Left Renal Stone Research Articles

V9-04 DIRECT VISUALIZATION PERCUTANEOUS NEPHROLITHOTOMY WITHOUT FLUOROSCOPY

INTRODUCTION AND OBJECTIVES: Percutaneous nephrolithotomy (PCNL) remains a challenging procedure associated with significant potential for patient morbidity. In an attempt to decrease the morbidity of PCNL, we have developed a novel technique employing direct visualization with ureteroscopy to decrease ambiguity associated with fluoroscopy guidance, while eliminating ionizing radiation exposure. In this video, we demonstrate PCNL techniques that obviate the need for fluoroscopy. METHODS: This video demonstrates fluoroless PCNL in a 56 year-old female with large left renal stone burden (>4 cm). The patient was positioned prone and split-leg. Utilizing visual and tactile cues, a super-stiff and standard guidewire were placed from below using a flexible cystoscope. Using flexible ureteroscopy, the ideal calyx for access was selected. Under ultrasound guidance, an access needle was placed into the selected calyx, which was directly visualized on ureteroscopy. With the aid of a stone basket, an access wire was pulled into the ureter to allow for subsequent exchange to a super-stiff guidewire. Under direct visualization with the ureteroscope, the balloon and access sheath were positioned. The ureteroscope was left with the tip occluding the ureteropelvic junction to prevent distal migration of fragments. Stone comminution was accomplished with an ultrasonic lithotripter. Stone-free status was assured intraoperatively using a combination of flexible nephroscopy and ureteroscopy. A nephrostomy tube and multipurpose angled ureteral catheter were placed under direct vision ureteroscopically to conclude the procedure. RESULTS: Operative time was 4 hours 36 minutes. Estimated blood loss was <50 mL. On post-operative day one, a 15 mAs low-dose CT (<1 mSv) demonstrated stone-free status. CONCLUSIONS: This technique combines the methods of many pioneering endourologic surgeons in a unique way to perform PCNL under direct visualization. We believe this technique offers significant promise both by eliminating uncertainties encountered when operating under fluoroscopic guidance and reducing the risk of radiation exposure to patients and operating room staff.

Renal rupture with perirenal hematoma after ureterorenoscopic holmium:YAG laser lithotripsy for a renal pelvic stone

We present a rare, but critical case of renal rupture after ureterorenoscopic holmium:YAG laser lithotripsy. This is the first case report of renal rupture after laser lithotripsy in managing an upper urinary tract stone. A 75-year-old male underwent retrograde ureterorenoscopic holmium:YAG laser lithotripsy for a left renal pelvic stone. A drop in blood pressure was noted postoperatively. Abdominal computed tomography confirmed a left subcapsular, perirenal hematoma and a stone which had dropped out to the left subcapsular space.

Laparoscopic management of a large staghorn stone

Urinary calculi are prevalent and result in significant morbidity,with a marked economic impact. Various therapeutic optionsexist, from medical to surgical management according to stonesize. Laparoscopic pyelolithotomy is a viable option for significantstaghorn renal stones. We report the case of a laparoscopicpyelolithotomy performed on a 48-year-old man with a left recurrent staghorn renal stone secondary to an ureteropelvic junction obstruction following a grade IV renal trauma several years ago.

Transmesocolic robotic extended pyelolithotomy of a large gas-containing renal stone: Case report and review of the literature

We present the fifth case in the world literature of a gas-containing urinary stone. Our patient is a 31-year-old woman referred for left flank pain and gross hematuria who was noted on imaging to have a 6.5 cm left renal pelvis stone containing gas. Cultures revealed Escherichia coli from the urine and stone material. Chemistry revealed underlying gouty diathesis. The stone was removed using robotic extended pyelolithotomy. Overall, renal function remained unchanged while drainage improved on nucleotide renography. Review of the world literature suggests that gas-containing renal stones are invariably associated with emphysematous pyelonephritis commonly caused by E. coli and Klebsiella. Contributing factors to gas-containing stone formation include urinary stasis, metabolic mineral derangement and, in a minority of the cases, diabetes.

A Giant Ureteral Stone without Underlying Anatomic or Metabolic Abnormalities: A Case Report

A 28-year old man presented with left flank pain and dysuria. Plain abdominal film and computed tomography showed a left giant ureteral stone measuring 11.5 cm causing ureteral obstruction and other stones 2.5 cm in size in the lower pole of ipsilateral kidney and 7 mm in size in distal part of right ureter. A left ureterolithotomy was performed and then a double J stent was inserted into the ureter. The patient was discharged from the hospital 4 days postoperatively with no complications. Stone analysis was consistent with magnesium ammonium phosphate and calcium oxalate. Underlying anatomic or metabolic abnormalities were not detected. One month after surgery, right ureteral stone passed spontaneously, left renal stone moved to distal ureter, and it was removed by ureterolithotomy. Control intravenous urography and cystography demonstrated unobstructed bilateral ureter and the absence of vesicoureteral reflux.

Tubercular renocolic fistula: an unusual presentation.

The development of a fistula between colon and kidney is very rare. An unusual case of renocolic fistula is reported in a middle-aged obese lady who presented with septicemia, acute respiratory distress syndrome and acute renal shut-down with underlying uncontrolled diabetes mellitus. The patient was stabilized after intensive care management and the diagnosis of left renocolic fistula with left renal stone was established on contrast-enhanced computed tomography of the abdomen and barium enema. She underwent left nephrectomy with left hemicolectomy and colocolic anastomosis. Surprisingly, the final diagnosis on histopathology turned out to be renocolic fistula with underlying tuberculosis. The aim of this rare case report is to create awareness of atypical presentation of renocolic fistula so that timely diagnosis and intervention can salvage such patients.

Laparoscopic management of a large staghorn stone

Urinary calculi are prevalent and result in significant morbidity, with a marked economic impact. Various therapeutic options exist, from medical to surgical management according to stone size. Laparoscopic pyelolithotomy is a viable option for significant staghorn renal stones. We report the case of a laparoscopic pyelolithotomy performed on a 48-year-old man with a left recurrent staghorn renal stone secondary to an ureteropelvic junction obstruction following a grade IV renal trauma several years ago.

Primary Hyperaldosteronism As A Risk Factor For Recurrent Nephrolithiasis

Primary hyperaldosteronism typically presents as hypertension, hypokalemia, and metabolic alkalosis. Several previous reports note an association between primary hyperaldosteronism and nephrolithiasis with secondary hyperparathyroidism. We report a case of a previously normotensive, normocalcemic, normokalemic young man with initial CT imaging of nephrolithiasis showing no adrenal abnormalities. Three years later, he presented with severe hypertension, hypokalemia, and an adrenal adenoma with incidental findings of recurrent nephrolithiasis. Literature review of hyperaldosteronism complicating nephrolithiasis and possible etiologic mechanisms are reviewed. A 25 year-old man with a history of ureteral calculi 3 years ago presented with gastroenteritis for over 24 hours. Initial evaluation included a BP of 194/140 mmHg, potassium of 2.2 mmol/l, bicarbonate of 40 mmol/l, and ionized calcium of 0.95 mmol/l. All electrolytes 3 years prior were normal. Plasma aldosterone concentration to plasma renin activity ratio was 21.1 with aldosterone of 4 ng/dl and renin of 0.19 ng/ ml/ hr. CT scan showed a new 3 cm left adrenal mass not seen on prior CT with multiple new left renal stones. Follow up aldosterone after correction of hypokalemia, spironolactone, and amiloride was 104 ng/dl. Laparoscopic adrenalectomy pathologically confirmed an adrenal adenoma. Postoperative labs showed relative hypoaldosteronemia albeit with persisting but much improved hypertension. Hyperaldosteronism can cause hypercalciuria, phosphaturia, and hypocitraturia, all of which are risk factors for nephrolithiasis. Additionally, hyperaldosteronism and deoxycorticosterone mediated hypertension have been associated with hypocalcemia and secondary hyperparathyroidism. Our case augments earlier literature suggesting increased risk for nephrolithiasis in patients with hyperaldosteronism and suggests that hyperaldosteronism should be considered as a risk factor for patient with nephrolithiasis. It remains unclear if both primary and secondary hyperaldosteronism increase the relative risk for nephrolithiasis and the role of aldosterone receptor antagonist therapy for recurrent nephrolithiasis associated with hyperaldosteronism.

Devons-nous consommer moins de sel ?

There is overwhelming evidence that dietary salt is a major cause of increased blood pressure. There is also a link between a high salt intake and risk of stroke, left ventricular hypertrophy, renal disease, obesity, renal stones and stomach cancer. Reduction of salt intake is efficacious and cost-effective. In developed countries, reduction in salt intake requires the participation of food industry.

Subcutaneous emphysema of the leg: Could be a fatal condition

Gas in the leg is not always a gas gangrene. Abdominal infection with gas forming organisms may spread to the thigh & leg. We report a case of critically ill patient who presented to the emergency department with features suggestive of septic arthritis of the left hip. Assessment and further intervention revealed subcutaneous emphysema of the leg secondary to an infection of a previously asymptomatic staghorn calculus. X-ray of the abdomen showed a left renal stone and gas in the soft tissue planes of the left retroperitoneal space while X-ray of the left femur showed gas in the soft tissue planes of the left hip region and whole thigh with no bony or joint abnormality. Such case has not been reported in English literature before. Physicians and surgeons should be aware of this condition that could be fatal but curable by early intervention.

Ureteroscopy assisted retrograde nephrostomy: a new technique for percutaneous nephrolithotomy (PCNL)

Study Type - Therapy (case series). Level of Evidence 4. What's known on the subject? and What does the study add? Retrograde nephrostomy was first developed by Lawson et al. in 1983, and Hunter et al. reported 30 cases of retrograde nephrostomy in 1987. This procedure uses less radiation exposure and has a shorter duration compared with the previous percutaneous nephrostomy techniques. Retrograde nephrostomy using Lawson's procedure was reported in the late 1980s by several authors. But since then, few studies have been reported about this procedure due to the development of ultrasonography assisted percutaneous nephrostomy. With the arrival and development of the flexible ureteroscope (URS) both observation and manipulation in the renal pelvis are now easily achieved. The present procedure provides less radiation exposure, less bleeding, and a shorter procedure than previous percutaneous nephrostomy techniques. Using this procedure, after the needle has exited through the skin, no further steps are required in preparation for dilatation. In the present study, we continuously visualised from puncture to inserting the nephron-access sheath with the URS. • To describe a technique for ureteroscopy assisted retrograde nephrostomy. • Under general and epidural anaesthesia, the patient is placed in a modified-Valdivia position. Flexible ureteroscopy is carried out, and a Lawson retrograde nephrostomy puncture wire is placed in the ureteroscope (URS). • After the needle has exited through the skin, no further steps are required in preparation for dilatation. • After informed consent was obtained, two patients (a 43-year-old man with left renal stones and a 57-year-old woman with right renal stones) underwent this procedure. • The URS was positioned in the middle posterior calyx and punctured toward the skin. • This procedure involves less radiation exposure and shorter surgery than the previous percutaneous nephrostomy technique. • Our technique represents another new option for percutaneous nephrolithotomy in patients with a non-dilated intrarenal collecting system.

2,8-Dihydroxyadenine Urolithiasis. Case Report and Literature Review

2,8-Dihydroxyadenine (DHA) urolithiasis is a rare type of urinary stone disease secondary to deficiency of adenine phosphoribosyltransferase (APRT) activity, a rare, inherited autosomal recessive disease with an incidental rate from 0.4 to 1.2%. The prevalence is higher among Japanese than other ethnic groups. APRT normally catalyzes the conversion of adenine to adenosine monophosphate and its deficiency results in 2,8-dihydroxyadenine (2,8-DHA) accumulation. This compound is extremely insoluble and its crystallization can lead to stone formation and renal failure. We report the case of 2,8-dihydroxyadenine (DHA) urolithiasis in a 52-year-old male patient. In December 2008 a 52-year-old Caucasian man was admitted to our hospital with sudden pain in the left lumbar region. Abdominal X-ray did not show any radiopaque urinary stone. I.V. pielography showed a radiolucent left lumbar ureteral (0.6 mm) and renal (1.5 cm) stone. After therapy with tamsulosin, the ureteral stone was excreted. Successful ESWL treatment was performed for renal stone. He presented a clinical history of several episodes of bilateral renal colic and two prior ESWL treatment for radiolucent stones. Chemolitholysis was never successful. RESULTS. Stone analysis by infrared spectroscopy and microscopic examination of urine reveal typical 2,8-DHA crystals. APRT deficiency was detected in the hemolysate of erythrocyte. Partial deficiency of APRT in the patient's relatives showed heterozygosity of the enzyme defect. Allopurinol therapy successfully prevented further stone formation. 20 months later the patient remains stone free. Two types of deficit are commonly distinguished, depending on the level of residual APRT activity. Type I is complete enzyme deficiency. Type II shows residual activity in cell lysates, but enzyme activity is not demonstrable in intact cells. About 78% of the Japanese patients belong to type II. The diagnosis of the disease is based on stone analysis by infrared spectroscopy or microscopic examination of urine, which may reveal typical 2,8-DHA crystals. Molecular approach can identify mutations, which are responsible of this inherited disease. Excessive water intake, restriction of foods with high adenine contents and administration of allopurinol are useful treatments. APRT deficiency is a rare disease but we can consider this pathology in case of recurrent radiolucent stones after chemolitolysis.

체외충격파쇄석술에서 투시 시 주요 장기별 방사선 피폭선량

We measured the radiation exposure for 55 persons (male: 36, female: 19) who was diagnosed with kidney and ureter stones and received ESWL. The absorbed dose was measured at the organ which is expected to absorb relatively much radiation (kidney, bladder, liver). The radiation dose measurement voltage 80kVp, current of 5mA as a fixed model of the human body by using the Rando phantom with Radiophotoluminescent Glass Dosimeter. Absorbed dose was measured for two times (5 minute and 10 minute, each) and converted to effective dose. Mean number of treatment was 1.8 times (1~4) per patient was the mean time of radiation exposure533 seconds (248-2516). For the treatment of right renal stone, the effective dose of right kidney, left kidney, liver and bladder was 2.458mSv, 0.152mSv, 1.404 mSv and 0.019mSv, respectively. For the treatment of left renal stone, the effective dose of right kidney, left kidney, liver and bladder was 2.496mSv, 0.252mSv, 0.178 mSv, and 0.017mSv, respectively. For the treatment of distal ureter stone, the effective dose of right kidney, left kidney and bladder was 0.009mSv, 0.01mSv and 3.742mSv, respectively.

Percutaneous nephrolithotomy in a patient with intrarenal arterial aneurysm

We report the case of a male patient with a left renal pelvic stone 2.5 cm in maximum diameter and a large upper pole intrarenal arterial aneurysm on the same side. The stone was treated with percutaneous nephrolithotomy (PCNL). This procedure was feasible even in this difficult clinical setting. Puncture of a calyx located at a safe distance from the aneurysm and meticulous surgical technique were essential in realizing the best possible outcome. To our knowledge, this is the first case of PCNL performed on a patient with a renal stone and an intrarenal arterial aneurysm.

Retroperitoneal ancient schwannoma

A 37-year-old patient presented with a 7 months history of vague pain in the right loin. She suffered from the left renal stones previously which were treated conservatively. Her physical examination was normal. Plain and contrast computerized tomography (CT) scan of the abdomen revealed a large cystic mass of 10.5 × 5.2 cm in the right paravertebral space at D12-L1 level. Contrast enhancement of the mass showed heterogeneous nature with both solid and cystic components. The kidney was displaced anterolaterally. Both the adrenals were within normal limit (Fig. 1). Exploratory laparotomy revealed a cyst of 10.5 × 5.2 cm containing blood stained fl uid and solid component, located postero-medially to the right kidney and posterior to right adrenal gland, in the right paravertebral space. Right renal vessels were splayed over the swelling. The cystic swelling was excised completely. Histopathological examination demonstrated Antoni- A and Antoni- B regions, suggestive of schwannoma (Fig. 2). The patient was asymptomatic at follow up, four months after the surgery. No further therapy was offered to the patient.

A case of staghorn stones in a kidney with an ileal ureter treated by percutaneous nephrolithotomy

A 59-year-old man was admitted to hospital for investigation of a 1-year history of intermittent hematuria. He had undergone ileal ureteral replacement for left renal stones 36 years earlier. Renal ultrasonography, physical examination, abdominal plain radiography, intravenous urography, CT urography, measurement of serum levels of creatinine, urea and electrolytes, renal scintigraphy, urinalysis and urine culture. Staghorn calculi in the left kidney, with a high-lying anastomosis between the renal pelvis and the proximal ileal segment. The patient underwent percutaneous nephrolithotomy via a middle-calyx access for the large staghorn stones. After surgery, no residual calculi were found and the patient was discharged with an uneventful postoperative course. At 1 month, renal scintigraphy showed normal bilateral kidney function. The patient received potassium citrate supplementation and was followed up with 6-monthly imaging studies. At the last report, he had been stone-free for 7 months.

Acute Hemothorax after Percutaneous Nephrolithotomy - A case report -

Percutaneous nephrolithotomy (PCNL) is a common procedure done for stone removal, as it is less invasive than an open procedure. But, several complications may occur. Hemothorax is a rare but severe chest complication of the supracostal puncture during PCNL. We experienced an acute hemothorax and lung collapse just after PCNL in a 66-year-old male patient with left renal stone. A chest tube was inserted for drainage and was removed after 9 days, when a chest X-ray revealed good expansion of lung.

Case Report: Scrotal Ecchymosis after Shockwave Lithotripsy

Shockwave lithotripsy (SWL) is the treatment of choice for most renal calculi because it is highly effective and relatively noninvasive. Although complications of SWL are relatively few, one that occurs more frequently is perirenal hematoma, usually diagnosed by radiologic procedures. We present an interesting case of scrotal ecchymosis as an unusual presentation of perirenal hematoma causing ipsilateral spermatic-vein thrombosis after SWL for a left renal stone. To our knowledge, this condition has not been reported previously.

Outcome of right hand–assisted retroperitoneoscopic living donor nephrectomy

Objectives To compare the results of right and left hand-assisted retroperitoneoscopic living donor nephrectomy (HARDN) and assess the usefulness and feasibility of right HARDN. Methods A total of 68 HARDNs performed from July 2001 to February 2005 in Akita University Medical Center were entered into this study. Of these, 12 cases were right-sided HARDN. The reasons for selecting right HARDN were wandering right kidney in 4, multiple left renal arteries in 3, lower glomerular function presenting in the right kidney in 2 patients, and left renal stone, right renal cyst, and right renal aneurysm in 1 patient each. We compared the perioperative and postoperative results of the 12 right-sided HARDNs with those of the 56 left HARDNs. Results No significant differences were found between the two groups in the demographic data (ie, age, sex, number of renal arteries), except for the body mass index. None of the right HARDNs resulted in major complications or open conversion, but two left HARDNs required conversion to open surgery. No difference was found between the two groups regarding estimated blood loss, warm ischemia time, or time to oral intake, although the right HARDN group had a longer mean operative time. No significant differences were found in the recipient’s postoperative graft function or in the frequency of delayed graft function. Conclusions Right HARDN provided almost similar perioperative and postoperative outcomes compared with those of left HARDN. Our results indicate that right HARDN is a choice for living donor nephrectomy because of its technical feasibility, safety, and minimal invasiveness, which are comparable to those of left HARDN.

Squamous cell carcinoma arising in the giant cutaneous horns accompanied with renal cell carcinoma

An 85-year-old man who presented with two giant cutaneous horns on his lower lip underwent an explorative laparotomy because of a left renal tumor and gall bladder stones. The cutaneous horns on the lower lip were excised at the same session. Histology revealed a renal cell carcinoma and minimally invasive squamous cell carcinoma at the base of the giant cutaneous horns. We present this case showing the simultaneous occurrence of squamous cell carcinoma at the base of a giant lower lip cutaneous horn and a renal cell carcinoma of the L kidney.