BERKELEY, CA (UroToday.com) - Treatment of ectopic pelvic kidney stones can be complex and controversial. Older generation urologists would choose open nephrolithotomy for time efficiency and because they are experts in that field, while the younger urologists with endourology training would favor minimally invasive surgery and its inherent advantages over open surgery. Yet, both approaches are not easy and require individualization of management for each patient.
Extracorporeal shock-wave lithotripsy was tried by some investigators with stone-free rate ranging from 54% to 82%, but it is not always feasible due to overlying spine or poor visualization of the pelvic kidney stone. Retrograde Intra-renal surgery can be challenging in patients with pelvic kidney stones. The abnormal orientation of the pelvicalyceal system, in addition to the abnormally curving ureter, make it difficult for the flexible ureteroscope to reach the stones -- especially if they are positioned in lower calyceal groups.
Percutaneous nephrolithotripsy (PCNL) is the preferred option if the stone burden is high. The difficulty in treating patients with pelvic kidney stones lies in obtaining proper access due to the abnormal anatomy and the overlying bowel loops with adjacent major vessels. Many previous reports described the technique of laparoscopic-assisted PCNL, by obtaining the renal access under direct laparoscopic visualization after mobilizing the overlying bowel. Other fewer reports described laparoscopic pyelolithotomy as an alternative treatment for patients with pelvic kidney stones. However, both laparoscopic-assisted PCNL and laparoscopic pyelolithotomy hold the risk of jeopardizing the vascularity of the uretero-pelvic junction if the patient had previous pyeloplasty.
With this concern in mind, we had the novel idea of accessing the kidney under computerized tomography arteriography (CTA) guidance, through the greater sciatic foramen, to avoid injuring the adjacent structures. The patient had smooth intraoperative course and uneventful postoperative recovery. Stone-free status was confirmed by CT scan in day 1 postoperative and the patient was discharged to home on day 2 postoperative. Only minor leakage from nephrostomy tract, after removal of nephrostomy tube, was encountered and managed successfully by urethral catheter insertion until day 4 postoperative. That was probably explained by draining the bladder and reducing the curving of the ureter, resulting in reduced “functional obstruction.”
CT-Guided transgluteal PCNL is one option to be considered in treating patients with ectopic pelvic kidney stones.
Written by:
Mohammad Alomar, MD, FRCS(C) and Husain Alenezi, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Urology Division, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.
CT-guided Transgluteal percutaneous nephrolithotripsy in ectopic pelvic kidney: Novel technique - Abstract
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