MULTIPLE CALCIUM PHOSPHATE STONES OCCUPYING A CALICEAL DIVERTICULUM

Abstract

A 71-year-old man presented with nephrolithiasis. Six months previously he was evaluated elsewhere for gross hematuria. Examination at that time revealed adenocarcinoma of the bladder dome and a left renal upper pole caliceal diverticulum containing more than 1,000 small stones (fig. 1). Two weeks later left flank pain developed. Radiographs showed the diverticulum had spontaneously opened, filling the collecting system and upper ureter with stones (fig. 2). A nephrostomy tube and ureteral stent were placed to relieve the obstruction. The patient subsequently underwent planned partial cystectomy. After a recovery period 3 percutaneous nephrolithotomies were performed through a lower pole access. At presentation significant numbers of stones remained in the diverticulum and there were concerns about safe access through the upper pole into the diverticulum. An additional 5Fr angiographic catheter was placed through the diverticulum, which permitted direct percutaneous stone extraction. Using both nephrostomy accesses, the entire stone burden was removed. Two sessions were required due to a significant amount of bleeding. The diverticular mouth was noted to be 4 mm wide and urine was actively refluxing from the upper pole calix into the diverticulum. At the end of the second procedure the neck of the diverticulum was dilated to 30Fr.