted. Records were evaluated with respect to age at presentation, preoperative imaging, surgical details, and postoperative course. Patients were followed up regularly for functional and morphologic outcome. Success was defined as symptomatic relief and radiographic improvement of obstruction at the last follow-up.

RESULTS

Between 1995 and 2010, 680 patients with primary UPJO underwent open dismembered pyeloplasty at our center. Of these patients, 43 (6.3%) had UPJO in ectopic pelvic kidneys. No perioperative complications were encountered in the study group. Mean follow-up was 42 months (range, 18-90 months), and 5 patients were lost to follow-up. The overall success rate was 82.6%. Postoperative hydronephrosis was improved in 20 (52.6%), stable in 11 (29%), and worsened in 7 (18.4%). Postoperative renal function was improved in 12 (31.6%), stable in 19 (50%), and deteriorated in 7 (18.4%). Redo pyeloplasty was required in 4 patients and secondary nephrectomy in 3. Preoperative differential renal function and surgeon experience were statistically significant predictors of improvement in renal function after pyeloplasty.

CONCLUSION

Open pyeloplasty for UPJO in ectopic pelvic kidneys is feasible, but varying degrees of hydronephrosis and radiologic obstruction persist after pyeloplasty that could be attributed to anatomy-related pelvocaliectasis, and so regular follow-up is warranted in this subpopulation.

Difficulties with access in percutaneous renal surgery

Percutaneous renal surgery provides a minimally invasive approach to the kidney for stone extraction in a number of different clinical scenarios. Certain clinical cases present inherent challenges to percutaneous access to the kidney. Herein, we present scenarios in which obtaining and/or maintaining percutaneous access is difficult along with techniques to overcome the challenges commonly encountered. Also, complications associated with these challenging percutaneous renal surgeries are discussed.

Laparoscopic pyelolithotomy in selected patients with ectopic pelvic kidney: a feasible minimally invasive treatment option

BACKGROUND AND PURPOSE

Ectopic pelvic kidney is a rare congenital anomaly. It carries more risks for obstruction and stone formation than a normal located kidney. The treatment of renal stones in these patients is challenging. We present our experience with laparoscopic pyelolithotomy for treatment of selected patients with large and multiple renal stones in ectopic pelvic kidneys.

PATIENTS AND METHODS

After insertion of a ureteral catheter, pneumoperitoneum was achieved by Veress needle, and the kidney was exposed. The renal pelvis was identified, dissected, and opened. The stones were extracted using laparoscopic forceps. The rigid nephroscope was used to extract any caliceal stones. The renal pelvis was sutured, and the stones were removed from the peritoneal cavity. The procedure was concluded after placement of an intraperitoneal drain.

RESULTS

A total of 11 patients with large renal pelvic and/or multiple stones underwent laparoscopic transperitoneal pyelolithotomy. A transmesenteric approach was used in eight patients while the colon was mobilized off the kidney in three patients. All stones were removed except one that needed Double-J stent placement and one session of shockwave lithotripsy. After one auxiliary procedure, the stone-free rate was 100%. There were no major intraopertive or postoperative complications. Within a mean follow-up period of 23 months, no stone recurrence occurred.

CONCLUSIONS

Laparoscopic pyelolithotomy for large and multiple stones in ectopic pelvic kidneys is a feasible minimally invasive treatment option. The technique allows removal of all the stones without fragmentation, which may decrease the possibility for rapid stone recurrence.

Robot-assisted laparoscopic pyeloplasty with stone removal in an ectopic pelvic kidney

The authors suggest that robotic technology may be used for pyeloplasty in difficult cases of ectopic position and concomitant stones.

Ectopic pelvic kidneys with ureteropelvic junction obstruction and stones present a treatment challenge for the minimally invasive surgeon. A pure laparoscopic approach is less invasive than an open approach but is technically difficult with longer operative time. The use of the da Vinci robotic interface has the potential to refine the laparoscopic technique and improve outcomes. Here, we present successful management using the robotic technique of one such case of concomitant pyeloplasty and pyelolithotomy.

Laparoscopic assisted percutaneous nephrolithotomy in ectopic pelvic kidneys

Three patients underwent laparoscopic assisted percutaneous nephrolithotomy (PNL). A kidneys, ureter and bladder (KUB), and intravenous pyelogram (IVP) of the first patient showed a 3 cm calculus in a right side ectopic pelvic kidney overlying on the sacrum. The second patient had bilateral ectopic kidneys. The right kidney was located in the true pelvis without calculi and the left kidney was located in the iliac cavity with a 2.5 cm calculus in the renal pelvis. The third one had a 4 cm stone in the infundibulum of the upper calyx of the left pelvic ectopic kidney. All of them had a history of failed shock wave lithotripsy after two sessions. Then the patients were scheduled for laparoscopic assisted percutaneous removal of calculi. Under fluoroscopic control the best access route was located and the kidney was punctured. A 24F nephroscope was introduced and all calculi were disintegrated and removed. Operating time was 150, 120 and 110 min in cases 1, 2 and 3, respectively. Complete stone clearance was documented with a plain X-ray KUB film and ultrasonography. Finally the patients underwent IVP three months following the operation. They were all well and there were no early or late complications.

[Importance of open and laparoscopic stone surgery]

INTRODUCTION

The increasing spread and technical enhancement of endourological methods has led to displacement of the surgical therapy of renal and ureteral calculi.

MATERIALS AND METHODS

Based on a review of current literature, we describe indications, technique, and clinical importance of the open and laparoscopic management of urolithiasis.

RESULTS

In Europe and North America, the surgical therapy of urolithiasis only plays a role in cases of very large or hard stones, after failure of shock wave lithotripsy, percutaneous nephrolithotripsy, or ureteroscopic stone removal, and in cases of abnormal renal anatomy, i.e., only in a few percent of all stone therapies. However, in developing countries and emerging markets with different structure and funding of the health care system where the methods of endourology are not readily available, these techniques still have a higher importance. Particularly in Europe, laparoscopic surgery is emerging because calculi can be removed from almost all locations in the kidney and ureter using a transperitoneal or retroperitoneal access. Functional outcomes and complication rates are comparable. The benefits of laparoscopy are less postoperative pain, shorter hospital stay, faster convalescence, and better cosmetic results.

CONCLUSIONS

Although procedures for open and laparoscopic removal of renal and ureteral calculi are only performed in rare cases in daily urological practice, they are superior to the endourological techniques in some circumstances. Therefore, they should still be part of the urologist's skills.

Pelvic kidney: associated diseases and treatment

The incidence of pelvic kidney has been approximated at between 1 in 2200 and 1 in 3000. The ectopic kidney is thought to be no more susceptible to disease than the normally positioned kidney, except for the development of calculi and hydronephrosis. Because of the greater risk of injuring aberrant vessels or overlying abdominal viscera and nerves, the pelvic kidney presents special treatment challenges. Alternative approaches to treating nephrolithiasis may yield better outcomes. The tortuous ureter often associated with a pelvic kidney hinders deflection of the flexible ureteroscope, potentially limiting access. Laparoscopy-guided intervention permits visual exposure of the kidney, enhancing safe puncture and tract placement integral to percutaneous nephrolithotomy. Laparoscopy-assisted anterior retrograde percutaneous nephroscopy involves percutaneous access using a Hunter-Hawkins retrograde nephrostomy needle with adjunctive laparoscopy to permit viewing and manipulation of overlying bowel. Ureteropelvic junction (UPJ) obstruction has been reported to occur in 22% to 37% of ectopic kidneys. Endoscopic incision presents difficulties beyond those of anatomically normal kidneys. The laparoscopic approach provides good surgical exposure, and operative times are comparable to those of laparoscopic pyeloplasty in anatomically normal kidneys. To date, only a handful of cases of malignancy in a pelvic kidney have been described. Like a nonfunctioning anatomically normal kidney, a nonfunctional pelvic kidney may require primary removal. There are a few reports of laparoscopic pelvic nephrectomy. Additional studies are needed to compare the various treatments for disease of the pelvic kidney in order to decide which options have the most beneficial outcomes.

Treatment of Stones Associated with Complex or Anomalous Renal Anatomy

This article reviews the most common renal anomalies and the management of patients with calculus disease in anomalous kidneys. The emphasis is on minimally invasive techniques to achieve a stone-free status with minimal morbidity.

Standard percutaneous nephrolithotomy on a pelvic kidney without any ancillary modalities

We are presenting a patient with two calculi in a right pelvic kidney managed by percutaneous nephrolithotomy with an access just above the iliac crest in the prone position.

Treatment of calculi in kidneys with congenital anomalies: an assessment of the efficacy of lithotripsy

We studied the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in the treatment of stones in kidneys with congenital anomalies to determine factors that may affect the results. Patients found to have renal calculi in kidneys with different types of congenital anomalies were treated using ESWL. All patients were investigated by intravenous urography (IVU) to confirm the diagnosis. J stents were inserted prior to therapy in renal units with calculi exceeding 1.5 cm in diameter. Complications encountered and factors affecting success using this treatment modality were analysed. Twenty-five patients (18 males, 7 females) were studied between August 1988 and July 2005. There were nine patients with horseshoe kidneys, eight with ectopic kidneys, three with malrotated kidneys, two with duplex renal system, and one patient each with polycystic kidneys and hypoplastic kidney. The IVU showed 31 isolated calyceal or renal pelvic stones with mean stone burden of 1.44cc. All 25 patients were treated by lithotripsy. Twenty-four (77.4%) renal units (in 19 patients) were completely cleared of stones, 2 (6.5%) renal units (2 patients) were partially cleared of calculi and the procedures failed in 5 (16.1%) renal units (4 patients). Out of five renal units in which the procedures failed, open surgery was performed in three renal units and percutaneous nephrolithotomy (PCNL) was performed in two. None of the 25 patients developed any major complications. No significant adverse changes in renal function tests were observed at 3-month follow-up. The stone-free rate was influenced and reduced by stone size and location in the pelvi-calyceal system. Calculi in kidneys with congenital anomalies may be treated successfully by ESWL as a first-line therapy in the majority of patients. With position modifications, localization of stones may be facilitated and disintegrated. The outcome in patients so treated does not differ significantly from that in those with normal kidneys.

Percutaneous nephrolithotomy for ectopic kidneys: over, around, or through

OBJECTIVES

The treatment of patients with complex urolithiasis in ectopic kidneys can be challenging. Because the location of an ectopic kidney can vary, each case requires a unique and, at times, unconventional approach. We reviewed the techniques we have developed to treat such patients, including laparoscopic-assisted tubeless, transhepatic, and transiliac percutaneous nephrolithotomy (PNL).

METHODS

We performed a retrospective analysis of all patients with congenital pelvic kidneys who underwent PNL at our institution. Six patients underwent laparoscopic-assisted PNL, one underwent transiliac PNL, and one underwent transhepatic PNL. All laparoscopic-assisted procedures were performed tubeless, with an internalized ureteral stent placed at the conclusion of the procedure.

RESULTS

All patients underwent successful PNL. On computed tomography, performed on the morning of postoperative day 1, all patients who underwent laparoscopic-assisted PNL were stone free. The patients who underwent transiliac PNL and transhepatic PNL required secondary procedures to attain a stone-free status. The mean length of hospitalization was 3 days for the laparoscopic-assisted cohort, 1 day for the transhepatic patient, and 3 days for the transiliac patient.

CONCLUSIONS

For the patient with a large or complex stone burden in an ectopic kidney, laparoscopic-assisted PNL is the optimal treatment. Performing such a procedure tubeless may be associated with a reduced hospital stay. For those patients with a hostile peritoneal cavity owing to prior surgical exploration, consideration should be given to a more individualized approach.

Laparoscopic Assisted Percutaneous Nephrolithotomy (PCNL) in Ectopic Kidneys: Two Different Techniques

Two patients presented with calculi in ectopic kidneys. Complete clearance of calculi was achieved by laparoscopic assisted percutaneous nephrolithotomy (PCNL), by different but related techniques. In one patient with prior history of open pyelolithotomy, the anterior surface of the kidney was exposed by mobilizing the overlying sigmoid colon laparoscopically and the percutaneous tract was established into the desired calyx under combined laparoscopic and fluoroscopic control. In the second patient, the tract was established between the major mesenteric vessels without any mobilization of the bowel. Herein, we outline the nuances of these two related techniques, and the indications and contraindications for their use for laparoscopic assisted PCNL in ectopic kidneys.

Management of Pelvic Stones Larger than 20 mm: Laparoscopic Transperitoneal Pyelolithotomy or Percutaneous Nephrolithotomy?

Large pelvic stones are frequently managed with percutaneous nephrolithotomy (PCNL) but laparoscopic transperitoneal pyelolithotomy (LTP) can be an alternative. We compared PCNL and LTP for the treatment of pelvic stones >20 mm in diameter.

PATIENTS AND METHODS

Between November 1999 and November 2004, 16 consecutive patients, mean age 42, with a single pelvic stone >20 x 10 mm (group I), underwent LTP as first-line treatment or after shockwave lithotripsy failure. They were compared with a similar population of 16 consecutive patients, mean age 45 (group II), who underwent PCNL for the same indication and were assessed retrospectively. We evaluated operative characteristics, complications, and results for each technique.

RESULTS

There was no difference between the two groups regarding the characteristics of patients and stones. Operative time duration was significantly longer in group I (129 vs. 75 min; p = 0.001) and conversion was required in 2 patients (12%). The main postoperative complications were urinary leakage (2 patients, 12%) in group I and bleeding (3 patients, 18%) in group II, but only 1 required blood transfusion. Mean hospital stay was respectively 6.5 and 5.6 days in groups I and II (p = 0.17). Stone-free rates were assessed at 3 months and were not different between group I and group II (88 vs. 82%).

CONCLUSIONS

The operative time of LTP is longer and the results of both techniques are comparable but postoperative morbidity is different. Specific indications of each technique must be determined although PCNL remains the gold standard for most large pelvic stones.

Ureteroscopic management of renal calculi in anomalous kidneys

OBJECTIVES

To review our experience with ureteroscopy in treating patients with renal calculi in anomalous kidneys and to evaluate the efficacy of this approach.

METHODS

Eight patients with renal calculi in anomalous kidneys who were managed by ureteroscopic procedures were identified. Demographic information, preoperative stone burden, operative information (ureteroscope size, lithotrite used, instruments used, duration of surgery, complications, stenting), follow-up imaging, and complications were obtained from the medical record. This information was analyzed to determine the most frequently used instruments and stone-free rates.

RESULTS

Our cohort consisted of 4 patients with horseshoe kidneys (HSK) and 4 patients with pelvic kidneys (PK) (6 male, 2 female, mean age, 50.6 years). The average preoperative stone burden of the 11 treated calculi was 1.4 cm, with 5 stones located in the renal pelvis, 2 in the upper pole, and 4 in lower pole calyces. A 7.5F flexible ureteroscope, holmium laser lithotripsy, and nitinol baskets and graspers were used in all patients. Six patients had complete clearance of the stone on postoperative imaging (75% HSK, 75% PK), with 88% of patients asymptomatic after their procedure. No patients required additional surgical intervention.

CONCLUSIONS

Flexible ureteroscopy with holmium laser lithotripsy and the use of nitinol baskets and graspers provides a reasonable alternative to shock wave lithotripsy in the management of patients harboring renal calculi in anomalous kidneys. In addition, ureteroscopy can be considered a primary option for managing select patients with symptomatic stones in PKs before a percutaneous surgical approach.

Laparoscopy in the management of stone disease of urinary tract

As in other fields of urology, the use of minimally invasive techniques has helped decrease the morbidity and convalescence associated with the management of urolithiasis. Laparoscopy has also been used as one of the minimally invasive techniques. This has developed particularly with the increasing experience and use of intracorporeal suturing techniques. However, in comparison with other surgeries, laparoscopy for stone removal is relatively uncommon and we review the current indications, technical limitation and results.

Role of laparoscopy in management of renal stones: single-center experience and review of literature

BACKGROUND AND PURPOSE

Laparoscopy can be an alternative modality in the management of renal stones. We present our experience with laparoscopic renal stone surgery.

PATIENTS AND METHODS

Eighteen patients (4 males, 14 females) with mean age of 51 years (range 18-86 years) underwent 19 laparoscopic procedures. The mean stone number and size, excluding five patients who had nephrectomy/heminephrectomy, were 1.9 (range 1-5) and 1.3 cm (range 0.5-4.5 cm), respectively. Three patients with ureteropelvic junction obstruction underwent pyeloplasty and concomitant pyelolithotomy. Three patients with upper-pole caliceal-diverticular stones had nephrolithotomy and fulguration of the diverticular mucosa. Three patients with stones and hydrocalix with scarred cortex had partial nephrectomy, two under cold and one under warm ischemia. Five patients, including one with a horseshoe kidney (who had one procedure on each kidney), had pyelolithotomy as an alternative to percutaneous nephrolithotomy. Patients with stones in a nonfunctioning kidney underwent nephrectomy (three patients) or heminephrectomy (one patient).

RESULTS

All procedures were completed laparoscopically. The operative time was variable depending on the complexity of the procedures, from 115 minutes for Fengerplasty to 315 minutes for partial nephrectomy under cold ischemia (mean 178 minutes). The estimated blood loss was 53.2 mL (range 20-120 ml), and none of the patients received a blood transfusion. Complete stone clearance was achieved in 93% of the procedures. The mean hospital stay was 10.5 days (range 5-35 days). Three patients needed temporary pigtail-catheter drainage for obstruction after pyelolithotomy. One patient with a solitary kidney and infected staghorn calculus had prolonged urinary leak, which stopped with conservative management. One nephrectomy for nephrocutaneous fistula was complicated by a late colonic perforation necessitating colostomy.

CONCLUSION

Laparoscopic surgery is effective for complex renal stones and allows for adjunctive procedures. It can also be an alternative to percutaneous nephrolithotomy. It complements other minimally invasive procedures, and a need for open stone surgery should be rare in the future.

Laparoscopy-assisted Percutaneous Nephrolithotomy (PCNL) In Previously Operated Ectopic Pelvic Kidney

A 35-year-old man with a left ectopic pelvic kidney and a prior history of open pyelolithotomy presented with recurrent multiple stones in the pelvic kidney. Complete clearance of calculi was achieved by laparoscopy-assisted PCNL (percutaneous nephrolithotomy). To the best of our knowledge this is the first report of laparoscopy-assisted PCNL in a previously operated ectopic pelvic kidney.

Laparoscopic pyelolithotomy--a technique for the management of stones in the ectopic pelvic kidney

We present our preliminary experience with the technique of laparoscopic pyelolithotomy for ectopic pelvic kidney calculi. This surgery has low morbidity and is ideally suited for the ectopic pelvic kidney with a laterally or anteriorly directed pelvis.

Computerized tomography guided access for percutaneous nephrostolithotomy

PURPOSE

Access for percutaneous nephrostolithotomy (PNL) using conventional fluoroscopic guidance may carry an increased risk of damage to surrounding organs in patients with renal calculi and aberrant anatomy. In these situations cross-sectional anatomical imaging may facilitate safe percutaneous access. We describe our experience with computerized tomography (CT) guided percutaneous access for such patients undergoing PNL.

MATERIALS AND METHODS

Between June 2000 and December 2001, 154 patients underwent PNL at our institution. Five of these patients (3%) required a total of 6 percutaneous access tracks under CT guidance. All patients in this group had anatomical abnormalities precluding standard access to the collecting system without risk to adjacent organs. These abnormalities included a retrorenal colon in 2 and a severely distorted body habitus due to spinal dysraphism in 3.

RESULTS

Percutaneous access was achieved without complication in all cases. At subsequent PNL 5 of the 6 renal units (83%) were rendered completely stone-free.

CONCLUSION

CT guided percutaneous access is infrequently required for PNL. However, there is a select group of patients with anatomical anomalies that may predictably require this procedure to facilitate safe and efficacious PNL.