Calyceal Diverticular Stones Research Articles

Could "Retrograde Intrarenal Surgery" be Used as an Efficient Technique in the Treatment of Calyceal Diverticula Stones.

To evaluate the efficacy of retrograde intrarenal surgery (RIRS) and holmium laser lithotripsy in the treatment of symptomatic renal calyceal diverticular (CD) stones. A case series. Department of Urology, Hisar Intercontinental Hospital, from 2008 and 2019. Patients who underwent holmium laser lithotripsy with RIRS to manage symptomatic CD stones were evaluated retrospectively. Demographics, stone size, operation and hospital stay duration, the success of treatment and complications were noted. Among the 30 treated patients, 13 patients were female and 17 were male. The mean age was 45.4 ± 11.9 (26-64), the stone diameter was 14.4 ± 4.1 mm, operation time was 70.47±35.7 (35-155) minutes, and mean length of hospital stay was 1.27±0.5 (1-3) days. In those patients who underwent RIRS, 26 (86.7%) were successfully treated while in 4 of 30 patients (13.3%) the procedure was not successful. Complications were observed in 10 (33.3%) patients. Clavien-I complications were demonstrated in 6 patients, Clavien III complications were demonstrated in 3 patients. One patient had urosepsis, 2 patients had ureteral laceration, and one patient with Clavien IV complication had perirenal hematoma. Laser lithotripsy therapy with RIRS is a safe and effective treatment for symptomatic calyceal diverticular stones and can be offered as the first-line treatment for calyceal diverticular stones. Calyceal diverticula, Stone disease, Flexible ureterorenoscopy, Holmium laser, RIRS.

Needle-perc-assisted endoscopic surgery for patients with complex renal stones: technique and outcomes.

Our aim was to investigate the safety and efficacy of needle-perc-assisted percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS), namely, needle-perc-assisted endoscopic surgery (NAES), in a series of patients with large and/or complex renal stones. From May 2018 to August 2021, a total of 119 patients underwent NAES at our institute. Among them, 94 patients underwent needle-perc-assisted standard PCNL in prone position and 25 underwent needle-perc-assisted RIRS in the Galdakao-modified supine Valdivia position or prone split-leg position. Clinical factors including age, sex, medical history, and stone characteristics were collected. Intraoperative and postoperative outcomes were retrospectively evaluated. The patients' mean age ± standard deviation was 50.3 ± 14.3years. The mean stone size was 7.6 ± 3.7 and 1.7 ± 0.8cm for needle-perc-assisted PCNL and RIRS, respectively. Of the 119 patients, 51 had staghorn stones, 16 had solitary kidneys, 17 had a history of ipsilateral renal surgery, and 6 had calyceal diverticular stones. The mean operative time was 83.4 ± 25.9min for needle-perc-assisted PCNL and 66.3 ± 21.8min for needle-perc-assisted RIRS. The stone-free rate (SFR) for needle-perc-assisted PCNL was 77.7% after the first treatment and 88.3% after auxiliary treatments. The SFR for needle-perc-assisted RIRS was 88.0% and no auxiliary treatments were carried out in this group. Eleven (11.7%) patients who underwent needle-perc-assisted standard PCNL developed Clavien-Dindo grade I or II complications. Three (12.0%) patients who underwent needle-perc-assisted RIRS developed a fever (grade I). The overall complication rate for NAES was 11.8%, with no urosepsis, angioembolization, or other grade III to V complications. In conclusion, NAES is a safe and effective procedure for one-step complete resolution of large and/or complex renal stones with no additional procedure-related complications.

Flexible Ureteroscopic Holmium Laser Infundibulotomy and Lithotrypsy for the Management of Calyceal Diverticular Stone with Infundibular Atresia: A Case Report

Renal calyceal diverticulum is a non-secretary urothelium cavity in the renal parenchyma communicating with calyx allowing for passive filling with urine. Calyceal diverticula are found incidentally in 0.21% to 0.6% of intravenous urograms in adults. Stone formation occurs in about 10-50% cases of renal calyceal diverticula. Symptomatic case needs treatment. Digital flexible ureteroscopy with Holmium laser infundibulotomy and laser lithotripsy is beneficial in terms of shorter hospital stay, better stone clearance and minimal complications in comparison with those of other modalities. Cases of stenotic infundibulum have been addressed adequately but infundibular atresia has been rarely reported. Therefore, we present a symptomatic case of calyceal diverticular stone with infundibular atresia managed by disposable flexible ureteroscopy with holimium laser infundibulotomy and laser lithotripsy.

Calyceal diverticular stones: Does the insistence on less invasive technique keep the patient away from a major complication?

Calyceal diverticular stones are rare clinical entities without a clearly defined consensus on the treatment. Treatment indicationsinclude recurrent urinary tract infections, chronic pain and renal impairment. Treatment modality of surgical approach is usuallybased on the location of calyceal diverticulum.A 23-year-old woman was presented with a calyceal diverticular stone of 16.5 mm. Her medical history revealed multiple urinary tractinfections caused by extended spectrum beta-lactamase (ESBL)-producing Escherichia coli of which the stone was predicted to be thereason. The patient was treated ureterorenoscopically, a decision of which was taken intra-operatively.In conclusion, insisting on performing nephroscopy following an intra-operative retrograde pyelography revealed no apparentostium which could be interpreted as ureterorenoscopic retriaval would fail and development of postoperative bacteremia despite allprecautions taken pre-and intra-operatively were two lessons indicating that all efforts must be exercised to reach the most minimalinvasive method for the treatment of calyceal diverticular stones.

Abstract 85 - Calyceal Diverticular Stones: A novel technique to access the diverticulum

Abstract 85 - Calyceal Diverticular Stones: A novel technique to access the diverticulum

Tubeless Supine Percutaneous Nephrolithotomy in Calyceal Diverticular Stone

Percutaneous Nephrolithotomy (PCNL) has routinely been performed in prone position as a treatment for calyceal diverticular stone. PCNL is performed supine as an alternate modality for calyceal diverticular stones. The objective of the procedure is to reduce operative time and anaesthetic morbidity during supine tubeless PCNL in calyceal diverticular stone. The series is about three patients with calyceal diverticular stones. These patients underwent supine tubeless PCNL in Galdakao modified supine Valdivia position. There was no intraoperative, postoperative or on follow-up complications in any of the the patients. In all the patients stones were cleared completely in single sitting. Supine PCNL in calyceal diverticular stone could be an alternative with similar outcomes to the standard prone PCNL. It provides an additional benefit of performing the procedure in a single position, which is known to reduce total operating time and also reduces anaesthesia complications.

Treatment Options for Calyceal Diverticula.

Calyceal diverticula are rare entities that can pose a significant challenge when it comes to their management. We analyse and summarise the literature with a focus on recent advances in the management of calyceal diverticula and discuss the advantages and disadvantages of each surgical technique. The identification of calyceal diverticula requires a certain level of suspicion and contrast-enhanced imaging. Conventional techniques of imaging the renal collecting system such as the classic intravenous urography are now superseded by the ease of access to contrast-enhanced CT imaging. Conventional surgical techniques for managing calyceal diverticula are not being superseded by new techniques but rather being progressively enhanced and improved through the amelioration of existing technology. Debate still exists over the best treatment approach for the management of symptomatic calyceal diverticula, the choice of which still very much depends on the location and anatomy of the diverticulum itself. The most significant advance in the management of calyceal diverticula and indeed stones, in general, seems to be the progressive miniaturisation of percutaneous nephrolithotomy (PCNL) equipment allowing effective treatment with a reduction in associated risks of conventional PCNL. The increasing accessibility of robotics has a role to play in the management of this condition but is not likely surpass flexible ureteroscopic (fURS) or percutaneous approaches. The future of surgical management for this condition lies in striking a balance between treatment efficacy and invasiveness. More recent identification of metabolic disturbances in patients with calyceal diverticular stones may provide further insights into the underlying pathology of this condition and is likely to play a role in future research of diverticular stones.

Utilizing da Vinci® surgical system to treat challenging urinary stones.

Introduction:A worldwide mounting in the incidence and prevalence of urolithiasis has been observed. The standard treatment of urologic stone disease (USD) has changed from open surgery to extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy (PCNL), or ureteroscopy depending on the size and location of the stone. We are sharing our experience in utilizing Da Vinci® robotic surgical system to treat patient with urolithiasis instead of open surgical approach.Patients and Methods:We reviewed prospectively collected data of 19 patients who underwent robotic-assisted stone surgery (RSS) between January 2010 and March 2018 at our institute for USD involving 22 nephroureteral units.Results:A total number of 22 RSS were accomplished with no conversion to open. Three patients had bilateral stone and needed to have RSS on each side separately. Eleven RSS were performed on the right. The indications for RSS included as follows: morbid obesity (n = 8, mean body mass index 56.4 kg/m2), need for concurrent renal surgery (n = 3) severe contractures limiting positioning for retrograde endoscopic surgery or PCNL (n = 2), symptomatic calyceal diverticular stone with failed endoscopic approach (n = 4), and after failed PCNL (n = 2). Twenty nephrouretral unit (91%) were rendered stone free on the first attempt with complication occurring after four cases (18%).Conclusion:RSS is viable options in the treatment of challenging urologic stone with high success rate and low risk of complication. The need for open stone surgery was eliminated by RSS at our center.

Percutaneous Management of Stone Containing Calyceal Diverticula: Associated Factors and Outcomes

We evaluated the outcomes of percutaneous treatment and metabolic evaluation of calyceal diverticula with associated stones. 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. 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. 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.

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.

Reduced radiation fluoroscopy protocol during retrograde intrarenal surgery for the treatment of kidney stones.

To discuss whether fluoroscopic imaging is essential during the ureteroscopic treatment of kidney stones in an effort to diminish radiation exposure. Seventy-six patients with kidney stones were treated with retrograde intrarenal surgery (RIRS). In the operation room, a mobile C-arm fluoroscopy system was ready to use in case fluoroscopic imaging was needed. The manipulations were performed with tactile and visual cues. The perioperative and postoperative parameters were retrospectively evaluated. The mean age of the patients was 39.9 ± 13.8 years. The mean stone size was 14.1 ± 4.1 mm. The insertion of the access sheath was performed over the guidewire under single shoot fluoroscopic imaging in all patients. Additional fluoroscopic imaging was required to localize the stone (n = 2) and to determine the collecting system anatomy (n = 2) for 4 (5.2%) patients with previous renal surgery and severe hydronephrosis. Stone-free status was accomplished in 63 (82.9%) patients. The RIRS with low-dose fluoroscopy protocol for kidney stones can be safely and effectively performed in patients with no special circumstances such as anatomical abnormalities or calyceal diverticular stones.

Is retrograde flexible nephrolithotripsy feasible for calyceal diverticular stone?

The aim of this study is to manage the calyceal diverticular (CD) stone, several treatment options were applied but it is still a challenging condition of endourology. In this retrospective study, we aim to report the results of our patients with CD stones treated with retrograde flexible nephrolithotripsy (RFNL). A total of 47 patients (55 procedures) who underwent RFNL by a single surgeon for CD stones from January 2004 to March 2013 were evaluated retrospectively. The demographic properties and initial complaints of those patients have been recorded along with their comorbidities and previous history of stone management. Moreover, the size and number of the stones, the duration of the surgery, fluoroscopy time, stone-free rate (SFR) and postoperative complications of the patients have been evaluated. The mean age was 41.8 years (range 16-71). Of the study population, 31 (65.9%) were male. Mean stone size was 21.1 (7-52) mm whereas in 3 (6.4%) of the cases the stones could not be reached. Mean duration of the surgery was 92.8 (57-163) min whereas mean fluoroscopy time was 35.9 (14-103) s. After 3 months of follow-up period, the SFR was 85.1%. No major complications occurred. RFNL with holmium laser and nitinol basket catheter application is a feasible and successful procedure in the management of CD stones. With its high success rates, low incidence of complications and minimal morbidity when compared with other treatment options, RFNL has the potential of becoming the preferred treatment option in the minimally invasive management of patients with CD stones.

Bacterial sepsis after extracorporeal shock-wave lithotripsy (ESWL) of calyceal diverticular stone

Most calyceal diverticula are asymptomatic but symptoms occur when there is urinary stasis leading to infection and calculi. Septic shock after ESWL of calyceal stone occurs rarely. A 24-year-old woman had septic shock due to after extracorporeal shock-wave lithotripsy (ESWL) of asymptomatic calyceal diverticular stone.

Percutaneous Holmium Laser Fulguration of Calyceal Diverticula

Introduction. Calyceal diverticular stones are uncommon findings that represent a challenge in their treatment, due to the technical difficulty in accessing the diverticulum, and the high risk of their recurrence. Current percutaneous technique for calyceal diverticular stones involves establishing a renal access, clearing the stone, and fulguration of the diverticular lining with a roller-ball cautery electrode using hypotonic irrigation solution such as sterile water or glycine solution which may be associated with the absorption of hypotonic fluids with its inherent electrolyte disturbances. Case Report. In this paper, we present for the first time percutaneous holmium laser fulguration of calyceal diverticula in 2 patients using normal saline. Their immediate postoperative sodium was unchanged and their follow-up imaging showed absence of stones. Both patients remain asymptomatic at 30 months post-operatively. Conclusion. This demonstrates that holmium laser is a safe alternative method to fulgurate the calyceal diverticulum after clearing the stone percutaneously.

Treating lower pole renal stones: in defence of shock wave lithotripsy

I have been invited to participate in this written debate, with Reem Al-Bareeq and John Denstedt, on the preferred treatment option for lower pole renal stones.

Management of calyceal diverticular stones with extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy: long‐term outcome

To review patients with an extended follow-up after extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) for calyceal diverticular stones (CDS), over a 15-year period, assessing the long-term outcome. In all, 56 patients were treated for symptomatic CDS disease by ESWL (38) or PCNL (18). The stone-bearing diverticula were in the upper calyces in 26, middle calyces in 24 and lower calyces in six patients, and in the right kidney in 22 and in the left in 34. The most frequent symptom was ipsilateral flank pain (84%) and 32% of patients presented with associated chronic urinary tract infections. In a retrospective analysis, we assessed stone size, diverticulum location, stone-free rate, symptom-free rate, complications and extended follow-up. In the short-term in the ESWL group, 21% of patients were stone-free and 61% were asymptomatic; 8% developed symptoms and 8% developed recurrence or stone-growth in the long term. There were six minor complications. In the PCNL group, 15 patients (83%) were stone-free in the short term; two had a recurrence (11%) and two had stone growth (11) in the long term. There were three complications after PCNL. This series shows that PCNL is an effective and durable means of treating CDS, regardless of stone size or location of the diverticulum. Despite low stone-free rates with ESWL, most patients were rendered symptom-free with minimal complications. The long-term recurrence rates, 8% for ESWL and 11% for PCNL, were comparable.

The pathogenesis of calyceal diverticular calculi

Controversy exists over whether metabolic factors or urinary stasis predominate in the pathogenesis of calyceal diverticular calculi. We performed a study to better define the effects urinary stasis and metabolic abnormalities have in the pathogenesis of calyceal diverticular stones. Twenty-nine patients who underwent percutaneous treatment of calyceal diverticular calculi were studied. All patients underwent 24 h urine collection to evaluate metabolic risk factors. In three patients, urine was sampled directly from the diverticulum for metabolic studies. The urinary stone risk parameters of the patients with calyceal diverticular stones (Tic SF) were similar to those of a well-characterized cohort of calcium oxalate stone formers (CaOx SF). When compared to a group of normal people, the Tic SF and CaOx SF were significantly more hypercalciuric and their urine was significantly more supersaturated with calcium oxalate. Urine aspirated directly from the diverticulum had the lowest SSCaOx when compared to ipsilateral and contralateral renal pelves. The urinary risk profiles of patients with diverticular calculi are similar to those of CaOx SF, suggesting a metabolic etiology of diverticular stones. However, the SS CaOx of urine aspirated directly from the diverticula is significantly lower than that of the renal pelves; these data support the hypothesis that urinary stasis significantly contributes to the pathogenesis of calyceal diverticular calculi. Taken together, it seems likely that calyceal diverticular calculi arise from a combination of metabolic abnormalities and urinary stasis.

Metabolic abnormalities associated with calyceal diverticular stones

To review the metabolic analyses of patients with calyceal diverticular stones who had surgical treatment of their calculi and to examine the effect of selective medical therapy on stone recurrence, as recent reports suggest that metabolic abnormalities contribute to stone development. In all, 37 patients who had endoscopic treatment of symptomatic calyceal diverticular calculi were retrospectively reviewed. Stone composition and initial 24-h urine collections (24-h urinary volumes, pH, calcium, sodium, uric acid, oxalate, citrate, and the number of abnormalities/patient per collection) were compared with 20 randomly selected stone-forming patients (controls) with no known anatomical abnormalities. Stone formation rates before and after the start of medical therapy were calculated in the patients available for follow-up. Twelve of the diverticulum patients (five men and seven women) had complete 24-h urine collections, all of whom had at least one metabolic abnormality. Seven patients had hypercalciuria, four had hyperuricosuria and three had mild hyperoxaluria. The most common abnormality was a low urine volume; 11 of the 12 patients had urine volumes of <2000 mL/day (range 350-1950). Ten patients had hypocitraturia in at least one of the two 24-h urine samples; seven had low urinary citrate levels (172-553 mg/day) on both samples. The findings were similar in the control group. The diverticulum patients had 3.1 abnormalities/patient, and the controls had 2.9 abnormalities/patient (P > 0.05). No patients had gouty diathesis and none developed cystine stones. Stone analyses were similar in the two groups; both developed either calcium oxalate or mixed calcium oxalate/calcium phosphate stones. Six patients were followed for a mean of 23.1 months while on selective medical therapy; only one passed any additional stones, thought to be existing calculi, for a remission rate of five of six (83%). All patients with symptomatic calyceal diverticular stones who had comprehensive metabolic evaluation had metabolic abnormalities. There were similar abnormalities in the control random stone-formers. The abnormalities were corrected with selective medical therapy, as shown by the high remission rate. We recommend that, for patients with symptomatic calyceal diverticular calculi, a metabolic evaluation should be considered to determine stone forming risk factors.