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Long Term Results of Percutaneous Treatment of Caliceal Diverticular Calculi
European Urology
European Urology 41 (2002) 474±477
Long Term Results of Percutaneous Treatment of Caliceal Diverticular Calculi Jean Luc Landry, Marc Colombel*, Olivier Rouviere, Mohamed Lezrek, Albert Gelet, Jean-Michel Dubernard, Xavier Martin Service d'Urologie et Chirurgie de la Transplantation, HoÃpital Edouard HERRIOT, 5 place d'Arsonval, 69437 Lyon Cedex 03, France Accepted 23 January 2002
Abstract Purpose: We reviewed the long term outcome of percutaneous caliceal diverticular stone extraction. The objective was to de®ne factors of treatment failure and recurrence. Material and Methods: Percutaneous caliceal diverticular stone extraction was performed in 24 women and 7 men (age range 21±69 years old). Diverticula were located throughout the kidney including the upper [12], middle [12] and lower [7] calices. In all cases stones were removed using a direct approach and diverticular neck was incised or dilated. Fulguration of the diverticular walls was performed in 6 cases. Trans-diverticular drainage was maintained from 3 to 5 days (mean 3.4 days) until a nephrostomogram demonstrated no extravasation. Patients were evaluated at 3 months and yearly thereafter. Success criteria were: no symptoms, no stone recurrence, no diverticulum left as assessed by IVP. Evaluation at 1 year minimum is presented. Results: The average operative time and hospital stay were 103 min (range 90±130) and 3 days (range 4±9 days), respectively. No major complications and no mortality were observed. At 1 year stone free rate was 84% and diverticulum obliteration was obtained in 68% of patients. Overall 88% of patients were asymptomatic at average followup 24.6 months (range from 18 to 96 months). In all cases morphological or symptomatic failures were related to the quality of immediate result at surgery which relates to the location of the diverticulum. Conclusion: The percutaneous management of diverticular caliceal stones is a well standardized technique, however, surgical alternatives must be discussed any time the percutaneous approach seems dif®cult because high failure rates are expected in these cases. # 2002 Elsevier Science B.V. All rights reserved. Keywords: Kidney calices; Diverticulum; Percutaneous surgery
1. Introduction Caliceal diverticular are intrarenal cavities of an embryonic etiology that communicate with the collecting system through a narrow forniceal channel [1]. This is a rare anatomical abnormality with an incidence from 0.21 to 0.6% on IVP reviews. These diverticula are frequently associated with stones formation and infections due to urinary stasis. It is estimated that a third of these patients will become symptomatic [2]. *
Corresponding author. Tel.: 33-4-72-11-05-70; Fax: 33-4-72-11-05-59. E-mail address: [email protected] (M. Colombel).
Therefore, therapeutic goals will be to eradicate the stone and treat the diverticulum either by destruction of the non-excreting transitional lined cavity using fulguration and/or by enlarging the narrow communicating channel to prevent further urinary retention. Up to 10 years ago, open extraction and diverticulum destruction by a lumbar approach was the treatment of choice [3±5]. This technique had satisfactory results, with a low risk of recurrence (3.5%). However, morbidity was high due to lumbar approach and required nephrotomies and partial nephrectomies in some cases. Therefore, alternatives to open surgical treatment were developed [6±8]. A variety of therapeutic endourological modalities now exist, such as extracorporeal
0302-2838/02/$ ± see front matter # 2002 Elsevier Science B.V. All rights reserved. PII: S 0 3 0 2 - 2 8 3 8 ( 0 2 ) 0 0 0 3 9 - 8
J.L. Landry et al. / European Urology 41 (2002) 474±477
shock wave lithotripsy [9,10], percutaneous endoscopy [11,12], ureteroscopy [13,14] and more recently laparoscopy [15,16]. Since percutaneous extraction and diverticulum fulguration associated with channel dilation, provides good immediate success rate and low morbidity, it is now accepted as the standard treatment [17]. However, little is known about long term risk of recurrence, the rate of symptoms after surgery or persistent diverticulum. We present the outcome of an antegrade endourological approach in 31 patients with symptomatic stone containing caliceal diverticula with postoperative followup greater than 1 year (range 18±96 months) in all cases. We also de®ned risk factors for failures of this technique. 2. Material and methods From January 1988 to march 1999, 31 consecutive patients (24 women and 7 men, mean age 41 range from 19 to 70 years old) with symptomatic caliceal diverticula were treated with percutaneaous endosurgical techniques at our institution. All patients presented a single or multiple diverticular calculi. Twelve had undergone unsuccessful prior shock wave lithotripsy of the diverticular calculi. Diverticula were located in the upper calices in 12, middle calices in 12 and lower calices in 7, and 15 in the left kidney. Size of diverticula ranged from 3 to 30 mm. The most frequent symptom was ipsilateral ¯ank pain although 13 patients (42%) presented with associated chronic urinary infection. The endosurgical technique has been previously described by Shalhav et al. [18]. A retrograde 7F ureteral catheter was placed under ¯uoroscopic control. Then the patient was placed in prone position, the chest elevated by a cushion to ease the puncture of the kidney. A direct percutaneous access to the caliceal diverticulum was done under ¯uoroscopic guidance and 20,035 in. guide wires were then coiled in the diverticulum. The tract was dilated with a nephrostomy dilator set, followed by the placement of a 10 mm Amplatz sheath. A 20F nephroscope was then inserted and stones were extracted directly or fragmented and aspired with a 26F ultrasonic lithotripsy unit. When all stones were cleared from the diverticulum, 5±10 cc boluses of methylene blue stained saline were gently instilled through the ureteral catheter to help identify the diverticular neck leading to the calyx. A non-conducting guide wire was then passed antegradely in the infundibulum and coiled in the renal pelvis. The walls of the diverticulum were then fulgurated using coagulating current delivered via an electrode passed through a standard resectoscope. The neck of the diverticulum was incised, with a 2 or a 3F electrosurgical probe. Cuts in the infundibulum were made radially to a depth of 1 to 2 mm, avoiding deeper lying pericaliceal vessels in the anteroposterior plane. A foley catheter was passed across the fulgurated diverticulum until a balloon could be in¯ated in the diverticular cavity. Percutaneous drainage by the foley catheter was left in place until a nephrostomogram (from 48 h postoperation) demonstrated no extravasation of contrast material. Subjective data and radiograms (IVP) and sonograms were obtained systematically at 3 months postoperatively and yearly thereafter. Results were evaluated as the percentage of patients with residual stones, the rate of persistent symptoms, the rate of patients with chronic urinary infection and the rate of persistent caliceal diverticulum.
475
3. Results Percutaneous endosurgical of extraction of stones from caliceal diverticulum was performed successfully in all cases. Direct percutaneous access was used in all cases. In seven cases (22%) the diverticulum fulguration was not performed, due to a dif®cult anterior location of the diverticulum in four cases necessitating a tangential access and preoperative local haemorrhage in three. Operative time ranged from 90 to 130 min (mean 103 min). Trans-diverticular drainage was maintained for a mean duration of 3.4 days (range 3±5) and the mean inpatient hospital stay was 6.1 days (range 3± 8). All patients were determined to be stone free by antegrade nephrostomogram before hospital discharge. Long term subjective and objective (IVP) followup from 18 to 96 months (mean 24.6) was obtained for all patients. Overall 88% of patients were asymptomatic at followup evaluation, 84% were stone free, 64% remained diverticulum free. 3.1. Failures We sought to duplicate the expected results of an open surgical approach and therefore, we considered diverticular persistence of any size a failure. As such, 11 of 31 patients (35%) were considered to have a long term failure based on postoperative IVP showing the persistence of a diverticulum, at a mean followup of 24.6 months. In seven of these patients, the review of the operative reports showed that the diverticulum channel could not be dilated. Of the patients with a persistent caliceal diverticulum, four were symptomatic with chronic lumbar pain. All had a recurrent stone at a mean time followup of 15 months. Patients were treated by extracorporeal shock wave lithotripsy (ESWL) in three cases, whereas a new percutaneous approach and treatment of the diverticulum was done in one patient. Postoperative radiograms showed persistence of the diverticulum in all patients treated by ESWL. Of the seven asymptomatic patients with the persistence of a diverticulum, one had a stone recurrence and was treated successfully by ESWL. The remaining six patients without symptoms nor stone recurrence but a persistent unobstructed diverticulum, are still under surveillance at a mean followup of 24 months. 3.2. Complications None of our patients had sustained complications related to the procedure. However, preoperative bleeding occurred in four cases necessitating rapid tamponade, impeaching complete fulguration of the diverticulum. Transient in¯ammatory ureteropelvic
476
J.L. Landry et al. / European Urology 41 (2002) 474±477
Table 1 Results of percutaneous treatment of caliceal diverticular calculi, from the literature References [24] [25] [26] [27] [18] [18] [28]
Number of patients (%) 10 14 16 10 26 19 14
Stone free (%) 70 100 80 100 93 95 100
junction obstruction required stent placement on postoperative day 2 and 3 in two patients. No atelectasis, no pneumothorax or pulmonary embolus were found. Postoperative fever persisted in two patients for 2 days, postoperative asymptomatic urinary infection occurred in two patients. Postoperative chronic infection was not observed. 4. Discussion Indications to treat calculi containing caliceal diverticula relies on symptoms, kidney anatomy and location of the diverticulum as assessed by radiograms. Radio-anatomical studies have shown that caliceal diverticulum is a rare anomaly and it becomes symptomatic when ®lled by a stone and/or a reservoir for chronic urinary infections. Therefore, the surgical management of caliceal diverticulum is mandatory only in case of complications. The percutaneous approach has been extensively described with good success rate although long term results show recurrence rates of 0±30%, persistence of a calculi in 0±20%, persistence of a diverticulum in 0±44% (Table 1). In the present study, we con®rmed that the failure rate of percutaneous procedure is around 20%. We also found that factors of failure were related to the quality of the destruction of the diverticulum. Although, the technique used was similar for all patients, in most cases of failure we found that technical dif®culties were involved, mostly in case of bleeding, dif®cult anterior access, or impossibility to retrieve the diverticular neck. Caliceal divertiulum are cystic, urine containing cavities lined by transitional cell epithelium that communicate through a narrow channel with the collecting system. The most widely accepted theory is that kidney diverticulum develop embryologicaly through failed degeneration of small ureteral buds which have branched within the metanephric blastema. Diverticula can develop anteriorly or posteriorly from the kidney collecting system although they occur more frequently
Symptom free (%) ? 100 80 70 85 100 ?
Diverticular obliteration (%) 66 ? ? 75 76 80 100
Major complication (nb) 0 3 3 1 2 2 1
posteriorly [2]. The aetiology of caliceal diverticulum is unknown. It is hypothesized that the narrowing of the diverticulum's neck occurs secondarily. The chronic urinary retention, calculi, local nephritis is a potential cause of clinical symptoms. It is at this time that urological investigation leads to the diagnosis. Previous reports have shown that 60±75% of patients with stone containing caliceal diverticulum will be successfully treated using ESWL [9,10]. ESWL treatment is non-invasive and can be performed on an outpatient basis with either minimal anaesthesia or none at all, but its effectiveness for caliceal diverticula calculi is doubtful. So far, no long term followup studies have been reported with regard to stone recurrence and some authors believe that ESWL will seldom lead to permanent success. However, ESWL may bene®t in selected cases with a small symptomatic diverticulum containing calculi with a large communicating channel [19]. Although percutaneous surgery is the standard treatment, we observed long term recurrences. The expected failure rate is around 20±25%, essentially due to incomplete treatment of the diverticulum. Percutaneous surgery may be dif®cult, particularly in the case of anterior diverticulum. In our experience, from 11 treatments who have failed, ®ve were anterior. Therefore, a complete morphological evaluation of the caliceal diverticulum by CT scan is recommended to de®ne preoperatively the best treatment approach. In dif®cult cases, open alternatives may be requested. Early results have shown that laparoscopic kidney diverticulectomy is feasible and gives reproducible results, further evaluation of this new approach is mandatory [15,16,20±23]. 5. Conclusion Percutaneous renal surgery for calculi containing kidney diverticula gives excellent results on the short term, in regards to stone free rates. However, there is a
J.L. Landry et al. / European Urology 41 (2002) 474±477
limit to this technique that is the risk of recurrence in cases of incomplete treatment of the diverticulum. In
477
some cases, more aggressive surgical approach should be discussed.
References [1] Devine Jr CJ, Guzman JA, Devine PC, Poutasse EF. Caliceal diverticulum. J Urol 1969:8±11. [2] Timmons Jr JW, Malek RS, Hattery RR, Deweerd JH. Caliceal diverticulum. J Urol 1975:6±9. [3] Brannen GE, Bush WH, Lewis GP. Caliceal calculi. J Urol 1986:1142±5. [4] Marshall VR, Singh M, Tresidder GC, Blandy JP. The place of partial nephrectomy in the management of renal caliceal calculi. Br J Urol 1975:759±64. [5] Frang D, Gotz F, Hubler J, Nagy Z. Surgery of calculous hydrocalyx (calyceoplastic surgery). Int Urol Nephrol 1987:129±35. [6] Leal JJ. A new technique for the transurethral or percutaneous removal of renal stones. J Urol 1985:936±9. [7] Chang R, Marshall FF, Auster M, Mitchell SE. Percutaneous displacement of caliceal calculi. Adjunct to percutaneous nephrolithotripsy. Urology 1985:376±82. [8] Antoon SJ, Koster LH. Percutaneous nephrolithotomy: An innovative extraction technique. J Urol 1978:709. [9] Streem SB, Yost A. Treatment of caliceal diverticular calculi with extracorporeal shock wave lithotripsy: Patient selection and extended followup. J Urol 1992:1043±6. [10] Psihramis KE, Dretler SP. Extracorporeal shock wave lithotripsy of caliceal diverticula calculi. J Urol 1987:707±11. [11] Hedelin H, Geterud K, Grenabo L, Henriksson C, Pettersson S, Zachrisson BF. Percutaneous surgery for stones in pyelocaliceal diverticula. Br J Urol 1988:206±8. [12] Schwartz BF, Stoller ML. Percutaneous management of caliceal diverticula. Urol Clin North Am 2000:635±45. [13] Chong TW, Bui MH, Fuchs GJ. Caliceal diverticula. Ureteroscopic management. Urol Clin North Am 2000:647±54. [14] Grasso M, Ficazzola M. Retrograde ureteropyeloscopy for lower pole caliceal calculi. J Urol 1999:1904±8. [15] Van Cangh PJ, Abi Aad AS, Lorge F, Wese FX, Opsomer R. Laparoscopic nephrolithotomy: The value of intracorporeal sonography and color Doppler. Urology 1995:516±9. [16] Ruckle HC, Segura JW. Laparoscopic treatment of a stone-®lled, caliceal diverticulum: A de®nitive, minimally invasive therapeutic option. J Urol 1994:122±4.
[17] Nakada SY, Streem S, Preminger GM, Wolf Jr JS, Leveillee RJ. Controversial cases in endourology: caliceal diverticular calculi. J Endourol 1999:61±4. [18] Shalhav AL, Soble JJ, Nakada SY, Wolf Jr JS, McClennan BL, Clayman RV. Long term outcome of caliceal diverticula following percutaneous endosurgical management. J Urol 1998:1635±39. [19] Lojanapiwat B, Soonthornpun S, Wudhikarn S. Lower pole caliceal stone clearance after ESWL: The effect of infundibulopelvic angle. J Med Assoc Thai 1999:891±4. [20] Curran MJ, Little AF, Bouyounes B, Nieh PT, Bihrle III W. Retroperitoneoscopic technique for treating symptomatic caliceal diverticula. J Endourol 1999:723±5. [21] Ramakumar S, Segura JW. Laparoscopic surgery for renal urolithiasis: pyelolithotomy, caliceal diverticulectomy and treatment of stones in a pelvic kidney. J Endourol 2000:829±32. [22] Wolf Jr JS. Caliceal diverticulum and hydrocalyx. Laparoscopic management. Urol Clin North Am 2000:655±60. [23] Hoznek A, Herard A, Ogiez N, Amsellem D, Chopin DK, Abbou CC. Symptomatic caliceal diverticula treated with extraperitoneal laparoscopic marsupialization fulguration and gelatin resorcinol formaldehyde glue obliteration. J Urol 1998:352±5. [24] Hulbert JC, Reddy PK, Hunter DW, Castaneda-Zuniga W, Amplatz K, Lange PH. Percutaneous techniques for the management of caliceal diverticula containing calculi. J Urol 1986:225±7. [25] Jones JA, Lingeman JE, Steidle CP. The roles of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy in the management of pyelocaliceal diverticula. J Urol 1991:724± 7. [26] Hendrikx AJ, Bierkens AF, Bos R, Oosterhof GO, Debruyne FM. Treatment of stones in caliceal diverticula: Extracorporeal shock wave lithotripsy versus percutaneous nephrolitholapaxy. Br J Urol 1992:478±82. [27] Ellis JH, Patterson SK, Sonda LP, Platt JF, Sheffner SE, Woolsey EJ. Stones and infection in renal caliceal diverticula: Treatment with percutaneous procedures. AJR Am J Roentgenol 1991:995± 1000. [28] Monga M, Smith R, Ferral H, Thomas R. Percutaneous ablation of caliceal diverticulum: Long term followup. J Urol 2000:28±32.
European Urology 41 (2002) 474±477
Long Term Results of Percutaneous Treatment of Caliceal Diverticular Calculi Jean Luc Landry, Marc Colombel*, Olivier Rouviere, Mohamed Lezrek, Albert Gelet, Jean-Michel Dubernard, Xavier Martin Service d'Urologie et Chirurgie de la Transplantation, HoÃpital Edouard HERRIOT, 5 place d'Arsonval, 69437 Lyon Cedex 03, France Accepted 23 January 2002
Abstract Purpose: We reviewed the long term outcome of percutaneous caliceal diverticular stone extraction. The objective was to de®ne factors of treatment failure and recurrence. Material and Methods: Percutaneous caliceal diverticular stone extraction was performed in 24 women and 7 men (age range 21±69 years old). Diverticula were located throughout the kidney including the upper [12], middle [12] and lower [7] calices. In all cases stones were removed using a direct approach and diverticular neck was incised or dilated. Fulguration of the diverticular walls was performed in 6 cases. Trans-diverticular drainage was maintained from 3 to 5 days (mean 3.4 days) until a nephrostomogram demonstrated no extravasation. Patients were evaluated at 3 months and yearly thereafter. Success criteria were: no symptoms, no stone recurrence, no diverticulum left as assessed by IVP. Evaluation at 1 year minimum is presented. Results: The average operative time and hospital stay were 103 min (range 90±130) and 3 days (range 4±9 days), respectively. No major complications and no mortality were observed. At 1 year stone free rate was 84% and diverticulum obliteration was obtained in 68% of patients. Overall 88% of patients were asymptomatic at average followup 24.6 months (range from 18 to 96 months). In all cases morphological or symptomatic failures were related to the quality of immediate result at surgery which relates to the location of the diverticulum. Conclusion: The percutaneous management of diverticular caliceal stones is a well standardized technique, however, surgical alternatives must be discussed any time the percutaneous approach seems dif®cult because high failure rates are expected in these cases. # 2002 Elsevier Science B.V. All rights reserved. Keywords: Kidney calices; Diverticulum; Percutaneous surgery
1. Introduction Caliceal diverticular are intrarenal cavities of an embryonic etiology that communicate with the collecting system through a narrow forniceal channel [1]. This is a rare anatomical abnormality with an incidence from 0.21 to 0.6% on IVP reviews. These diverticula are frequently associated with stones formation and infections due to urinary stasis. It is estimated that a third of these patients will become symptomatic [2]. *
Corresponding author. Tel.: 33-4-72-11-05-70; Fax: 33-4-72-11-05-59. E-mail address: [email protected] (M. Colombel).
Therefore, therapeutic goals will be to eradicate the stone and treat the diverticulum either by destruction of the non-excreting transitional lined cavity using fulguration and/or by enlarging the narrow communicating channel to prevent further urinary retention. Up to 10 years ago, open extraction and diverticulum destruction by a lumbar approach was the treatment of choice [3±5]. This technique had satisfactory results, with a low risk of recurrence (3.5%). However, morbidity was high due to lumbar approach and required nephrotomies and partial nephrectomies in some cases. Therefore, alternatives to open surgical treatment were developed [6±8]. A variety of therapeutic endourological modalities now exist, such as extracorporeal
0302-2838/02/$ ± see front matter # 2002 Elsevier Science B.V. All rights reserved. PII: S 0 3 0 2 - 2 8 3 8 ( 0 2 ) 0 0 0 3 9 - 8
J.L. Landry et al. / European Urology 41 (2002) 474±477
shock wave lithotripsy [9,10], percutaneous endoscopy [11,12], ureteroscopy [13,14] and more recently laparoscopy [15,16]. Since percutaneous extraction and diverticulum fulguration associated with channel dilation, provides good immediate success rate and low morbidity, it is now accepted as the standard treatment [17]. However, little is known about long term risk of recurrence, the rate of symptoms after surgery or persistent diverticulum. We present the outcome of an antegrade endourological approach in 31 patients with symptomatic stone containing caliceal diverticula with postoperative followup greater than 1 year (range 18±96 months) in all cases. We also de®ned risk factors for failures of this technique. 2. Material and methods From January 1988 to march 1999, 31 consecutive patients (24 women and 7 men, mean age 41 range from 19 to 70 years old) with symptomatic caliceal diverticula were treated with percutaneaous endosurgical techniques at our institution. All patients presented a single or multiple diverticular calculi. Twelve had undergone unsuccessful prior shock wave lithotripsy of the diverticular calculi. Diverticula were located in the upper calices in 12, middle calices in 12 and lower calices in 7, and 15 in the left kidney. Size of diverticula ranged from 3 to 30 mm. The most frequent symptom was ipsilateral ¯ank pain although 13 patients (42%) presented with associated chronic urinary infection. The endosurgical technique has been previously described by Shalhav et al. [18]. A retrograde 7F ureteral catheter was placed under ¯uoroscopic control. Then the patient was placed in prone position, the chest elevated by a cushion to ease the puncture of the kidney. A direct percutaneous access to the caliceal diverticulum was done under ¯uoroscopic guidance and 20,035 in. guide wires were then coiled in the diverticulum. The tract was dilated with a nephrostomy dilator set, followed by the placement of a 10 mm Amplatz sheath. A 20F nephroscope was then inserted and stones were extracted directly or fragmented and aspired with a 26F ultrasonic lithotripsy unit. When all stones were cleared from the diverticulum, 5±10 cc boluses of methylene blue stained saline were gently instilled through the ureteral catheter to help identify the diverticular neck leading to the calyx. A non-conducting guide wire was then passed antegradely in the infundibulum and coiled in the renal pelvis. The walls of the diverticulum were then fulgurated using coagulating current delivered via an electrode passed through a standard resectoscope. The neck of the diverticulum was incised, with a 2 or a 3F electrosurgical probe. Cuts in the infundibulum were made radially to a depth of 1 to 2 mm, avoiding deeper lying pericaliceal vessels in the anteroposterior plane. A foley catheter was passed across the fulgurated diverticulum until a balloon could be in¯ated in the diverticular cavity. Percutaneous drainage by the foley catheter was left in place until a nephrostomogram (from 48 h postoperation) demonstrated no extravasation of contrast material. Subjective data and radiograms (IVP) and sonograms were obtained systematically at 3 months postoperatively and yearly thereafter. Results were evaluated as the percentage of patients with residual stones, the rate of persistent symptoms, the rate of patients with chronic urinary infection and the rate of persistent caliceal diverticulum.
475
3. Results Percutaneous endosurgical of extraction of stones from caliceal diverticulum was performed successfully in all cases. Direct percutaneous access was used in all cases. In seven cases (22%) the diverticulum fulguration was not performed, due to a dif®cult anterior location of the diverticulum in four cases necessitating a tangential access and preoperative local haemorrhage in three. Operative time ranged from 90 to 130 min (mean 103 min). Trans-diverticular drainage was maintained for a mean duration of 3.4 days (range 3±5) and the mean inpatient hospital stay was 6.1 days (range 3± 8). All patients were determined to be stone free by antegrade nephrostomogram before hospital discharge. Long term subjective and objective (IVP) followup from 18 to 96 months (mean 24.6) was obtained for all patients. Overall 88% of patients were asymptomatic at followup evaluation, 84% were stone free, 64% remained diverticulum free. 3.1. Failures We sought to duplicate the expected results of an open surgical approach and therefore, we considered diverticular persistence of any size a failure. As such, 11 of 31 patients (35%) were considered to have a long term failure based on postoperative IVP showing the persistence of a diverticulum, at a mean followup of 24.6 months. In seven of these patients, the review of the operative reports showed that the diverticulum channel could not be dilated. Of the patients with a persistent caliceal diverticulum, four were symptomatic with chronic lumbar pain. All had a recurrent stone at a mean time followup of 15 months. Patients were treated by extracorporeal shock wave lithotripsy (ESWL) in three cases, whereas a new percutaneous approach and treatment of the diverticulum was done in one patient. Postoperative radiograms showed persistence of the diverticulum in all patients treated by ESWL. Of the seven asymptomatic patients with the persistence of a diverticulum, one had a stone recurrence and was treated successfully by ESWL. The remaining six patients without symptoms nor stone recurrence but a persistent unobstructed diverticulum, are still under surveillance at a mean followup of 24 months. 3.2. Complications None of our patients had sustained complications related to the procedure. However, preoperative bleeding occurred in four cases necessitating rapid tamponade, impeaching complete fulguration of the diverticulum. Transient in¯ammatory ureteropelvic
476
J.L. Landry et al. / European Urology 41 (2002) 474±477
Table 1 Results of percutaneous treatment of caliceal diverticular calculi, from the literature References [24] [25] [26] [27] [18] [18] [28]
Number of patients (%) 10 14 16 10 26 19 14
Stone free (%) 70 100 80 100 93 95 100
junction obstruction required stent placement on postoperative day 2 and 3 in two patients. No atelectasis, no pneumothorax or pulmonary embolus were found. Postoperative fever persisted in two patients for 2 days, postoperative asymptomatic urinary infection occurred in two patients. Postoperative chronic infection was not observed. 4. Discussion Indications to treat calculi containing caliceal diverticula relies on symptoms, kidney anatomy and location of the diverticulum as assessed by radiograms. Radio-anatomical studies have shown that caliceal diverticulum is a rare anomaly and it becomes symptomatic when ®lled by a stone and/or a reservoir for chronic urinary infections. Therefore, the surgical management of caliceal diverticulum is mandatory only in case of complications. The percutaneous approach has been extensively described with good success rate although long term results show recurrence rates of 0±30%, persistence of a calculi in 0±20%, persistence of a diverticulum in 0±44% (Table 1). In the present study, we con®rmed that the failure rate of percutaneous procedure is around 20%. We also found that factors of failure were related to the quality of the destruction of the diverticulum. Although, the technique used was similar for all patients, in most cases of failure we found that technical dif®culties were involved, mostly in case of bleeding, dif®cult anterior access, or impossibility to retrieve the diverticular neck. Caliceal divertiulum are cystic, urine containing cavities lined by transitional cell epithelium that communicate through a narrow channel with the collecting system. The most widely accepted theory is that kidney diverticulum develop embryologicaly through failed degeneration of small ureteral buds which have branched within the metanephric blastema. Diverticula can develop anteriorly or posteriorly from the kidney collecting system although they occur more frequently
Symptom free (%) ? 100 80 70 85 100 ?
Diverticular obliteration (%) 66 ? ? 75 76 80 100
Major complication (nb) 0 3 3 1 2 2 1
posteriorly [2]. The aetiology of caliceal diverticulum is unknown. It is hypothesized that the narrowing of the diverticulum's neck occurs secondarily. The chronic urinary retention, calculi, local nephritis is a potential cause of clinical symptoms. It is at this time that urological investigation leads to the diagnosis. Previous reports have shown that 60±75% of patients with stone containing caliceal diverticulum will be successfully treated using ESWL [9,10]. ESWL treatment is non-invasive and can be performed on an outpatient basis with either minimal anaesthesia or none at all, but its effectiveness for caliceal diverticula calculi is doubtful. So far, no long term followup studies have been reported with regard to stone recurrence and some authors believe that ESWL will seldom lead to permanent success. However, ESWL may bene®t in selected cases with a small symptomatic diverticulum containing calculi with a large communicating channel [19]. Although percutaneous surgery is the standard treatment, we observed long term recurrences. The expected failure rate is around 20±25%, essentially due to incomplete treatment of the diverticulum. Percutaneous surgery may be dif®cult, particularly in the case of anterior diverticulum. In our experience, from 11 treatments who have failed, ®ve were anterior. Therefore, a complete morphological evaluation of the caliceal diverticulum by CT scan is recommended to de®ne preoperatively the best treatment approach. In dif®cult cases, open alternatives may be requested. Early results have shown that laparoscopic kidney diverticulectomy is feasible and gives reproducible results, further evaluation of this new approach is mandatory [15,16,20±23]. 5. Conclusion Percutaneous renal surgery for calculi containing kidney diverticula gives excellent results on the short term, in regards to stone free rates. However, there is a
J.L. Landry et al. / European Urology 41 (2002) 474±477
limit to this technique that is the risk of recurrence in cases of incomplete treatment of the diverticulum. In
477
some cases, more aggressive surgical approach should be discussed.
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