Management of renal calculi in pelvic kidneys

585 FLEXIBLE URETERORENOSCOPY (FLEXURS) AS AN AUXILIARY PROCEDURE IN UROLITHIASIS: A RETROSPECTIVE ANALYSIS OF 56 CASES

MULTIMODAL MANAGEMENT TRANSPLANTATION

OF UROLITHIASIS

IN RENAL

Choone S.‘, Khan M.S.‘, Tiptaft R.C.‘. Glass I.‘, Goldsmith I.*. Taylor J.‘. Koffman G.’ Koermann

Kai Uwe’, Stephan’, Alken Peter’

Ptahnyk

Taras’, Cueva-Martinez

‘Urological. University Guadalajara, Mexico

Hospital, Mannham,

Armando’,

Germany. ‘Urological.

Michel

University

Maurice

Hospital.

INTRODUCTION & OBJECTIVES: ESWL. PCNL and rigid URS are primary choice for treatment of Urolithiasis. In cabe of unaucceaaful procedure, contraindlcatmns or as an additional tool flexible URS belongs to the armamentarium of auxiliary measures. The aim of this study was to evaluate efficacy of flexURS of 56 consecutive procedures in a retrospective study. MATERIALS & METHODS: From 7X flexURS performed in our department between 19Y6 and May 2001 56 procedure\ concerning treatment of urolithiasis were evaluated. In all cases preview ESWL, ngid URS and PCNL were not aucceasful or contraindicated. Additional auxiliary measure\ were recorded. Procedures efficacy was determined by stone clearance. Complications were classified in severe (haemorrhage requiring transfusion. sepsis, ureter rupture) and mild (fever <38S”C. colic, small ureter perforation. moderate bleeding).Additmnally the chemical analy\i\ of removed stone\ was evaluated. RESULTS: 56 flexURS were performed ,n SO cases by retrograde and in 6 cases ,n antegrade. percutaneous way. Stone powions were following: calyx N=30 (from them N=20- lower calyx): proximal ureter N=6. diverrtculum N=6: multiple locations N=9 (Including lower calix). treatment of papillae-calcification (N=5). Flexible 7.5 and 10 F flexible ureteroscopes were uwd under general anaesthesia. After intervention the patients were stone free or had residual stone?. which could pass spontaneously in 41156 case\ (73%‘). In 9156 (16%) tlexURS had no or non-sufficient effect due to the following reasons: diverticulum access WZIEnot founded (N=3). no acce.s~ to calyx (N=5). bleeding (N=l). In S/56 (9%) technical problew hindered the successful performance of procedure. There were 6/56 (I I%) mild complications and no severe complication\ during the procedure performance. Mild po\toperatwe complications (fever. colic. and macrohaematurie) appeared in IJi56 (25% JCL~EC\. There were no severe complication\ in postoperative period. The chcmlcal analy\i\ of removed stone\. performed m 3X patients revealed: -Ca-oxalate had more than 75% \tone-contain in 31 case\ (X2% ): -Pure Ca-oxnlate (mono-dihydrate) was revealed m 2 I patient\ (55% 1: -The hardest Ca~oxalate-tnonohydrate had more than 75% of \tone-contain in 24 cast\ (63%). CONCLUSION: FlexURS I\ an effectiw and safe tool for treatment of ?tones m the upper urinary tract when the treatment by conventmnal procedures failed. Taking into account the locatmn and chemical composition of stones which nececsitated the repeated treatment we heheve that patient\ with Ca-oxalate-stone hIstory. and qtone\ located in lower calyx (especially m case\ of unfavourable spatial anatomy-acute infundibulo-pelvic angle. long and narrow’ infundlbulum) should he considered candidates for primary flcxURS treatment.

‘Urology. Guy’s and St. Thornab’ Hospital Trust. London. United Kingdom, *Nephrology, Guy’s and St. Thomar’ Hospital Trust, London, United Kingdom INTRODUCTION & OBJECTIVES: To present the largest series of renal transplant patients in adults and children with urolithiasis, to identify the incidence and factors wociated with urolithiasis and report the outcome of the multimodal management by endourologic and open procedures. MATERIALS & METHODS: Between 1977 and 1999, 1476 patients underwent renal transplantation m a single centre and I6 patients (13 adults and 3 children) developed urinart tract calculi. Their mode of presentation, investigations. treatment modalitres, complications and outcome were recorded. Management of these calculi involved extracorporeal shock wave lithotripsy (ESWL), cystoscopy and stenting, nephrostomy tube insertion, flexible uretemrenoscopy. percutaneous nephrolithotomy (PCNL), open cystohtholapaxy and open nephrolithotomy. RESULTS: Nine patients had renal calculi. six had uretenc calcuh and one had bladder calculi. The incidence of urolithiasis in renal transplant patients was 1311325 (0.98%) in adults and 3115 I (I .9X%) m children. Urolithiasis was inadentally discovered on routine USS in 6 patients, 5 presented with oliguria or anuria including one with acute renal failure, 4 presented with a painful graft, 3 had haematuria, one with sepsiscaused by obstruction and mfectlon, and in one urolithiasis war discovered due to failure of stent removal. Ten patients (62.5%) formed calculi due to metabolic causes, two were due to obstruction. two uere stent related, one WBFsecondary to infection. and in one no cause was identifiable. Eleven patients (69%‘) were treated by ESWL, 7 of which required multiple sessions. Three patients required cystoacopy and stent insertion and 2 patients required a nephrostomy tube to relieve obstruction. T&o patients underwent flexible ureterorenoacopy and stone extractmn. 2 had PCNL and one patient had open nephrolithotomy and open removal of bladder htones. Complication\ were few: it was not possible to remove the calculi by PCNL in one patient who had successful Stone removal by an open nephrolithotomy.The stone free rate was 100% when different treatment modalities were combined. CONCLUSION: There i\ a high incidence of metabolic cause\ and renal transplant patients with urolithla?i? should undergo a comprehensive metabolic screening. Flexible ureterorenoscopy and stone disintegration by laser currently adds another effective method of treating calculi m the transplanted ureter or kidney. Management of patient5 with urolithiaais requires il multidisciplinary approach by renal physicians, transplant surgeons and none qpeciali\t? and urologist\ who can provide treatment by a multimodal approach.

587 MANAGEMENT

OF RENAL CALCULI

Lianoa Emmanuel, David Scottish Lithotriptor Kingdom

INTRODUCTION

Esposito Michael,

Centre,

Western

IN PELVIC KIDNEYS

LONG TERM RESULTS OF PERCUTANEOUS CALICEAL DIVERTICULAR CALCULI

OF

Moussa Sami, Smith Gordon. Tolley

general

hospital,

Edinburgh,

United

Landrv Jean Luc. Colombel Marc. Gelet Albert, Dubernard Jean Michel, Martin Xavier Urology and Transplantation Surgery, Edouard Herriot Hospital, Lyon, France

& OBJECTIVES:

The pelvic kidney represents the most common form of single renal ectopia and nearly fifty percent of kidneys are reportedly involved by pathologic processes including nephrolithiasis. Management of stones in ectopic kidneys is challenging due to the abnormal anatomy. We reviewed the treatment for 7 patients with pelvic kidneys and symptomatic nephrolithiasis to determine which radiographic studies are most helpful when planning treatment and which therapeutic modalities are most successful.

MATERIALS

TREATMENT

& METHODS:

All 7 patients underwent an intravenou\ urogram (IVU) for diagnosis. Two patients had solitary pelvic kidney\ and one patient had bilateral pelvic kidneys. Mean patient age was 27 years (range 16. 35). Three patients had full staghom calculi. two patients had IO mm upper ureteric calculi and two patients had renal pelvic calculi measuring 30x10 mm and 15x IS mm respectively. Those with ureteric calculi had failed ureteroscopy prior to other treatments. All except those with ureteric calculi underwent CT scan and pelvic ultrasonopraphy to determine the position and degree of stone burden and to viaualise any intervening bowjel prior to percutaneous nephrolithotomy.

INTRODUCTION & OBJECTIVES: We reviewed the long term outcome of percutaneous caliceal diverticular stone extraction. The objective was to define fxtors of treatment failure and recurrence. MATERIALS

& METHODS:

Percutaneous

caliceal

diverticular

stone

extraction was performed in 24 women and 7 men (age range 2 I to 69 years old). The diverticula were located throughout the kidney including the upper (I 2), middle (12) and lower (7) calices. In all cases the stone was removed using a direct approach and the diverticular neck was incised or dilated. Fulguration of the diverticular walls was performed in 6 cases. Transdiverticular

drainage was

maintained from 3 to 5 days (mean 3.4 days) until a nephrostomogram demonstrated no extravasation. Patient\ were evaluated at 3 months and yearly thereafter. Success criteria were: no symptoms. no atone recurrence, and no divcrticulum left a\ assessed by IVP. Evaluation at one-year minimum is presented.

RESULTS:

The average operative time and hospital stay were IO3 minutes

(range 90 to 130) and 3 days (range 4 to 9 days), respectively. No major

RESULTS: Overall 2 patients had PCNL and SWL, I patient had PCNL alone, two patients had SWL alone, one patient required open ureterolithotomy and one patient required laparoscopically assisted percutaneous nephrolithotomy. All patient\ were rendered stone free following a mean of 2.1 procedures.

CONCLUSION: The main principles of treatment for stones in normally poGtioned kidneys should be followed utilising SWL or URS wjhen possible. Cases chosen for PCNL should be assessed by CT scan to establish the orientation of kidney, collecting elements and surrounding anatomy. In thoac unsuitable for a single PCNL. laparoscopic assisted approach or conventional open surgery will have to be considered.

complications and no mortality were observed. Follow-up for more than one year showed a stone free rate of 84%. with obliteration of the diverticulum in 68% of patients. Overall 88% of patients are asymptomatic at average follow up 24.6 months (range from I8 to 96 months). In all cases morphological or symptomatic failure\ were related to the quality of immediate result at Eurgery which relates to the location of the diverticulum.

CONCLUSION:

The percutaneous management of diverticular caliceal stones is a well-ytandardixd technique. howevet- alternati\,eb such as laparoscopy must be discurhed any time the percutaneous approach \eems difficult. European

Urology

Supplements

1 (2002)

No. 1, pp. 149