Stones In Pelvic Kidneys Research Articles

P073 - Percutaneous management of stones in pelvic kidneys - A tertiary hospital experience

P073 - Percutaneous management of stones in pelvic kidneys - A tertiary hospital experience

Laparoscopy assisted percutaneous stone surgery can be performed in multiple ways for pelvic ectopic kidneys.

Pelvic kidney stones remain a unique challenge to the endourologists. Treatment options include open surgery, extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy (PNL), retrograde intrarenal surgery, and laparoscopy assisted PNL (LA-PNL). As a minimal invasive option, LA-PNL can decrease the risk for bowel and major vessel injury. Here, we describe our experience using the LA-PNL procedures with different combinations, to treat kidney stones in multiple patients with a pelvic ectopic kidney (PEK). Eight patients, with PEK, kidney stones, and no other treatment choice, but open surgery, were included in the study. Two different laparoscopic techniques such as mesocolon dissection and transmesocolic, and four different percutaneous procedures such as standard-PNL, mini-PNL, micro-PNL, and a PNL through the renal pelvis were used for stone extraction in these patients. The mean age of patients was 25.6±12.9years and mean stone size was 524.1±430.3mm(2). Mean operation time was 150.5±40.0 (77-210) min which was composed of retrograde catheterization (14.8±2.9min), laparoscopic procedure (48.7±20.6min) and PNL procedure (86.8±31.1min). Residual stones were seen in two patients (no additional treatment was need), while a 'stone-free' procedure was achieved in six patients (75.0%). On the post-operative first month visit, a stone was observed on radiological examinations in only one patient (87.5% stone-free). Mean hospitalization time was 2.8±0.9days. No perioperative or post-operative complication was observed in all patients. LA-PNL surgery is a safe and effective option for treatment of PEK stones, and has several alternative approaches.

Flexible ureteroscopy with holmium laser lithotripsy in the management of renal calculi in ectopic pelvic kidney

Objective To evaluate the efficacy and safety of the flexible ureteroscopy (FURS) with holmium laser lithotripsy in the management of stones in ectopic pelvic kidney (PK).Methods We retrospectively reviewed the records of 11 patients,ranged from 37-52 years old,who were underwent FURS with holmium laser for PK stones from January 2007 to April 2012.Three cases had solitary stones in renal pelvis,3 cases had solitary stones at lower calyx and multiple stones were found in 5 cases.Mean size of stone was 2.3 cm (ranged 1.8-3.7 cm).One case had history of ESWL and PCNL before surgery with unsatisfied result and 7 cases were underwent ESWL with poor outcome.The double J stent was placed into the ureter two weeks before the operation.Under the general anesthesia,the ureteral access sheath was placed firstly during operation.Then,flexible ureteroscopy was inserted into the renal pelvis through ureteral access sheath.Holmium laser was used to perform the procedure with the power less than 20 W (0.6-1.0 J/10-20 Hz).The stone fragments were taken out by stone baskets and double-J stent was set at the end of the procedure for additional two weeks.Results The successive rate of the ureteroscopic insertion was 100％.The average operation time was 62 min (ranged 31-87 min).No severe complications such as heavy bleeding,perforation or ureteral avulsion occurred.Small stone fragments were found in 3 cases.All of them located in the lower calyx.Since no one complained about the upper urinary obstruction or related symptoms,conservative observation was considered.All patients discharged the day after the operation.Within three months follow-up,no sign of urinary obstruction was found.Conclusions FURS with holmium laser is a safe,effective and minimally invasive technique.It could be the best option in the management of renal calculi in ectopic pelvic kidney. Key words: Flexible ureteroscopy; Holmium laser; Renal calculi; Pelvic kidney

Prospective Randomized Comparison of Retroperitoneoscopic Pyelolithotomy versus Percutaneous Nephrolithotomy for Solitary Large Pelvic Kidney Stones

Objectives: We performed a prospective randomized comparison of retroperitoneoscopic pyelolithotomy (RP) versus percutaneous nephrolithotomy (PNL) for solitary pelvic stones >3 cm and assessed the outcome results. Methods: From 2010 to 2012, 44 patients with a solitary pelvic stone >3 cm without any anatomical abnormality were randomized to either RP or PNL on a 1:1 ratio. Stone-free rate, number of procedures per patient and complications were recorded. Results: The stone-free rate on the first postoperative day was 95.5% in the RP group versus 72.7% in the PNL group (p = 0.04). The stone-free rates at 3 months were similar between the two groups. Blood loss, visual pain analog score and analgesic requirement on the first postoperative day were significantly higher in the PNL group whereas the mean operative time and overall complications were similar between the two groups. Conclusion: In patients with solitary large pelvic stones, RP is associated with lesser blood loss, postoperative pain and analgesia as well as with a higher stone-free rate in the immediate postoperative period in comparison to PNL. However, the stone clearance rate remains the same at 3 months in both groups.

Computed Tomography-Guided Transgluteal Percutaneous Nephrolithotripsy in an Ectopic Pelvic Kidney: Novel Technique

Management of stones in the ectopic pelvic kidney can be very challenging. Treatment of each patient should be individualized. We describe a new approach that is CT-guided transgluteal percutaneous nephrolithotripsy (PCNL). A 19-year-old male presented with symptomatic right ectopic pelvic kidney stones. He was treated with CT-guided transgluteal PCNL. The patient was stone free at postoperative day 1. No major complications were observed, and the patient was discharged home on postoperative day 2. CT-guided transgluteal PCNL is a safe and effective option for selected patients with ectopic pelvic kidney stones.

Laparoscopic-Assisted “Microperc” of a Stone in a Pelvic Kidney of a 3-Year-Old Girl

Treatment of kidney stones in pelvic ectopic kidneys of children is a challenging procedure for urologists. Herein we report a case of laparoscopy-assisted "microperc" in a 3-year-old girl with a stone in her pelvic ectopic kidney. This micro-optical system is helpful in confirming the percutaneous access and provides the possibility of fragmenting the stone without the necessity of dilating the tract.

The Combination of Laparoscopy and Nephroscopy for Treatment of Stones in Pelvic Ectopic Kidneys

Introduction: Minimally invasive treatment modalities for patients with large stone burden within pelvic kidneys present a special challenge. Interposing bowel loops between the kidney and the anterior abdominal wall, abnormalities in the vascular supply, and mal-rotation of the caliceal system are reasons of difficulties in percutaneous nephrolithotomy (PNL). Minimally invasive treatment modalities of large stones in ectopic pelvic kidneys have included pure laparoscopic pyelolithotomy,1–3 laparoscopy-assisted PNL,4–7 and ultrasound-guided PNL.8 These are attractive treatment options because they have the advantages of reduced analgesic requirement, shorter hospital stay, early convalescence, and better cosmoses in addition to high safety and efficacy profiles. The combination of laparoscopic and percutaneous approaches allows the establishment of the percutaneous tract into the kidney under direct vision, thus avoiding the risk of injury to abdominal viscera and blood vessels. This video presents the technique of the combination of laparoscopy and nephroscopy for treatment of stones in pelvic ectopic kidneys. Patients and Methods: The study included seven men and four women (mean age, 43 ± 9 years). Laparoscopy-assisted PNL was performed for caliceal stones in five patients after failure of shockwave lithotripsy. Laparoscopic pyelolithotomy was performed for six patients with large or branched renal pelvic stones. The patient was placed in the Trendelenburg position with slight lateral elevation of the side to be operated. In laparoscopy-assisted PNL the primary surgeon stands on the same side of the affected kidney and the assistant on the opposite side, whereas in laparoscopic pyelolithotomy the surgeon stands on the opposite side of the affected kidney. Three or four transperitoneal ports were placed in a fan-shaped distribution. The stone or the renal pelvis was identified using intraoperative fluoroscopy. Intermittent fluoroscopy was used to identify the point of entry to the desired calix during dilatation and during fixation of the nephrostomy tube. Results: The average preoperative stone length was 3 ± 1 cm (range, 1.1–4.2). There were some adhesions between the intestinal loops and the peritoneum on the anterior surface of the kidney in three patients (27%). There were neither intraoperative nor postoperative complications, and conversion to open surgery was not required. The mean hospital stay was 3.5 ± 0.7 days (range, 2–4). The stone-free rate was 91% as all stones were removed completely in 10 patients, whereas 1 patient had residual caliceal fragment that was treated with shockwave lithotripsy. After a mean follow-up of 27 ± 6 months, two out of the five patients who underwent laparoscopy-assisted PNL showed stone recurrence and were treated with extracorporeal shockwave lithotripsy. Conclusion: The combination of laparoscopy and nephroscopy for treatment of stones in pelvic kidneys is feasible, safe, and effective. The authors has nothing to disclose. Runtime of video: 8 min 24 sec

Retrograde Holmium:YAG Laser Disintegration of Stones in Pelvic Ectopic Kidneys: Would It Minimize the Risk of Surgery?

To study the safety and efficacy of the holmium:YAG laser for disintegration of stones in pelvic ectopic kidneys. Between October 2005 and October 2006 four consecutive patients with large obstructing calculi (>3 cm in diameter) in the pelves of pelvic ectopic kidneys were prepared to be treated using retrograde ureterorenoscopy and holmium:YAG laser lithotripsy. All the patients were investigated with x-rays of the kidney, ureters, and bladder (KUB) and intravenous urography (IVU). Holmium:YAG laser lithotripsy was performed in a retrograde manner using energy ranging from 1 to 1.5 J/pulse with a frequency ranging from 15 to 20 Hz. Four patients were included in the study. The average age of the patients was 44 years (range 35-56 years). The average operative time for the laser lithotripsy procedure was 120 minutes (range 100-180 minutes). Three of the patients (75%) were rendered stone-free at 3 months. None of the patients developed back-pressure changes, gross hematuria, or abdominal pain during the follow-up period. One of the patients could not be treated endoscopically and required open surgery. Hospital stay ranged between 2 and 3 days. Retrograde ureteroscopy and holmium:YAG laser lithotripsy is efficacious for managing patients with stones in pelvic kidneys. The procedure is safe and effective and avoids the complications of open surgery.

Combination of Laparoscopy and Nephroscopy for Treatment of Stones in Pelvic Ectopic Kidneys

To present the combination of laparoscopy and nephroscopy for the treatment of stones in pelvic ectopic kidneys. The series included seven male and four female patients (mean age 43 +/- 9 years). Laparoscopy-assisted percutaneous nephrolithotomy (PCNL) was performed for caliceal stones in five patients after failure of shockwave lithotripsy, while laparoscopic pyelolithotomy was performed for large or branched renal pelvic stones in six patients. The mean operative time was 164 +/- 30 minutes. There were neither complications nor conversions to open surgery. The stone-free rate was 91% (10 patients). One patient had a residual caliceal fragment that was treated with shockwave lithotripsy. The mean hospital stay was 3.5 +/- 0.7 days. The combination of laparoscopy and nephroscopy is feasible, safe, and effective for the treatment of stones in pelvic kidneys.

MP-05.06: The effect of impaction on the outcome of treatment of pelvic kidney stones: Comparing shock wave lithotripsy and percutaneous nephrolithotomy

The efficacy of therapeutic options in treatment of “impacted kidney stones” which completely obstruct urinary flow, are not clearly determined. Our objective was to compare the efficacy of SWL vs. PCNL in treatment of renal “impacted stones”.

Ureteroscopic management of renal calculi in anomalous kidneys

To review our experience with ureteroscopy in treating patients with renal calculi in anomalous kidneys and to evaluate the efficacy of this approach. Eight patients with renal calculi in anomalous kidneys who were managed by ureteroscopic procedures were identified. Demographic information, preoperative stone burden, operative information (ureteroscope size, lithotrite used, instruments used, duration of surgery, complications, stenting), follow-up imaging, and complications were obtained from the medical record. This information was analyzed to determine the most frequently used instruments and stone-free rates. Our cohort consisted of 4 patients with horseshoe kidneys (HSK) and 4 patients with pelvic kidneys (PK) (6 male, 2 female, mean age, 50.6 years). The average preoperative stone burden of the 11 treated calculi was 1.4 cm, with 5 stones located in the renal pelvis, 2 in the upper pole, and 4 in lower pole calyces. A 7.5F flexible ureteroscope, holmium laser lithotripsy, and nitinol baskets and graspers were used in all patients. Six patients had complete clearance of the stone on postoperative imaging (75% HSK, 75% PK), with 88% of patients asymptomatic after their procedure. No patients required additional surgical intervention. Flexible ureteroscopy with holmium laser lithotripsy and the use of nitinol baskets and graspers provides a reasonable alternative to shock wave lithotripsy in the management of patients harboring renal calculi in anomalous kidneys. In addition, ureteroscopy can be considered a primary option for managing select patients with symptomatic stones in PKs before a percutaneous surgical approach.

Percutaneous transpouch management of a ureteral stone and ureteral-pouch stricture in a pelvic kidney

Stones in pelvic kidney collecting systems have not been routinely managed percutaneously in most urologic practices. Especially challenging is the management of stones in a pelvic kidney collecting system positioned posteriorly to a urinary diversion. In the present case, a 32-year-old man with a pelvic kidney and continent urinary diversion presented with fever and hydronephrosis. Drainage of the kidney was obtained percutaneously by way of an anterior approach through-and-through the urinary diversion. The patient was found to have both a ureteral stone and a ureteral-pouch anastomotic stricture on subsequent imaging. We were able to successfully treat both these problems endoscopically through a solitary percutaneous access.

Extracorporeal shock-wave lithotripsy monotherapy in renal pelvic ectopia

Objectives To determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in the treatment of urinary stones in pelvic kidneys. Methods Fourteen male patients with renal pelvic ectopia and stones were treated with ESWL monotherapy using the unmodified Dornier HM3 lithotriptor with its original generator and ellipsoid. Twelve patients were treated in the prone position using cystoscopically placed ureteral catheters to aid in fluoroscopic localization, whereas 2 patients were treated in the supine position. A review of their stone disease, ESWL treatment, ancillary procedures, outcome, and complications is presented. Results All pelvic kidneys were free of infection and obstruction in this group. The mean stone burden was 30.2 ± 37.8. Most patients required a single session (9 of the 14 [64%]), 2 patients required two sessions, and 2 patients required multiple sessions. The average number of shock waves per session was 1689 (range 450 to 3500), with average kilovoltage of 21.5 (range 18 to 24). Eighty-two percent of the patients followed (9 of 11 ) were stone-free at 3 months. No ancillary endourologic procedures were required to deal with the presenting stones. Obstructive steinstrasse complicated treatment in only 2 patients (14%) and was successfully treated by further ESWL in both patients; in 1 of them, ureteroscopy was needed. Conclusions ESWL monotherapy of renal pelvic ectopia stones is very effective and should be considered as the first therapeutic option for these patients, provided that accurate localization of the stone treated and proper positioning of patients that ensures adequate delivery of shock-wave energy can be maintained.

Multimodal Therapy for Stones in Pelvic Kidneys

Stones located in pelvic kidneys can be successfully treated by extracorporeal lithotripsy, either alone or in combination with endourology and open surgery. A multimodal approach was used in 16 patients with pelvic kidney stone disease and a 87.5% stone-free rate was achieved. The proper positioning of the patient on the lithotripter apparatus and the correct integration of the different therapeutic procedures were the real clues for obtaining a remarkable success rate with a minimally invasive approach.