Management of stones associated with intrarenal stenosis: infundibular stenosis and caliceal diverticulum

Efficacy of flexible ureterorenoscopy with holmium laser in the management of calyceal diverticular calculi

The purpose of this study was to evaluate the efficacy and safety of flexible ureteroscopy with holmium laser lithotripsy in the management of calyceal diverticular calculi. In this study, we retrospectively analyzed the clinical data of 27 patients with calyceal diverticular calculi admitted to the Department of Urology of the Zigong First People's Hospital from May 2018 to May 2021. Intraoperatively, the diverticular neck was found in all 27 patients, but flexible ureterorenoscopy lithotripsy was not performed in 2 cases because of the slender diverticular neck, and the success rate of the operation was 92.6%. Of the 25 patients with successful lithotripsy, the mean operative time was 76.9 ± 35.5 (43-200) min. There were no serious intraoperative complications such as ureteral perforation, mucosal avulsion, or hemorrhage. Postoperative minor complications (Clavien classification I-II) occurred in 4 (16%) patients. The mean hospital stay was 4.4 ± 1.7 (3-12) days. The stone-free rate was 80% at the 1-month postoperative follow-up. After the second-stage treatment, the stone-free rate was 88%. In 22 cases with complete stone clearance, no stone recurrence was observed at 5.3 ± 2.6 (3-12) months follow-up. This retrospective study demonstrated that flexible ureterorenoscopy with holmium laser is a safe and effective choice for the treatment of calyceal diverticular calculi, because it utilizes the natural lumen of the human body and has the advantages of less trauma, fewer complications, and a higher stone-free rate.

Percutaneous nephrolithotomy for staghorn calculi: Troubleshooting and managing complications

Staghorn calculi comprise a unique subset of complex kidney stone disease. Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for staghorn stones. Despite continuous refinements to the technique and instrumentation of PCNL, these stones remain a troublesome challenge for endourologists and are associated with a higher rate of perioperative complications than that for non-staghorn stones. Common and notable intraoperative complications include bleeding, renal collecting system injury, injury of visceral organs, pulmonary complications, thromboembolic complications, extrarenal stone migration, and misplacement of the nephrostomy tube. Postoperative complications include infection and urosepsis, bleeding, persistent nephrocutaneous urine leakage, infundibular stenosis, and death. In this review, we report recommendations regarding troubleshooting measures that can be used to identify and characterize these complications. Additionally, we include information regarding management strategies for complications associated with PCNL for staghorn calculi.

Robotic Management of Urolithiasis in the Pediatric Population

A variety of surgical techniques exist for the management of urolithiasis. Minimally invasive techniques have replaced open surgery in the last few decades. For complex stone management, robotic-assisted laparoscopic surgery (RALS) has emerged as a safe and feasible alternative in adults. The literature for RALS for urolithiasis (RALS-UL) in the pediatric population is scarce. Herein, we present a review of the literature in both adult and pediatric patients as well as our experience using RALS-UL at our institutions. Special attention is given to the synchronous management of urolithiasis when surgery is performed for other conditions such as ureteropelvic junction obstruction (UPJO), and a supplemental video is provided.

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.

Retrograde intrarenal surgery for renal stones - Part 2

Retrograde intrarenal surgery (RIRS) has become an effective and safe treatment modality in the management of urinary system stone disease. Recent developments and innovations in the flexible ureterorenoscope and auxiliary equipment have made this procedure easier and more effective with increased success rates. RIRS can be used as a primary treatment in patients with renal stones smaller than 2 cm, prior unsuccessful shock wave lithotripsy, infundibular stenosis, renoureteral malformation, skeletal-muscular deformity, bleeding diathesis and obese patients. In the second part of this detailed review for RIRS, effect of stone composition on success rate, preoperative assessment of stone-free rate, the cost of this modality, education for RIRS, fluoroscopy use, the current role of RIRS in the treatment of various urolithiasis types and special conditions, and combined treatment methods are discussed with up-to-date literature.

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.

Flexible ureteroscopy: Technological advancements, current indications and outcomes in the treatment of urolithiasis

The last 3 decades have witnessed great improvements in the technology and clinical applications of many minimally invasive procedures in the urological field. Flexible ureteroscopy (fURS) has advanced considerably to become a widely utilized diagnostic and therapeutic tool for multiple upper urinary tract pathologies. The most common indication for fURS is the treatment of upper urinary tract stones with the aid of Holmium:Yttrium Aluminium Garnet (YAG) laser lithotripsy. Advancements in endoscope technologies and operative techniques have lead to a broader application of fURS in the management of urolithiasis to include larger and more complex stones. fURS has proved to be an effective and safe procedure with few contraindications. Continued progression in fURS may increase its clinical applicability and supplant other procedures as the first line treatment option for urolithiasis.

Laparoscopic and robotic calyceal diverticulectomy: outcomes and modifications of technique

OBJECTIVE

To examine the technique and outcomes of robotic and laparoscopic calyceal diverticulectomy in the management of symptomatic calyceal diverticula at a single center.

SUBJECTS AND METHODS

Perioperative outcomes of six minimally invasive calyceal diverticulectomies (four laparoscopic and two robotic) between March 2011 and May 2014 were analyzed. Postoperative complications were categorized by Clavien-Dindo grade.

RESULTS

The median age of the cohort was 35 years (range, 24-51 years), and mean body mass index was 24 kg/m(2). All 6 patients were female and presented with ipsilateral flank pain, and 3 of the 6 had coexisting recurrent urinary tract infections attributed to the calyceal diverticulum. Five of the 6 patients had failed prior surgical intervention with either endoscopic intervention or extracorporeal shock wave lithotripsy. Hilar clamping was performed in 2 of the 6 cases, with a mean warm ischemia time of 12 minutes (range, 10-14 minutes). Mean operative time was 162 minutes (range, 121-270 minutes), with no intraoperative complications. Mean blood loss was 150 mL (range, 50-300 mL), with no blood transfusions. There was one Clavien grade 1 complication and no major (Clavien grade 3 or higher) complications. Mean hospital stay was 2 days (range, 1-4 days). Four of the 6 patients were seen in follow-up, and all had complete resolution of flank pain and urinary tract infections, with no residual stones on imaging.

CONCLUSIONS

Laparoscopic and robotic calyceal diverticulectomies for symptomatic calyceal diverticulum are safe, effective treatment options for symptomatic calyceal diverticula.

Robotic-assisted laparoscopic management of a caliceal diverticular calculus

PURPOSE

To report the first case of robotic-assisted laparoscopic management of a symptomatic caliceal diverticular calculus and review the literature on laparoscopic treatment for this condition.

CASE REPORT

A 33-year-old obese woman with a 2×1 cm calculus within an anterior caliceal diverticulum located in the middle pole of the left kidney was referred to our service. She had already undergone two flexible ureterorenoscopies without success. We considered that a percutaneous approach would be very challenging due to stone location, thus we elected to perform a robotic-assisted laparoscopic procedure for stone removal and diverticulum fulguration. The procedure was uneventfully performed with no intraoperative or postoperative complications. The patient was discharged from the hospital on the second postoperative day and after 1.5 years of follow-up she is asymptomatic with no recurrence.

CONCLUSIONS

The robotic-assisted laparoscopic approach to caliceal diverticular calculi is feasible and safe, providing one more option for treatment of stones in challenging locations.

Pushing the boundaries of ureteroscopy: current status and future perspectives

Substantial advances in ureteroscopy have resulted in the incorporation of this procedure into routine urological practice in many centres worldwide. Subsequently, an abundance of clinical data and technological progression have enabled the development of novel solutions that have increased the efficacy of ureteroscopy, and reduced associated morbidity and costs. In addition the indications for this retrograde approach have been expanded, and pyelocalyceal diverticulum, infundibular stenosis, urolithiasis in pregnant women or in patients with urinary diversions, as well as upper urinary tract tumours can now be managed using this methodology. New endoscopes are continuously developed, with different manufacturers choosing various technical solutions to further increase the efficacy and safety-and sometimes decrease costs-of ureteroscopy, including miniaturization, inclusion of digital optical systems and dual working channels, and the introduction of disposable apparatus. The holmium laser, currently the most-versatile energy source available, enables tissue incision, tumour ablation, and intracorporeal lithotripsy. Modern ancillary instruments are diverse, flexible, and durable, and novel devices used in daily clinical practice can minimize ascendant migration of stone fragments and, therefore, decrease the failure rate of the retrograde ureteroscopic approach. However, the peak of ureteroscopy evolution seems to remain distant, with further improvement of endoscopes and ancillary instruments, and robot-assisted ureteroscopy representing only some of the areas in which future developments are possible.

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.