Percutaneous management of caliceal diverticuli

Percutaneous treatment of stone containing calyceal diverticula: Strategies and outcomes from a University teaching hospital in a developing country

INTRODUCTION

There is a dearth of research available on the outcomes, complications, and recurrence rates of the modalities employed in treatment of diverticula after stone clearance by PCNL. We present our experience of various approaches employed in our institute for treatment of caliceal diverticulum after stone clearance by PCNL. We aimed to review the outcomes, complications, and recurrence rates of these procedures which can provide valuable insights into the effectiveness of these techniques in the treatment of stone containing caliceal diverticulum.

METHODS

A retrospective analysis of a prospectively maintained database of patients diagnosed with caliceal diverticular stone was conducted. The primary outcome was the stone-free rate (SFR) at the time of hospital discharge, determined by a combined nephroscopic/fluoroscopic assessment, and the obliteration of the diverticular sac. Secondary outcomes included the evaluation of operative time, duration of hospital stay and postoperative complications.

RESULTS

A total of 53 patients were evaluated. The mean diverticulum size was 23.2 mm, most common location was the superior calyx (30 (56.7%)). Group 1 (diverticular neck treatment + DJ stent) included 27 patients, group 2 (diverticular wall fulguration + PCN) included 18 patients and group 3 (PCN alone) included 8 patients. Mean operating time was highest in group 1 (80 min). Stone clearance was 100% in group 1, 91% in group 2 and 88% in group 3. Obliteration of caliceal diverticulum was highest in group 1 (90%). Mean duration of hospital stay was lowest in group 1 (3.2 days). Overall complications were lowest in group 2 (3/18).

CONCLUSION

PCNL followed by combination of diverticular wall fulguration and PCN or treatment of diverticular neck and DJ stenting is safe and effective in causing diverticular obliteration. Placement of nephrostomy tube alone was not found to be effective in causing diverticular obliteration in our study.

Percutaneous management of caliceal diverticula: a narrative review

PURPOSE OF REVIEW

Caliceal diverticula are relatively uncommon within urologic practice and may be difficult to diagnose and treat. We aim to highlight contemporary studies examining surgical interventions for patients with caliceal diverticula, with a focus on percutaneous intervention, and provide updated practical recommendations for the management of these patients.

RECENT FINDINGS

Studies within the last 3 years examining surgical treatment options for caliceal diverticular calculi are limited. When flexible ureteroscopy (f-URS) and percutaneous nephrolithotomy (PCNL) are examined within the same observational cohorts, PCNL is associated with improved stone-free rates (SFRs), lower requirement for re-intervention, and longer lengths of stay (LOS). Retrograde f-URS for the treatment of caliceal diverticula and diverticular calculi is associated with satisfactory safety and efficacy outcomes. There are no studies in the last 3 years that provide supporting evidence to use shock wave lithotripsy to treat caliceal diverticular calculi.

SUMMARY

Recent studies examining surgical interventions for patients with caliceal diverticula are limited to small observational studies. Heterogeneity in LOS and follow-up protocol limits comparisons between series. Despite technological advancements in f-URS, PCNL appears to be associated with more favorable and definitive outcomes. PCNL continues to be the preferred treatment strategy for patients with symptomatic caliceal diverticula when deemed technically feasible.

The treatment option for calyceal diverticulum stones: flexible ureteroscopy lithotripsy (FURL) or all-seeing needle-assisted percutaneous nephrolithotomy (PCNL)?

The purpose of this study was to investigate the effectiveness and safety of flexible ureteroscopy lithotripsy (FURL) and all-seeing needle-assisted percutaneous nephrolithotomy (PCNL) for the treatment of calyceal diverticula (CD) stones. From June 2012 to November 2020, 24 patients, including 14 females and 10 males, with an average age of 45.6 ± 17.4 years were retrospectively reviewed in this study. Among these patients, 14 were treated with FURL, and 10 underwent all-seeing needle-assisted PCNL. The demographic data, perioperative parameters and complications, as well as follow-up data, were recorded. In the FURL group, the ostium of CD was not identified in two patients, and these patients were finally treated with all-seeing needle-assisted PCNL. The stone clearance rate (SCR) was 64.3%, and the mean blood loss was 0.9 ± 0.8 g/dL. The average operation time was 57.5 ± 17.4 min, and the mean hospital stay was 3.5 ± 1.4 days. A complete resolution of CD was observed in five (41.7%) patients over the average follow-up of 10.8 months. In terms of the all-seeing needle-assisted PCNL, the average operation time was 83.5 ± 32.4 min, and the mean hospital stay was 4.38 ± 2.25 days. The SCR reached 91.7%, and the blood loss was 1.7 ± 1.1 g/dL. Nine patients (75%) were observed to have complete CD resolution over an average of 12.2 months of follow-up. All complications were grade I and II in both the groups. CD stones can be treated minimally invasive and effectively by FURL and PCNL. The effect of FURL greatly depends on the location and anatomy of the diverticula. PCNL is more efficient, and its safety was improved with the help of the all-seeing needle assistance.

Calyceal Diverticula Disease: Diagnosis and Management Options in the Era of Non-Contrast CT Scan

INTRODUCTION

Calyceal diverticula (CD) are traditionally diagnosed by contrast studies. However, non-contrast CT is the standard imaging modality for kidney stones. Therefore, we aimed to determine if the lack of contrast imaging affected outcomes of the management of symptomatic CD with stone.

MATERIALS AND METHODS

This is a retrospective study of patients diagnosed with CD with intracalyceal stone from 2000 to 2017 analyzing demographics, clinical data, and success of different treatment options. The timing of CD diagnosis is correlated to the success of the first treatment.

RESULTS

Forty-eight patients were found. CD was diagnosed prior to intervention in 20 (42%) cases and intraoperatively during flexible ureteroscopy in 17 (35%) and 11 (23%) cases were diagnosed after failed intervention, mainly ESWL. We found that the success rate of treatment was highly affected by the timing and modality of diagnosis. Preoperative diagnosis of CD was associated with 69% success rate of the first intervention. In contrast, there was a 0% success rate of first treatment if CD was not diagnosed with contrast imaging. Furthermore, univariate analysis showed no significant association between sociodemographics and clinical variables and success treatment (p > 0.05).

CONCLUSIONS

The delay in diagnosing CD with stone contributes significantly to the success rate and the number of treatments.

Challenges in the diagnosis of calyceal diverticulum: A report of two cases and review of the literature

BACKGROUND

Calyceal diverticula outpouchings that occur rarely in the upper collecting system of the kidney and is often difficult to detect. In this study, we present two cases of calyceal diverticula and discuss their clinical characteristics and radiologic features.

PATIENTS AND METHODS

In the presented two cases, we applied several imaging examinations, including delayed intravenous pyelography, retrograde pyelography and axial computerized tomographic (CT) scanning of the kidneys with and without contrast. Serum creatinine levels in fluid withdrawn from the diverticula were found to be significantly higher than the simultaneous serum creatinine levels. Intravenous injection of methylene blue through a ureteral catheter was also aided in the diagnosis. Calyceal diverticulum neck dilatation was performed through a percutaneous nephroscope.ResultsThe two cases were diagnosed preoperatively and the operation was successful performed. The nephrostomy tube was removed seven days after surgery without complications. CT scans of the kidney after six months showed that the size of the calyceal diverticulum of two patients were considerably smaller than pre-surgery. There were no reports of pain in the lumbar region or other discomfort.

COMMENTS

Diagnosis of calyceal diverticulum mainly depend on a variety of imaging examinations, including the delayed intravenous pyelography, retrograde pyelography, and kidney CT plain scan plus enhanced scan. If the patient cannot be diagnosed by above methods, cyst fluid can be aspirated percutaneously to measure the preoperative creatinine level. If it is significantly higher than the serum creatinine level, the cyst fluid is considered urine, which can assist in the diagnosis of calyceal diverticulum. A ureteral catheter should also be inserted before operation namely, intravenous injection of methylene blue through a ureteral catheter is helpful for diagnosis. The choice of surgical treatment is based on the size and location of calyceal diverticulum and clinical manifestations.

Systematic Review of Caliceal Diverticulum

PURPOSE

We performed a systematic review of the literature regarding the diagnosis and treatment of caliceal diverticulum (CD).

METHODS

The search strategy was conducted according to the Cochrane review guidelines for systematic reviews and Preferred Reporting Items for Systematic reviews and Meta-Analyses checklist.

RESULTS

In total 1189 titles and abstracts were reviewed, of which 101 were selected for article evaluation. Of these 101 articles, 40 were selected for inclusion after full article evaluations. In the extracted article, intravenous urography (IVU), rather than CT urography, was the main imaging tool for diagnosis, although many articles had failed to provide any imaging modality information. The extracted articles included 88, 153, and 487 patients who underwent shock wave lithotripsy (SWL), flexible ureteroscopy/retrograde intrarenal surgery (fURS/RIRS), and percutaneous nephrolithotomy (PCNL), respectively. Stone-free rates were 21.3% (SWL), 61.4% (fURS/RIRS), and 83.0% (PCNL). The complication rates were 8.0% (SWL), 3.3% (fURS/RIRS), and 11.9% (PCNL). There was incomplete and inconsistent reporting of even basic clinical parameters, such as the size and location of the CD, number of stones, outcomes, and complications. There was a striking lack of follow-up data, despite a known high recurrence rate. The literature on laparoscopic management was too sparse to analyze.

CONCLUSIONS

This meta-analysis revealed that there are not enough high-quality studies to evaluate the ideal strategy for the diagnosis and treatment of CDs. This systematic review emphasizes (a) the importance of contrast imaging for CD diagnosis, (b) higher success rates but also higher complication rates in PCNL compared with SWL and FURS, and (c) the need for standardized reporting of outcomes to include complications, number of interventions, symptom resolution, stone clearance, and CD ablation.

Long-Term Outcomes of Laparoendoscopic Single-Site Nephrolithotomy for Caliceal Diverticular Calculi: A Case Series

OBJECTIVE

To evaluate the outcomes of laparoendoscopic single-site nephrolithotomy (LESS-NL) for symptomatic caliceal diverticular calculi.

PATIENTS AND METHODS

From November 2009 to March 2014, 11 cases of LESS-NL with a homemade single-port device for caliceal diverticular calculi were performed by a single experienced laparoscopic surgeon. All patients were assessed at postoperative 1 month, 1 year, and 3 years for symptom-free status and by CT for stone-free and caliceal diverticular obliteration status. All complications were categorized by the Clavien-Dindo classification. Demographic parameters and postoperative outcomes were retrospectively analyzed.

RESULTS

All procedures were effectively performed without conversion to open or conventional laparoscopic surgery. Median patient age was 53 years (range 22-73), and median diverticular size was 26 mm (range 15-58). Six patients (54.5%) had multiple stones, and five patients (45.5%) had a single stone; median stone size was 20.6 mm (range 12.1-66.4). The transperitoneal approach was used in seven patients (63.6%) and retroperitoneal approach in four patients (36.4%). Median operative time was 161 minutes (range 110-250), median estimated blood loss was 50 mL (range 20-400), and median hospital stay was 4 days (range 3-6). An additional needlescopic instrument was used in five cases (45.5%). There were three cases (27.3%) of grade I complications (two postoperative fever, one ileus), and no intraoperative or major complications. Median visual analog scale score significantly improved by discharge day (from 4.9 preoperatively to 1.4; p = 0.003). After a median follow-up of 38 months (range 36-41), all patients were symptom free with no evidence of stone or caliceal diverticulum on imaging.

CONCLUSIONS

LESS-NL is a safe, feasible, and definitive treatment option for symptomatic caliceal diverticular calculi.

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.

Management of renal caliceal diverticular stones: A decade of experience

Objective:

The objective of this study is to evaluate our methods for management of renal caliceal diverticular stones (CDS).

Materials and Methods:

We conducted a retrospective study from January 2005 to July 2015 and included patients who were treated for renal CDS. Patients were evaluated for treatment modality, puncture site (in case percutaneous nephrolithotomy [PCNL] attempted), operative time, stone clearance rate, and complications. During PCNL, if the infundibulum was found to connect the diverticulum to the calyx, then a double J stent was placed. No attempt was made to dilate the diverticular neck or to create a neoinfundibulum.

Results:

Twenty-four patients were treated for CDS during the study period. Two patients underwent shockwave lithotripsy, and 22 were managed by PCNL. Mean stone size was 16.37 mm (range: 6–35 mm) and mean diverticulum size was 20.62 mm (range: 12–37 mm). No fulguration was done in initial 17 patients, while fulguration by Holmium Laser was performed in the last five cases treated with PCNL. Mean operative time was 70.31 min (range: 47–90 min). Mean follow-up was 34 months, diverticulum resolved in 14 patients and reduced in size in 7 patients.

Conclusion:

Caliceal diverticular calculi can be treated most efficiently by PCNL. Stone-guided puncture and no attempt to dilate or create neoinfundibulum reduces operative time and morbidity while yielding high stone-free rate.

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.

Getting Out of a PCCL: Percutaneous Cholecystolithotomy as a Salvage Treatment Option for Gallstone Removal in Patients Deemed Unfit for Standard Surgical Approaches

Definitive management of acute cholecystitis or symptomatic cholelithiasis in exceedingly high-risk patients remains a clinical dilemma. In certain cases, treatment through a percutaneous approach following standard techniques and principles similar to those of percutaneous nephrolithotomy may be considered. However, one potential challenge, particularly among a high-risk population, is the possible necessity to stay on obligate anticoagulation for pre-existing medical reasons. To date, there have been no prior reports documenting the role of this procedure in patients on systemic anticoagulation, particularly clopidogrel. Here we report a case of a percutaneous cholecystolithotomy performed on an elderly patient unable to stop dual antiplatelet therapy (aspirin and clopidogrel) secondary to recent drug eluting stent placement for myocardial infarction.

Retrograde intrarenal surgery in the management of symptomatic calyceal diverticular stones: a single center experience

To evaluate the outcome of RIRS in managing symptomatic calyceal diverticular as a minimally invasive option, we retrospectively reviewed the records of 43 patients who underwent RIRS from 2005 to 2014 for symptomatic calyceal diverticular stones. A month after the initial operation, the success rate was (81.4%, 35 patients) of which 21 (48.83%) patients were stone free and 14 (32.6%) patients had clinically insignificant residual fragments (CIRFs), and 90% patients were symptom free. Eight patients (16.6%) had significant residual fragments (>3 mm), five of them became completely stone free after the second procedure, other three patients were symptom free and underwent a routine follow-up. The final treatment success rate was 93.0%. The initial success rate in the lower calyx was significantly lower than the other calices (P = 0.040). In addition, the association between the stone size and the initial treatment success was significant (P = 0.036). There was no association between any of our other variables and the success rate. The mean first operative time was 60.95 ± 12.43 min (range 34-92). No major complication (Clavien III-V) occurred, although there were five minor complications (11.6%) (Clavien I-II). There were no admissions to intensive care or deaths in our series, the mean hospitalization time was 1.77 ± 0.80 days. The management of calyceal diverticular calculus with RIRS is highly effective and can be accomplished with low morbidity.

Calyceal diverticulum with a large extra-renal extension in a 5-year-old child

Calyceal diverticula are rare findings in children, often identified due to symptomatic presentation. We present the unique case of an incidentally found calyceal diverticula in a 5-year-old girl with a large extra-renal component, which was successfully excised in a robot-assisted laparoscopic procedure that was without complication.

Robotic partial nephrectomy for caliceal diverticulum: a single-center case series

The aim of this study is to examine the role of robotic partial nephrectomy (RPN) in the management of caliceal diverticula by assessing our single-center outcomes. Between July 2007 and July 2013, 7 of 670 patients underwent RPN procedures as a reason of caliceal diverticula. The indications for RPN in all cases were recurrent urinary tract infection and pain attributed to the diverticulum in addition to failed management by endourologic or extracorporeal shockwave lithotripsy (SWL) treatments. One patient with a calcified diverticulum and another with an unsuccessful SWL treatment underwent RPN without further endourologic intervention. The other five patients had a history of unsuccessful percutaneous nephrolithotomy (one case), ureteroscopy (URS) (two cases), and a combination of SWL+URS (two cases). No intraoperative or postoperative complications were observed. No patient was readmitted postoperatively. Unique features of the robotic platform facilitate the excision of diverticulum and subsequent kidney reconstruction for this benign, but complex pathology.

Calyceal diverticula: a comprehensive review

Calyceal diverticula are rare outpouchings of the upper collecting system that likely have a congenital origin. Stones can be found in up to 50% of calyceal diverticula, although, over the combined reported series, 96% of patients presented with stones. Diagnosis is best made by intravenous urography or computed tomography urogram. Shock wave lithotripsy (SWL) is an option for first-line therapy in patients with stone-bearing diverticula that have radiologically patent necks in mid- to upper-pole diverticula and small stone burdens. Stone-free rates are the lowest with SWL, although patients report being asymptomatic following therapy in up to 75% of cases with extended follow-up. Ureteroscopy (URS) is best suited for management of anteriorly located mid- to upperpole diverticular stones. Drawbacks to URS include difficulty in identifying the ostium and low rate of obliteration. Percutaneous management is best used in posteriorly located mid- to lower-pole stones, and offers the ability to directly ablate the diverticulum. Percutaneous nephrolithotomy remains effective in the management of upperpole diverticula, but carries the risk of pulmonary complications unless subcostal access strategies such as triangulation or renal displacement are used. Laparoscopic surgery provides definitive management, but should be reserved for cases with large stones in anteriorly located diverticula with thin overlying parenchyma, and cases that are refractory to other treatment. This article reviews the current theories on the pathogenesis of calyceal diverticula. The current classification is examined in addition to the current diagnostic methods. Here we summarize an extensive review of the literature on the outcomes of the different treatment approaches.

Percutaneous management of renal caliceal diverticular stones: Ten-year experience of a tertiary care center with different techniques to deal with diverticula after stone extraction

Introduction:

Caliceal diverticulae are a frequent surgical problem. We present our experience with caliceal diverticular stones (CDS) managed with percutaneous nephrolithotomy (PCNL) and describe the two different techniques to deal with diverticula after stone retrieval.

Materials and Methods:

We retrospectively analyzed 10-year data of 44 consecutive patients who underwent PCNL for CDS. During PCNL, if the guide wire could be negoted through the neck of the diverticula, we dilated and stented it. If we couldnot find the neck, we fulgurated the diverticular walls. Follow-up included intravenous urogram at 3 months and annual plain films thereafter. We analyzed the outcome, complications, and recurrence rate.

Results:

Total stone clearance was obtained in 40 (90.90%) patients. We dilated and stented the diverticula in 35 (79.5%) patients and fulgurated the walls in nine (20.5%) patients. Complications occurred in three patients. The postoperative intravenous urogram showed obliteration of diverticula in seven patients and the improved drainage in 37 patients. At the average follow-up of 2 years, 41 (93.18%) patients were asymptomatic and two (4.5%) patients showed the recurrence of stone.

Conclusions:

PCNL can clear calculi from caliceal diverticula in most cases with minimal morbidity. After stone retrieval, the diverticula may be drained into the pyelocaliceal system, if the neck is negotiable and fulgurated if the neck cannot be dilated.

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.

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.

Percutaneous nephrolithotomy of caliceal diverticular calculi: a single center experience

BACKGROUND AND PURPOSE

Caliceal diverticula are rare renal anomalies present in approximately 0.6% of the population. They are associated with calculi in 50% of cases. Therapeutic options include several minimally invasive techniques. We report a retrospective review of outcomes and complications from our series of patients who were treated with a percutaneous approach.

PATIENTS AND METHODS

A database of outcomes related to percutaneous nephrolithotomy (PCNL) has been maintained at our institution since 1992. Data on all patients with caliceal diverticular stones who underwent PCNL during a 17-year period from 1992 to 2009 were reviewed retrospectively. Our preferred approach to PCNL in these patients is to puncture directly into the diverticulum and to try to advance a guidewire through the infundibular neck. In cases where the caliceal neck could not be intubated, we performed a transdiverticular approach with creation of a neoinfundibulum as a salvage procedure. We evaluated the two techniques with regard to stone-free rates and early postoperative complications.

RESULTS

Seventy-six procedures were performed. The mean age was 43 years (range 17-72 y). The mean stone area was 583 mm(2). The surgical approach was direct puncture in 47, transdiverticular in 20, retrograde in 8, and unknown in 1 patient. Eight patients underwent lining fulguration. The average duration of surgery was 75 minutes (23-169 min) with an average hospital stay of 4.7 days. There were a total of 23 complications, of which 11 necessitated additional intervention. The overall stone-free rates were 77% and 89% for direct puncture and transdiverticular approaches, respectively.

CONCLUSIONS

The percutaneous management of caliceal diverticular calculi is highly effective and can be accomplished with low morbidity.