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Technique and follow-up of percutaneous management of caliceal diverticula
TECHNIQUEAND FOLLOW-UPOF PERCUTANEOUS MANAGEMENT OF CALICEALDIVERTICULA GARYC. BELLMAN,M.D. JEFFREY I. SILVERSTEIN,M.D. SCOTT BLICKENSDERFER,D.O. ARTHUR D. SMITH. M.D. From the Department of Urology, Long Island Jewish Medical Center, New Hyde Park, New York
ABSTRACT-Between June 1985 and July 1992 we treated 20 patients who had symptomatic caliceal diverticula [13 in upper calix, 6 in middle calix, and 1 in lower calix) in whom long-term (3 months to 3 years) evaluation of persistent symptoms, physical condition, and radiologic findings was possible. Of the 20 patients, 19 had had stones in the diverticulum preoperatively, and the other had a huge diverticulum but no stones. Eighteen patients (95%) with stones preoperatively had been rendered stone free, and the other patient demonstrated only small residual stones in the area of the obliterated diverticulum. Sixteen patients (80%) had obtained complete resolution of their diverticula, and the remaining 4 had at least a 50 percent diminution of the original size of the lesion. All patients had been rendered free of infection and symptoms. Percutaneous management of caliceal diverticula is the most effective approach to rendering patients with caliceal diverticula stone free and achieving diverticular ablation.
The appropriate choice of management for symptomatic caliceal diverticula is still being debated. The percutaneous approach, extracorporeal shock-wave lithotripsy of caliceal stones, and retrograde management all have been reported to be effective.le4 However, there is little long-term follow-up in the literature documenting ablation of the lesions. We present the results and followup of 20 patients with symptomatic diverticula managed percutaneously MATERIAL AND METHODS From June 1985 to July 1992, 28 patients with symptomatic caliceal diverticula were treated at our institution. This group consisted of 23 women and 5 men who ranged in age from thirteen to fifty-eight years (mean age 38 years). Twenty patients were available for follow-up. Many patients came from other institutions for treatment, and a follow-up urogram was requested from the referring physician in these Submitted: January 18, 1993, accepted (with revisions): March 161993
UROLOGY I JULY1993 I VOLUME 42, NUMBER1
cases. Eight patients refused follow-up studies on
the grounds that they were asymptomatic. Of these 20 patients, 13 had diverticula of upper calices, 6 of middle calices, and 1 of a lower calix. The most frequent indication for intervention was ipsilateral flank pain. One patient with a huge diverticulum had recurrent Pseudomonas urinary infections localized to the diverticulumcontaining kidney, and eradication of infection was the specific indication for treatment in this patient. In all, 7 of the original 28 patients (25%) had a history of recurrent infections that were thought to be related to the diverticula. Our technique of diverticular ablation utilizes standard endourologic principles. A preoperative plain film and retrograde pyelogram are used to demonstrate the stones in the caliceal diverticulum (Fig. 1). The patient is placed prone on the operating table. With the aid of C-arm fluoroscopy and contrast medium instilled via a ureteral catheter (Fig. ZA), a direct puncture of the diverticulum is performed using an 18-gauge diamond-tipped needle. For those patients in whom the diverticulum is located above the 21
FIGURE 1. (A) Plain film showing two opaque calculi, and (B] retrograde pyelogram demonstrating caliceal diverticulum.
Diverticulum,
“su A
Amplatr Sheath I
Stone Lithotripey and Removal /
Uret&al Catheter
lnfundibulum
FIGURE 2. Management of lesion. Low-current endoscopic fulguration (Dj Utilizing guide wire positioned Nephrostomy tract and diverticular
22
(A) Retrograde filling of diverticulum. (B) Lithotripsy and removal of stone. (C) and obliteration of caliceal lining performed via nephroscope or resectoscope. through neck of diverticulum, neck is dilated with Amplatz system to 3417 (E) neck are intubated with 24F re-entry tube for forty-eight hours.
UROLOGY I
JULY
1993 I VOLUME42, NUMBER1
twelfth rib, an intercostal approach or, more recently, a renal displacement or triangulation technique is utilized for direct access below the twelfth rib.5 A 0.038-inch J-tip guide wire is fed through the nephrostomy needle. Through a 10F Amplatz dilator placed over the guide wire, a second (safety) guide wire is coiled in the diverticulum. Sequential dilation of the tract to 34F is then performed, being careful not to dislodge the guide wire from its position in the diverticulum. A nephroscope is passed through the 34F sheath to inspect the lesion and extract any stones. With the stone removed, the opening of the narrow neck of the diverticulum can be viewed, and a guide wire can be negotiated through it into the main collecting system (Fig. 2B). Infusion of blue dye or carbon dioxide gas via the ureteral catheter often aids in location of the neck. Low-current endoscopic fulguration and obliteration of the caliceal lining is then performed via the nephroscope (Fig. 2C). Utilizing a long 8F catheter placed over the guide wire passed through the neck of the diverticulum, the neck is dilated with Amplatz dilators to 34F (Fig. 2D). If access across the ureteropelvic junction into the ureter has not yet been obtained, the previously placed ureteral catheter can be grasped via the nephroscope and a guide wire passed through it. It has been our experience that anteriorly positioned diverticula require particular modifications of this technique. Because of the acute angle, direct puncture of such lesions does not permit endoscopic vision or negotiation of the neck of the lesion. Therefore, these diverticula can be fulgurated, but the neck cannot be dilated. The nephrostomy tract together with the diverticulum and its dilated neck is intubated with a 24F re-entry nephrostomy tube (Fig. 2E). A nephrostogram is performed forty-eight hours postoperatively to evaluate the kidney for retained stones, obstruction, or extravasation. If there is no evidence of any of these problems, the nephrostomy tube is removed, and the patient is discharged the next day if the flank is dry A follow-up intravenous urogram is performed at three months (Fig. 3), and the patient is questioned in detail about persisting symptoms and infection. If the study demonstrates complete or partial persistence of the diverticulum, another intravenous urogram is obtained three months later to see if there is any change. If this study does not clearly show either obliteration or persistence of the diverticulum, a retrograde pyelogram is obtained. In this series, the length of fol-
UROLOGY
/ JULY 1993
/ VOLUME~~, NUMBER1
FIGURE 3. Foollow-up intravenous urogram at two months shows obliteration of diverticulum and elimination of stones.
low-up ranged from three months with a mean of six months.
to three years
RESULTS Of the 19 patients who had stones preoperatively, 18 (95%) were stone free at follow-up. Sixteen patients had complete resolution of their diverticula with normal urograms. The remaining 4 patients had at least a 50 percent diminution of the size of the diverticulum. In 2 of these patients, the three-month intravenous urogram showed essentially no change in lesion size, but the six-month study revealed extensive shrinkage. All 20 patients were free of pain. Also, all were free of infection, including the patient who had suffered repeated Pseudomonas infections preoperatively. She was one of the patients in whom shrinkage, not complete obliteration, of the lesion had been obtained. Complications were graded as either major or minor. The two major complications consisted of hemothorax or hydrothorax, necessitating chest
23
tube drainage. Both cases involved massive hydrothorax, and it was felt that simple aspiration, which may be used in small or medium-size collections, was not appropriate in these patients. Both of these patients were treated early in the series when intercostal punctures were performed for high-lying diverticula. Since we began using the renal displacement technique, no patients have required a chest tube postoperatively. Thus, the rate of major complications was 7 percent in the entire series of 28 patients. The three minor complications were persistent extravasations that necessitated insertion of a double-pigtail stent. Thus, the rate of minor complications was 11 percent. The average blood loss was 300 mL. However, 4 of the 28 patients (14%) required transfusion of one or two units of blood. COMMENT Patients with symptomatic caliceal diverticula pose a therapeutic challenge. Traditionally, treatment has included nephrostomy with extraction of the calculus, closure of the communicating tract, and obliteration of the diverticulum by marsupialization and fulguration. In more severe cases, partial or total nephrectomy has been advised. In 1986, Hulbert et al.’ reported on 10 patients with caliceal diverticula managed percutaneously In this study, the procedure was performed using intravenous sedation. Our experience has made us choose general anesthesia, which is preferable during the often-challenging creation of the percutaneous access. Hulbert and associates3 did not fulgurate the diverticular wall, although they used fulguration in 1 patient in a later series. It is difficult to say if our results in lesion ablation are attributable to the fulguration or to the dilation alone. At present, there is no study comparing dilation and fulguration with dilation alone. Until such a study appears showing that fulguration is unnecessary, we will continue to do both, since it is our belief that if the diverticulum persists, it is at risk for future stones or infection. The role of extracorporeal shock-wave lithotripsy (SWL) in the management of caliceal stones remains controversial. A serious concern is that the narrow neck of the diverticulum will not allow adequate passage of stone fragments. In fact, SWL has proved rather unsatisfactory in rendering patients stone free. Psihramis and Dretler2 found a stone-free rate of only 20 percent, and Ritchie and associates6 achieved a stone-free rate of 25 percent. A curious finding is that relief of 24
symptoms does not necessarily require that the patient be rendered stone free. Psihramis and Dretler obtained symptomatic relief in 70 percent of their patients. Likewise, Ritchie and associates found 75 percent of their patients to be asymptomatic. Enthusiasm for this approach must be tempered by the short follow-up in these studies, however. The natural history of the disease is that residual calculi are likely to grow and cause renewed symptoms eventually Also, SWL has been particularly unsuccessful in curing patients who have concomitant urinary tract infections. Approximately 65 percent of the patients with caliceal diverticula and recurrent infections had persistent infections after SWL.7 Dretle? has proposed a classification for caliceal diverticula that would help the urologist select the optimal form of therapy The original system classified Type I as those diverticula arising from the tip of a minor calix and Type II as those arising from a major calix or infundibulum. Dretlers proposes classifying as Type 1 diverticula with an open mouth and short neck, as Type 2 those with a closed mouth and short neck, as Type 3 those with a closed mouth and long neck, and as Type 4 those with an obliterated neck. He suggests that Type 1 lesions are best treated with SWL, and Type 2 are most suited to management by ureterorenoscopy The description of a Type I diverticulum is very similar to that of a calix, and most would agree that caliceal stones are best managed by SWL. In Dretler’s view, Types 3 and 4 and all diverticula containing stones larger than 2 cm should be treated by the percutaneous approach. When patient selection along these lines is used, the results of SWL are better than those just described. For example, in one series of patients who had stones smaller than 1.5 cm and a radiologically patent diverticular neck, a stone-free rate of 58 percent was achieved.7 Pang, David, and Fuchs4 described the retrograde approach to diverticula. They attempted to treat 36 patients in this manner. However, in 4 patients, the diverticula were found to be in the lower pole and had to be treated percutaneously Of the remaining patients, 24 (75%) were rendered stone free. Stones were removed under direct endoscopic control or with SWL. Although SWL was performed under the same anesthesia, it nevertheless entailed an additional procedure. Of the 8 patients with residual calculi, 4 (12% of the series) had persistent symptoms and underwent an additional procedure: 2 by a retrograde approach and 2 percutaneously. The other UROLOGY
/ JULY1993
f VOLUME42, NUMBER1
4 patients with residual calculi were free of symptoms and were being managed conservatively. Thus, 23 percent of the patients in whom a retrograde approach to a caliceal diverticulum was attempted or used required either a second retrograde or a percutaneous procedure. There is another concern about retrograde management of diverticula. In a recent review of endopyelotomy performed by the retrograde approach, Meretyk, Meretyk, and Clayman found a 21 percent rate of distal stricture of the ureteropelvic junction. They theorized that the prolonged ischemia of the ureteral wall during the long procedure was responsible for this complication. This finding has led them to abandon the retrograde approach. One often must work in the ureter for an extended period of time to find the neck of the diverticulum when dealing retrogradely with these lesions, and long-term followup is needed to see what is the late stricture rate. We believe that patients with symptomatic caliceal diverticula are best treated by the percutaneous approach. If the lesion lies above the twelfth rib, complications can be minimized by using the renal displacement technique.5 We believe that one is obliged to make every effort both to render the patient stone free and to obliterate the diverticulum. All of our patients are asymptomatic and infection free, and all have obtained either extensive shrinkage (20% of the series) or obliteration (80%) of the diverticulum. Only 1 patient has any residual stone. Arthur D. Smith, M.D. 270-0576th Avenue New Hyde Park, New York 11042
REFERENCES 1. Hulbert JC, Reddy PK, Hunter DW, Castaneda-Zuniga WR, Amplatz K, and Lange PH: Percutaneous techniques for the management of caliceal diverticula containing calculi. J Urol135: 22%227,1986. 2. Psihramis KE, and Dretler SP: Extracorporeal shockwave lithotripsy of caliceal diverticula calculi. J Urol 138: 707-711,1987.
UROLOGY
/ JULY1993 / VOLUME42, NUMBER1
3. Hulbert JC, Hemandez-Graulau JM, Hunter DW, and Castaileda-Zufiiga WR: Current concepts in the management of pyelocaliceal diverticula. J Endouro12: ll-17,1988. 4. Pang K, David R, and Fuchs GJ: Tmtment of stones in caliceal diverticula using retrograde endoscopic approach: critical assessment after 2 years (Abstr). J Endourol (Suppl) 6: F-15, 1992. 5. Karlin GS, and Smith AD: Approaches to the superior calix: renal displacement technique and review of options. J Urol 142: 774-777, 1989. 6. Ritchie AWS, Parr NJ, Moussa SA, and Tolley DA: Lithotripsy for calculi in caliceal diverticula? Br J Ural 66: 6-8, 1990. 7. Streem SB, and Yost A: Treatment of caliceal diverticular calculi with extracorporeal shock-wave lithotripsy: patient selection and extended follow-up. J Ural 148: 1043-1046,1992. 8. Dretler SP: A new useful endourologic classification of calyceal diverticula (Abstr), J Endourol (Suppl) 6: F-17, 1992. 9. Meretyk I, Meretyk S, and Clayman RV: Endopyelotomy: comparison of ureteroscopic retrograde and antegrade percutaneous techniques. J Uroll48: 775783, 1992. EDITORIAL COMMENT Pain, calculi, and/or infection occurring in the presence of caliceal diverticula are merely the symptoms of a more basic underlying condition, i.e., stasis within the upper urinary tract. When treatment of caliceal diverticula is indicated, the preferred approach would not only treat patient’s symptoms but also would attempt to address the underlying pathophysiology Clearly, shock-wave lithotripsy does not address the poor drainage and stasis associated with caliceal diverticula, and given the nonsecretory nature of caliceal diverticula, the extremely poor results associated with lithotripsy are not surprising. As Bellman et al. have demonstrated in this article, an endourologic approach provides far better results than shock-wave lithotripsy and also allows for simultaneous ablation of the diverticulum. Although the percutaneous approach is more invasive than shock-wave lithotripsy, in experienced hands the far superior results achieved are clearly justified. I concur with the authors that direct puncture into the diverticulum is the best approach. Retrograde ureteroscopic techniques have been advocated by some, but such an approach represents a long run for a short slide. Additionally, the retrograde approach is usually not technically possible for most diverticula in the lower pole of the kidney. James E. Lingeman Methodist Hospital oflndiana Indianapolis, Indiana 46202
25
ABSTRACT-Between June 1985 and July 1992 we treated 20 patients who had symptomatic caliceal diverticula [13 in upper calix, 6 in middle calix, and 1 in lower calix) in whom long-term (3 months to 3 years) evaluation of persistent symptoms, physical condition, and radiologic findings was possible. Of the 20 patients, 19 had had stones in the diverticulum preoperatively, and the other had a huge diverticulum but no stones. Eighteen patients (95%) with stones preoperatively had been rendered stone free, and the other patient demonstrated only small residual stones in the area of the obliterated diverticulum. Sixteen patients (80%) had obtained complete resolution of their diverticula, and the remaining 4 had at least a 50 percent diminution of the original size of the lesion. All patients had been rendered free of infection and symptoms. Percutaneous management of caliceal diverticula is the most effective approach to rendering patients with caliceal diverticula stone free and achieving diverticular ablation.
The appropriate choice of management for symptomatic caliceal diverticula is still being debated. The percutaneous approach, extracorporeal shock-wave lithotripsy of caliceal stones, and retrograde management all have been reported to be effective.le4 However, there is little long-term follow-up in the literature documenting ablation of the lesions. We present the results and followup of 20 patients with symptomatic diverticula managed percutaneously MATERIAL AND METHODS From June 1985 to July 1992, 28 patients with symptomatic caliceal diverticula were treated at our institution. This group consisted of 23 women and 5 men who ranged in age from thirteen to fifty-eight years (mean age 38 years). Twenty patients were available for follow-up. Many patients came from other institutions for treatment, and a follow-up urogram was requested from the referring physician in these Submitted: January 18, 1993, accepted (with revisions): March 161993
UROLOGY I JULY1993 I VOLUME 42, NUMBER1
cases. Eight patients refused follow-up studies on
the grounds that they were asymptomatic. Of these 20 patients, 13 had diverticula of upper calices, 6 of middle calices, and 1 of a lower calix. The most frequent indication for intervention was ipsilateral flank pain. One patient with a huge diverticulum had recurrent Pseudomonas urinary infections localized to the diverticulumcontaining kidney, and eradication of infection was the specific indication for treatment in this patient. In all, 7 of the original 28 patients (25%) had a history of recurrent infections that were thought to be related to the diverticula. Our technique of diverticular ablation utilizes standard endourologic principles. A preoperative plain film and retrograde pyelogram are used to demonstrate the stones in the caliceal diverticulum (Fig. 1). The patient is placed prone on the operating table. With the aid of C-arm fluoroscopy and contrast medium instilled via a ureteral catheter (Fig. ZA), a direct puncture of the diverticulum is performed using an 18-gauge diamond-tipped needle. For those patients in whom the diverticulum is located above the 21
FIGURE 1. (A) Plain film showing two opaque calculi, and (B] retrograde pyelogram demonstrating caliceal diverticulum.
Diverticulum,
“su A
Amplatr Sheath I
Stone Lithotripey and Removal /
Uret&al Catheter
lnfundibulum
FIGURE 2. Management of lesion. Low-current endoscopic fulguration (Dj Utilizing guide wire positioned Nephrostomy tract and diverticular
22
(A) Retrograde filling of diverticulum. (B) Lithotripsy and removal of stone. (C) and obliteration of caliceal lining performed via nephroscope or resectoscope. through neck of diverticulum, neck is dilated with Amplatz system to 3417 (E) neck are intubated with 24F re-entry tube for forty-eight hours.
UROLOGY I
JULY
1993 I VOLUME42, NUMBER1
twelfth rib, an intercostal approach or, more recently, a renal displacement or triangulation technique is utilized for direct access below the twelfth rib.5 A 0.038-inch J-tip guide wire is fed through the nephrostomy needle. Through a 10F Amplatz dilator placed over the guide wire, a second (safety) guide wire is coiled in the diverticulum. Sequential dilation of the tract to 34F is then performed, being careful not to dislodge the guide wire from its position in the diverticulum. A nephroscope is passed through the 34F sheath to inspect the lesion and extract any stones. With the stone removed, the opening of the narrow neck of the diverticulum can be viewed, and a guide wire can be negotiated through it into the main collecting system (Fig. 2B). Infusion of blue dye or carbon dioxide gas via the ureteral catheter often aids in location of the neck. Low-current endoscopic fulguration and obliteration of the caliceal lining is then performed via the nephroscope (Fig. 2C). Utilizing a long 8F catheter placed over the guide wire passed through the neck of the diverticulum, the neck is dilated with Amplatz dilators to 34F (Fig. 2D). If access across the ureteropelvic junction into the ureter has not yet been obtained, the previously placed ureteral catheter can be grasped via the nephroscope and a guide wire passed through it. It has been our experience that anteriorly positioned diverticula require particular modifications of this technique. Because of the acute angle, direct puncture of such lesions does not permit endoscopic vision or negotiation of the neck of the lesion. Therefore, these diverticula can be fulgurated, but the neck cannot be dilated. The nephrostomy tract together with the diverticulum and its dilated neck is intubated with a 24F re-entry nephrostomy tube (Fig. 2E). A nephrostogram is performed forty-eight hours postoperatively to evaluate the kidney for retained stones, obstruction, or extravasation. If there is no evidence of any of these problems, the nephrostomy tube is removed, and the patient is discharged the next day if the flank is dry A follow-up intravenous urogram is performed at three months (Fig. 3), and the patient is questioned in detail about persisting symptoms and infection. If the study demonstrates complete or partial persistence of the diverticulum, another intravenous urogram is obtained three months later to see if there is any change. If this study does not clearly show either obliteration or persistence of the diverticulum, a retrograde pyelogram is obtained. In this series, the length of fol-
UROLOGY
/ JULY 1993
/ VOLUME~~, NUMBER1
FIGURE 3. Foollow-up intravenous urogram at two months shows obliteration of diverticulum and elimination of stones.
low-up ranged from three months with a mean of six months.
to three years
RESULTS Of the 19 patients who had stones preoperatively, 18 (95%) were stone free at follow-up. Sixteen patients had complete resolution of their diverticula with normal urograms. The remaining 4 patients had at least a 50 percent diminution of the size of the diverticulum. In 2 of these patients, the three-month intravenous urogram showed essentially no change in lesion size, but the six-month study revealed extensive shrinkage. All 20 patients were free of pain. Also, all were free of infection, including the patient who had suffered repeated Pseudomonas infections preoperatively. She was one of the patients in whom shrinkage, not complete obliteration, of the lesion had been obtained. Complications were graded as either major or minor. The two major complications consisted of hemothorax or hydrothorax, necessitating chest
23
tube drainage. Both cases involved massive hydrothorax, and it was felt that simple aspiration, which may be used in small or medium-size collections, was not appropriate in these patients. Both of these patients were treated early in the series when intercostal punctures were performed for high-lying diverticula. Since we began using the renal displacement technique, no patients have required a chest tube postoperatively. Thus, the rate of major complications was 7 percent in the entire series of 28 patients. The three minor complications were persistent extravasations that necessitated insertion of a double-pigtail stent. Thus, the rate of minor complications was 11 percent. The average blood loss was 300 mL. However, 4 of the 28 patients (14%) required transfusion of one or two units of blood. COMMENT Patients with symptomatic caliceal diverticula pose a therapeutic challenge. Traditionally, treatment has included nephrostomy with extraction of the calculus, closure of the communicating tract, and obliteration of the diverticulum by marsupialization and fulguration. In more severe cases, partial or total nephrectomy has been advised. In 1986, Hulbert et al.’ reported on 10 patients with caliceal diverticula managed percutaneously In this study, the procedure was performed using intravenous sedation. Our experience has made us choose general anesthesia, which is preferable during the often-challenging creation of the percutaneous access. Hulbert and associates3 did not fulgurate the diverticular wall, although they used fulguration in 1 patient in a later series. It is difficult to say if our results in lesion ablation are attributable to the fulguration or to the dilation alone. At present, there is no study comparing dilation and fulguration with dilation alone. Until such a study appears showing that fulguration is unnecessary, we will continue to do both, since it is our belief that if the diverticulum persists, it is at risk for future stones or infection. The role of extracorporeal shock-wave lithotripsy (SWL) in the management of caliceal stones remains controversial. A serious concern is that the narrow neck of the diverticulum will not allow adequate passage of stone fragments. In fact, SWL has proved rather unsatisfactory in rendering patients stone free. Psihramis and Dretler2 found a stone-free rate of only 20 percent, and Ritchie and associates6 achieved a stone-free rate of 25 percent. A curious finding is that relief of 24
symptoms does not necessarily require that the patient be rendered stone free. Psihramis and Dretler obtained symptomatic relief in 70 percent of their patients. Likewise, Ritchie and associates found 75 percent of their patients to be asymptomatic. Enthusiasm for this approach must be tempered by the short follow-up in these studies, however. The natural history of the disease is that residual calculi are likely to grow and cause renewed symptoms eventually Also, SWL has been particularly unsuccessful in curing patients who have concomitant urinary tract infections. Approximately 65 percent of the patients with caliceal diverticula and recurrent infections had persistent infections after SWL.7 Dretle? has proposed a classification for caliceal diverticula that would help the urologist select the optimal form of therapy The original system classified Type I as those diverticula arising from the tip of a minor calix and Type II as those arising from a major calix or infundibulum. Dretlers proposes classifying as Type 1 diverticula with an open mouth and short neck, as Type 2 those with a closed mouth and short neck, as Type 3 those with a closed mouth and long neck, and as Type 4 those with an obliterated neck. He suggests that Type 1 lesions are best treated with SWL, and Type 2 are most suited to management by ureterorenoscopy The description of a Type I diverticulum is very similar to that of a calix, and most would agree that caliceal stones are best managed by SWL. In Dretler’s view, Types 3 and 4 and all diverticula containing stones larger than 2 cm should be treated by the percutaneous approach. When patient selection along these lines is used, the results of SWL are better than those just described. For example, in one series of patients who had stones smaller than 1.5 cm and a radiologically patent diverticular neck, a stone-free rate of 58 percent was achieved.7 Pang, David, and Fuchs4 described the retrograde approach to diverticula. They attempted to treat 36 patients in this manner. However, in 4 patients, the diverticula were found to be in the lower pole and had to be treated percutaneously Of the remaining patients, 24 (75%) were rendered stone free. Stones were removed under direct endoscopic control or with SWL. Although SWL was performed under the same anesthesia, it nevertheless entailed an additional procedure. Of the 8 patients with residual calculi, 4 (12% of the series) had persistent symptoms and underwent an additional procedure: 2 by a retrograde approach and 2 percutaneously. The other UROLOGY
/ JULY1993
f VOLUME42, NUMBER1
4 patients with residual calculi were free of symptoms and were being managed conservatively. Thus, 23 percent of the patients in whom a retrograde approach to a caliceal diverticulum was attempted or used required either a second retrograde or a percutaneous procedure. There is another concern about retrograde management of diverticula. In a recent review of endopyelotomy performed by the retrograde approach, Meretyk, Meretyk, and Clayman found a 21 percent rate of distal stricture of the ureteropelvic junction. They theorized that the prolonged ischemia of the ureteral wall during the long procedure was responsible for this complication. This finding has led them to abandon the retrograde approach. One often must work in the ureter for an extended period of time to find the neck of the diverticulum when dealing retrogradely with these lesions, and long-term followup is needed to see what is the late stricture rate. We believe that patients with symptomatic caliceal diverticula are best treated by the percutaneous approach. If the lesion lies above the twelfth rib, complications can be minimized by using the renal displacement technique.5 We believe that one is obliged to make every effort both to render the patient stone free and to obliterate the diverticulum. All of our patients are asymptomatic and infection free, and all have obtained either extensive shrinkage (20% of the series) or obliteration (80%) of the diverticulum. Only 1 patient has any residual stone. Arthur D. Smith, M.D. 270-0576th Avenue New Hyde Park, New York 11042
REFERENCES 1. Hulbert JC, Reddy PK, Hunter DW, Castaneda-Zuniga WR, Amplatz K, and Lange PH: Percutaneous techniques for the management of caliceal diverticula containing calculi. J Urol135: 22%227,1986. 2. Psihramis KE, and Dretler SP: Extracorporeal shockwave lithotripsy of caliceal diverticula calculi. J Urol 138: 707-711,1987.
UROLOGY
/ JULY1993 / VOLUME42, NUMBER1
3. Hulbert JC, Hemandez-Graulau JM, Hunter DW, and Castaileda-Zufiiga WR: Current concepts in the management of pyelocaliceal diverticula. J Endouro12: ll-17,1988. 4. Pang K, David R, and Fuchs GJ: Tmtment of stones in caliceal diverticula using retrograde endoscopic approach: critical assessment after 2 years (Abstr). J Endourol (Suppl) 6: F-15, 1992. 5. Karlin GS, and Smith AD: Approaches to the superior calix: renal displacement technique and review of options. J Urol 142: 774-777, 1989. 6. Ritchie AWS, Parr NJ, Moussa SA, and Tolley DA: Lithotripsy for calculi in caliceal diverticula? Br J Ural 66: 6-8, 1990. 7. Streem SB, and Yost A: Treatment of caliceal diverticular calculi with extracorporeal shock-wave lithotripsy: patient selection and extended follow-up. J Ural 148: 1043-1046,1992. 8. Dretler SP: A new useful endourologic classification of calyceal diverticula (Abstr), J Endourol (Suppl) 6: F-17, 1992. 9. Meretyk I, Meretyk S, and Clayman RV: Endopyelotomy: comparison of ureteroscopic retrograde and antegrade percutaneous techniques. J Uroll48: 775783, 1992. EDITORIAL COMMENT Pain, calculi, and/or infection occurring in the presence of caliceal diverticula are merely the symptoms of a more basic underlying condition, i.e., stasis within the upper urinary tract. When treatment of caliceal diverticula is indicated, the preferred approach would not only treat patient’s symptoms but also would attempt to address the underlying pathophysiology Clearly, shock-wave lithotripsy does not address the poor drainage and stasis associated with caliceal diverticula, and given the nonsecretory nature of caliceal diverticula, the extremely poor results associated with lithotripsy are not surprising. As Bellman et al. have demonstrated in this article, an endourologic approach provides far better results than shock-wave lithotripsy and also allows for simultaneous ablation of the diverticulum. Although the percutaneous approach is more invasive than shock-wave lithotripsy, in experienced hands the far superior results achieved are clearly justified. I concur with the authors that direct puncture into the diverticulum is the best approach. Retrograde ureteroscopic techniques have been advocated by some, but such an approach represents a long run for a short slide. Additionally, the retrograde approach is usually not technically possible for most diverticula in the lower pole of the kidney. James E. Lingeman Methodist Hospital oflndiana Indianapolis, Indiana 46202
25