Percutaneous nephrolithotomy of horseshoe kidney: Our institutional experience

"Percutaneous Nephrolithotomy (PCNL) versus other treatments for stone management in horseshoe kidneys: A systematic review"

Urolithiasis represents the most frequent complication of horseshoe kidneys. All known approaches for stone disease management have been reported in these patients, including Extracorporeal Shockwave Lithotripsy, ureteroscopy, Percutaneous Nephrolithotomy, open surgery and laparoscopy. The purpose of this systematic review is to compare Percutaneous Nephrolithotomy with other least-invasive procedures in patients with horseshoe kidneys. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines, PubMed®, Scopus® and Cochrane® primary databases were systematically screened, from inception to 29 May 2023. Both prospective and retrospective comparative studies including patients with horseshoe kidneys and urolithiasis, who underwent Percutaneous Nephrolithotomy and other treatments for stones management, were eligible. Non comparative studies and case series were also included. A total of 10 studies met inclusion criteria and were included in final qualitative synthesis. In total 583 patient underwent Percutaneous Nephrolithotomy and other treatments for stone management in included studies. Stone free rates ranged from 57.1% to 88% for Percutaneous Nephrolithotomy, from 55.6% to 100% for ureteroscopy, from 27.3% to 83.3% for Extracorporeal Shockwave Lithotripsy and was 100% for pyelolithotomy and 71.4% for Percutaneous Nephrolithotomy in combination with ureteroscopy. Although percutaneous Nephrolithotomy was associated with more complications when compared to other treatment modalities, most of them were Grade I or Grade II ones, according to the Clavien-Dindo Classification System. Management of urolithiasis can be efficiently and safely accomplished in almost all cases of horseshoe kidneys. Extracorporeal Shockwave Lithotripsy, ureteroscopy, Percutaneous Nephrolithotomy and pyelolithotomy all represent excellent choices for the treatment of stones in these patients, being feasible, efficient and safe. Percutaneous Nephrolithotomy was associated with the highest stone-free rates, but also with the highest complication rates. Access should be ideally performed via the upper poles. Optimal stone management in patients with horseshoe kidneys depends on stone burden, stone location and surgeon's preference.

Optimal patient position for percutaneous nephrolithotomy in horseshoe kidneys: Traditional prone or supine?

OBJECTIVE

Although it was stated that supine percutaneous nephrolithotomy (PCNL) was associated with relatively shorter surgical times and comparable success and complication rates, there is no consensus in the current literature concerning the safety and efficacy of supine PCNL in patients with horseshoe kidneys. We aimed to compare supine and prone PCNL regarding safety and efficacy in patients with horseshoe kidneys.

METHODS

Data of the patients with horseshoe kidneys who underwent PCNL for renal stones larger than 2 cm between January 2010 and May 2021 were retrospectively reviewed. The study patients were categorized as Group 1 (i.e., supine PCNL-SPCNL) and Group 2 (i.e., prone PCNL-PPCNL). Both groups were compared regarding demographic, clinical, and surgical data.

RESULTS

Sixty-five patients were included. Among these patients, 31 (47.7%) were in Group 1, while 34 (52.3%) were in Group 2. Both groups were statistically similar in terms of demographic data, stone characteristics, perioperative parameters, and complication rates (p > 0.05). There was no statistical difference in terms of additional treatment rates, stone-free rates in the postoperative second-day and third-month evaluations (p > 0.05). Mean surgical time was significantly longer in Group 2 (113 ± 17.1 min) than in Group 1 (90.6 ± 11.3 min) (p = 0.000).

CONCLUSION

Although it is traditionally performed in the prone position, the supine approach is as safe and effective as the prone approach. In addition, the supine approach is associated with significantly shorter surgical times.

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.

Alternating Biplanar Fluoroscopy in Percutaneous Nephrostomy to Approach Stones in Patients With Horseshoe Kidney: An Institutional Experience

This case series aims to evaluate the use of alternating perpendicular biplanar fluoroscopy in percutaneous nephrostomies/percutaneous nephrolithotripsies (PCNs/PCNLs) to approach renal stones in patients with horseshoe kidneys. Between January 2012 and December 2019, PCNs/PCNLs were done for six patients with horseshoe kidneys having renal stones. Skin and renal calyceal entry points were determined by alternating perpendicular biplanar fluoroscopy using a portable C-arm machine in the conventional fluoroscopy unit. The site of renal access, postoperative complications, and residual stones was assessed.

The mean age of the patients was 36.8 years. The mean stone size was 6.1 cm (2.1-16.05cm). In five out of six (5/6; 83%) patients, there was one access site. Four patients had their access site through the upper calyx, and one patient had it through the lower calyx. The stone-free rate was four out of six (4/6; 66.6%). One patient had a mild drop in hemoglobin postoperatively. There were no major complications reported.

The implementation of alternating biplanar fluoroscopy was found safe and helpful in providing a better appreciation of renal anatomy and stone location in patients with horseshoe kidneys. This technique helps in approaching horseshoe kidney stones in PCN/PCNL without moving the patient or fluoroscopy machine, with a potential decrease in operation time and radiation exposure.

Percutaneous Nephrolithotomy in Horseshoe Kidneys: Results of a Multicentric Study

Objective: To report the outcomes of percutaneous nephrolithotomy (PCNL) in horseshoe kidneys (HSK) in 12 institutions worldwide and evaluate the impact of patient position during operation. Methods: We carried out a retrospective analysis of PCNL procedures performed between 2008 and 2018 in patients with HSK. Pre-, peri-, and postoperative data were collected, and a subgroup analysis was performed according to patient position. Success was defined as an absence of >4-mm fragments. Values of p < 0.05 were considered significant. Results: We analyzed 106 procedures. The transfusion, complication, and immediate success rates (ISRs) were 3.8%, 17.5%, and 54.7%, respectively. The final success rate (FSR) increased to 72.4% after a mean of 0.24 secondary procedures. Logistic regression showed that higher body mass index (BMI) and stone size were significantly associated with residual fragments ≥4 mm. Sixty-seven patients (63.2%) were treated in prone and 39 (36.8%) in supine position. The prone group had a significantly higher BMI than the supine group (30.1 vs 27.7, p = 0.024). The transfusion, complication, and ISRs between the prone and supine groups were 4.5% vs 2.6% (p = 0.99), 16.9% vs 18.4% (p = 0.99), and 52.5% vs 69.2% (p = 0.151), respectively. Surgical time was significantly longer in the prone group (126.5 vs 100 minutes, p = 0.04). Upper pole was the preferred access in 80.3% of the prone group and 43.6% of the supine group (p < 0.001). The prone group had significantly more Clavien 2 complications than the supine (p = 0.013). The FSR in the prone and supine groups increased to 66.1% and 82.1% after 0.26 and 0.21 secondary procedures, respectively. No complications higher than Clavien 3 occurred. Conclusion: PCNL in patients with HSK is safe and effective with a low complication rate. Higher BMI and stone size negatively impacted outcomes. Supine PCNL may be an option for treating kidney stones in patients with HSK.

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.