Giant renal calculus in a solitary functioning kidney

We report a case of giant renal calculus 230 x 140 mm in size and weighing 1,350 g in a solitary functioning kidney treated by nephrolithotomy. A 47-year-old man presented with right lumbar pain, abdominal mass and microscopic hematuria. Physical examination revealed a stony hard mass on the right side of the abdomen, extending from the subcostal region to the iliac crest. A giant renal calculus in his right kidney and atrophic nonfunctioning left kidney was diagnosed by ultrasonography, IVP and CT scan. Right nephrolithotomy was performed. Analysis revealed a calcium phosphate stone. This case is the largest and the heaviest stone reported in the literature in a solitary functioning kidney.     

A case of ureteral triplication (type 1) associated with vesicoureteral reflux in a solitary kidney

Ureteral triplication is a rare congenital anomaly of the upper urinary tract. It is reported to be associated with an increased incidence of congenital anomalies as well as a predisposition to infection and calculus formation. We report a case of type 1 variant of ureteral triplication associated with vesicoureteral reflux into lower and mid pole ureters in a solitary kidney. To our knowledge ureteral triplication in a solitary kidney has not been described previously.     

Matrix obstruction of solitary kidney during pregnancy

A matrix calculus obstructed the ureter of a solitary kidney during pregnancy. Anuria and azotemia were reversed by extracting the calculus. The matrix was an amorphous mass of glycoprotein and mucopolysaccharide; there were only microscopic nests of calcium. Only electron micrographs demonstrated a tendency of the crystals and matrix to display lamellae. This unusual architecture suggests matrix calculi can grow without organized lamellae.     

Pinball calculus in a ureterosigmoidostomy

We report a complication during the treatment of lithiasis with extracorporeal shock wave lithotripsy in a patient with a ureterosigmoidostomy. This woman presented with renal colic bilaterally and renal insufficiency and was found to have an extremely mobile calculus. A significant gaseous reflux from the sigmoid colon was found to propel the solitary calculus in a retrograde fashion across the ureteroileal anastomosis up the ureter into one kidney, and then later, after re-descent to the level of the anastomosis, up into the opposite kidney. After several days of playing hide and seek with this migrating calculus, using extracorporeal shock wave lithotripsy, the patient became stone free.     

不同体位多镜联合治疗复杂性肾结石简

目的 探讨针对不同患者选择合适体位联合多种内腔镜治疗复杂性肾结石的安全性及疗效。方法 对在2011年7月至2013年1月选择适合体位联合多种内腔镜进行治疗的78例复杂性肾结石患者资料进行回顾性分析。男51例,女27例,平均年龄49（26-73）岁,肾鹿角形结石47例,多发肾盂、肾盏结石31例。其中孤立肾结石3例（左侧2例,右侧1例）,合并肾盂输尿管连接部（UPJ）狭窄3例,合并同侧输尿管结石13例,合并对侧输尿管结石6例,合并双侧输尿管结石4例,同侧肾切开取石术后复发6例,合并肾功能不全3例。选择俯卧位57例,向健侧倾斜45°的仰卧位8例,斜仰卧截石位13例。所有患者均联合应用多种内腔镜进行碎石、取石治疗。结果 该组78例患者肾穿刺通道均一次成功建立,未出现大出血、气胸、严重感染等并发症。肾结石一期清除率86.7%,输尿管结石清除率100%。5例残留肾结石经原经皮肾通道二次取石,3例术后配合体外冲击波碎石治疗,2例行二期经皮肾镜取石术（PCNL）。手术时间70-120 min,平均85 min;住院时间平均76 d。结论 针对不同患者选择适合体位联合多种内腔镜治疗复杂性肾结石,安全、高效,能明显减少二次麻醉及手术的几率,值得推广应用。     

Is there a role for tamsulosin in shock wave lithotripsy for renal and ureteral calculi?

PURPOSE: We evaluated the effect of the alpha-blocker tamsulosin on stone clearance, analgesic requirements and steinstrasse in shock wave lithotripsy for solitary renal and ureteral calculus. MATERIALS AND METHODS: A prospective, double-blind, randomized placebo controlled study was performed during 1 year involving 60 patients with a solitary renal or ureteral calculus undergoing shock wave lithotripsy. The control group (30) received 0.4 mg tamsulosin and the study group (30) received placebo daily until stone clearance or for a maximum of 30 days. An oral preparation of dextropropoxyphene hydrochloride and acetaminophen was the analgesic used on an on-demand basis. The parameters assessed were stone size, position, clearance time, effect on steinstrasse and analgesic requirement. RESULTS: The overall clearance rate was 96.6% (28 of 29) in the study group and 79.3% (23 of 29) in the control group (p = 0.04). With larger stones 11 to 24 mm the difference in the clearance rate was significant (p = 0.03) but not so with the smaller stones 6 to 10 mm (p = 0.35). The average dose of analgesic used was lower with tamsulosin than with controls, without statistical significance. Steinstrasse resolved spontaneously in the tamsulosin group whereas 25% (2 of 8) required intervention in the placebo group. There was no difference between the 2 groups with regard to age, stone size or location. CONCLUSIONS: The alpha-blocker tamsulosin seemed to facilitate stone clearance, particularly with larger stones during shock wave lithotripsy for renal and ureteral calculus. It also appeared to improve the outcome of steinstrasse. Tamsulosin may have a potential role in routine shock wave lithotripsy.     

Use of fistula director to enlarge the port site opening to retrieve a stone packed bulky gall bladder during laparoscopic cholecystectomy: a simple and safe technique.

Retrieval of the gall bladder through the port site opening is technically difficult and challenging when it is bulky either due to packed multiple calculi or a large solitary calculus. We describe in this article a simple technique that involves enlargement of the port site opening to facilitate the gall bladder removal in these difficult situations, using a scalpel and a fistula grooved director.     

Anatrophic nephrolithotomy in the solitary kidney

A retrospective analysis was conducted on 30 patients who had undergone anatrophic nephrolithotomy for staghorn calculus disease in a solitary kidney. No statistically significant difference (p greater than 0.1) was found between the average preoperative and postoperative renal function values. Of 27 patients who were infected preoperatively 19 were rendered free of further urinary tract infection and 24 of 30 patients (80 per cent) had no further recurrence of renal calculi. Because of the predictable morbidity and mortality associated with the non-operative management of staghorn calculus disease these patients are managed best by the complete surgical removal of all calculi and intensive antimicrobial therapy.     

Retrograde intrarenal surgery for a staghorn renal calculus in a patient with solitary kidney and urinary tract deformity: a case report

Staghorn renal calculi are large, branched stones in the kidney that partially or completely fill the renal pelvis and renal calyces. Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for staghorn calculi. However, we report a retrograde intrarenal surgery (RIRS) performed to treat a staghorn calculus in a patient with a solitary kidney and a deformed urinary tract. The 37-year-old male patient presented with right-sided lumbar pain. The computed tomography (CT) scan found a solitary kidney on the right side with an opaque 4.5 cm × 2.4 cm renal stone and grade I hydronephrosis. Additionally, a urinary tract deformity was observed, and it was secondary to the deformity of the pelvis caused by a previous pubis fracture, which significantly increased the risk and the difficulty of intrarenal surgery. A total number of 3 sessions of RIRS were conducted, and the patient was discharged 3 days after each session on average. The postoperative X-ray exam of the third session revealed that the renal stone was completely removed. The patient recovered well without any complications. This case demonstrates that RIRS is a safe and effective treatment of staghorn calculi with the presence of urinary tract deformation. This suggests RIRS may be of particular interest in minimizing the procedure-related damage of a solitary kidney.     

Retroperitoneal pyelolithotomy for management of renal calculi.

OBJECTIVE: We evaluated the role of retroperitoneoscopic pyelolithotomy in the management of renal calculi. METHODS: Fifty-six cases (male, 27; female, 29) of solitary or multiple renal calculi were evaluated in the study. There were 46 patients with a single calculus, 4 patients with a staghorn calculus, and 6 with a caliceal calculus. Retroperitoneoscopic pyelolithotomy was carried out after creating a retroperitoneal space with the balloon dissection method. Pneumoretroperitoneum was maintained by carbon dioxide insufflation. RESULTS: Stone clearance was achieved in all cases barring 2 cases of caliceal calculi that were converted to the open procedure. The postoperative hospital stay averaged 4 days. Patients were ambulatory within 24 hours and back to work within 7 days on average. Complications encountered were peritoneal rent, subcutaneous emphysema, and superficial wound infection. The postoperative analgesic requirement averaged 100 mg of diclofenac (2 tablets). CONCLUSIONS: Retroperitoneoscopic pyelolithotomy is a safe, simple, and effective minimally invasive procedure and is a feasible option that can be recommended for management of renal calculi.     

Shock wave lithotripsy in solitary functioning kidneys: is prophylactic stenting necessary?

OBJECTIVE: To assess the safety of shock wave lithotripsy (SWL) without prophylactic stents in solitary functioning kidneys. PATIENTS AND METHODS: Sixteen solitary functioning kidneys with 23 renal stones with a size of <15 mm were treated with SWL as the primary modality. All patients were counseled about the possibility of obstruction, and treatment was offered to those who consented. The safety of SWL was assessed by the need for interventions and the posttreatment renal function. RESULTS: In 14 patients lithotripsy was uneventful. The duration of treatment ranged from 5 to 35 days. One patient with a 15-mm pelvic calculus presented with anuria which resolved before intervention. In 1 patient fragmentation failed, and percutaneous nephrolithotomy was performed. CONCLUSIONS: In solitary functioning kidneys, SWL is safe without prophylactic stents in properly selected and closely monitored patients. Avoiding stents decreases costs, duration of treatment, and stent-related morbidity without unduly compromising safety.     

A giant renal calculus treated without nephrectomy

The case of a patient with a giant renal calculus weighing 770 g in a solitary functioning kidney is reported. A 57-year-old man presented with right lumbar pain and macroscopic hematuria, and a giant stone was diagnosed in his right kidney. Nine days after a percutaneous nephrostomy placement, the patient underwent selective right renal angiography and transcatheter superselective embolization due to a sudden gross hematuria observed from both the nephrostomy tube and urethra. Embolization was successful. Right anatrophic nephrolithotomy was performed after stabilization of the patient. There were no complications during the recovery period. The case reported here is significant not only because it is the 7th biggest and the heaviest stone in the literature but also because it is the first giant stone reported to be in a solitary functioning kidney and treated without nephrectomy.     

Ureterocalycostomy for postpyelolithotomy stenosis after failure of intubated infundibuloplasty

Extended pyelolithotomy for staghorn calculus in a uremic patient with solitary functioning kidney was followed by development of stenosis of the infundibulum draining the superior and middle calyces. Drainage of the lower calyx down the ureter remained intact. Intubated infundibuloplasty proved unsuccessful since scarring and occlusion promptly recurred. Anastomosis of the middle calyx to the ureter was then performed with good results. We believe this is the first reported case of ureterocalycostomy for providing drainage to the middle calyx without lower polar nephrectomy.     

Surgical removal of the staghorn calculi in the solitary kidney patients

Seven patients undergoing surgical removal of extensive renal calculi involving a solitary kidney are reviewed. Problems arising from the surgery for the extensive renal calculi in a solitary kidney patient are demonstrated and indication of the surgery is also discussed. From January, 1978 to July, 1984, extensive renal calculi were removed in 7 solitary kidney patients. The operative technique for removing calculi consisted of anatrophic nephrolithotomy (in 2 patients) and ex vivo surgery (in 5 patients). There were 2 operative deaths and 2 major complications. Calculi were completely removed in 6 and 1 patient undergoing anatrophic nephrolithotomy, had a 3 X 4 mm residual calculus. The postoperative serum creatinine was improved in 5 patients. These major complications were observed in the patients who had severe renal dysfunction during the early postoperative period. It was indicated that good renal function should be maintained even during the early postoperative period in the surgery on a solitary kidney patient. Investigating injury to the operated kidney, the early postoperative serum creatinine level was analysed in these 7 patients and 3 patients undergoing ex vivo surgery for removal of aneurysm in a solitary kidney. The results indicated that nephrotomy was the most extensive damage to the kidney. However, pyelotomy and cold ischemia during ex vivo surgery, are not always harmful. In performing surgery for extensive renal calculous disease involving a solitary kidney, we should choose pyelotomy rather than nephrotomy in in situ operation. Ex vivo surgery can provide an effective treatment.     

Extracorporeal surgery and autotransplantation for complicated renal calculous disease in 108 kidneys

One hundred and eight kidneys in 97 patients with staghorn (72%) or multiple pyelocalyceal (28%) calculi were treated by extracorporeal surgery and autotransplantation, and followed up for 1-12 (mean 3) years. Twenty-seven patients had a solitary kidney, and 11 were operated on bilaterally. Sixty-nine % had a history of previous stone surgery, 74% had urinary tract infection and 30% renal dysfunction. Postoperative and late mortality rates were 3.1 and 2.1%, respectively. In addition, three kidneys were lost postoperatively and two later. Only one case of renal calculus recurrence was observed. Sixty-nine per cent of preoperatively infected patients were cured of infection, and 18% improved. Ninety-two per cent of patients with functioning autograft had preserved or improved renal function at follow-up. We find extracorporeal calculus removal a highly effective procedure with an acceptable risk.     

Ultrasonic lithotripsy of a large staghorn calculus

We describe the removal of an infected 9 cm. staghorn calculus by ultrasonic lithotripsy in a man with a solitary kidney and a pyelocolonic conduit, who had undergone 2 prior operations on the involved kidney. Lithotripsy was performed through the conduit with the patient under epidural anesthesia in 3 staged procedures. Subsequently, the patient underwent successful urinary undiversion. Recent advances in the technical equipment available for the management of stone disease have reduced substantially patient morbidity associated with renal stone surgery in the previously operated kidney.     

Laparoscopic pyelolithotomy: indications and technique

BACKGROUND AND PURPOSE: Laparoscopic pyelolithotomy, although uncommonly performed, may be considered in patients who have renal anomalies, are poorly compliant, and have a large single renal-pelvic calculus. We present our experience with this procedure in five patients. PATIENTS AND METHODS: Three patients underwent laparoscopic pyelolithotomy because of a horseshoe kidney, one for a pelvic kidney, and one for a large renal-pelvic calculus. All stones were solitary with a mean size of 2280 mm2 (range 540-8200 mm2). All were approached transperitoneally with passage of a flexible cystoscope through a laparoscopic port to aid in stone extraction. RESULTS: All cases were completed laparoscopically. The length of surgery was 74, 92, 134, 158, and 159 minutes. There were no minor or major complications, and the estimated blood loss was <50 mL in all cases. All patients were discharged on postoperative day 1 with the drains removed. Four patients were stented for 4 to 6 weeks. The remaining patient was not stented because of poor compliance. The stents were removed with office cystoscopy. All patients were stone free on follow-up imaging. CONCLUSIONS: Laparoscopic pyelolithotomy can be done safely, effectively, and efficiently with proper patient selection and adherence to standard laparoscopic surgical principles.     

CT三维成像在肾脏复杂性结石手术治疗中的意义

目的：探讨CT三维成像处理技术对判断肾脏多发结石的形状及其与肾脏关系的意义。方法：对16例肾脏多发结石、铸型结石患者行KUB、IVU和CT检查,并应用CT三维成像处理技术对CT图像进行处理。所有患者均行手术治疗。结果：CT三维成像处理技术可使肾脏结石和肾脏获得较直观、全面而清晰的三维图像,可以准确判断结石的立体形状及其与肾脏的关系、结石所在肾脏皮质的厚度。结论：CT三维成像处理获得的三维图像较KUB、IVU和普通CT图像更具有临床指导意义。     

Long-Term Renal Fate and Prognosis After Staghorn Calculus Management

We analyzed retrospectively 177 consecutive staghorn calculus patients to determine risk factors for ultimate renal deterioration and renal cause specific death. Mean followup was 7.7 years. Overall rate of renal deterioration was 28 percent. Renal deterioration was associated more frequently among patients with solitary versus nonsolitary kidneys (77 percent versus 21 percent, p less than 0.001), previous versus initial stones (39 percent versus 14 percent, p = 0.03), recurrent versus nonrecurrent calculi (39 percent versus 22 percent, p = 0.07), hypertension versus normotension (50 percent versus 22 percent, p = 0.006), complete versus partial staghorn calculi (34 percent versus 13 percent, p = 0.02), diversion versus no diversion (58 percent versus 19 percent, p less than 0.001) and neurogenic bladder versus normal voiding (47 percent versus 21 percent, p = 0.006), as well as those who refused treatment versus treated patients (100 percent versus 28 percent, p less than 0.001). No patient with complete clearance of fragments died of renal related causes compared to 3 percent of those without clearance of fragments and 67 percent of those who refused treatment (p less than 0.001). Our study suggests that long-term renal preservation in the staghorn calculus patient may depend on normal blood pressure, staghorn size, absence of diversion or voiding dysfunction, and complete stone eradication.     

La nephrolithotomie sur rein unique: a propos de vingt cas

IntroductionPercutaneous nephrolithotomy (PCNL) is the most important therapeutic alternative in the management of large or complex renal calculi. Through a series of 20 patients, we study the feasibility and morbidity of this technique in a solitary kidney.Patients and methodswe retrospectively reviewed a series of twenty patients with a calculus in a solitary kidney during a 9-year period, all treated with (PCNL). The results were analyzed emphasizing complications with a special focus on the evolution of renal function.ResultsPatients were divided into two groups depending on the size of the renal stone. The average age was 39 years (23-56 years). Pain was the dominant symptom, found in 60% of the patients. The stone free rate was 87.5% in group 1 and 84% in group 2. Further complementary treatment was necessary in 3 cases. Preoperative renal function was normal in 75% of the cases. After a moderate deterioration in the immediate postoperative period, renal function improved at one month follow up, and this improvement remained sustained for one year.ConclusionThe PCNL in a solitary kidney is safe and the results are comparable to those obtained with two functioning kidneys. Renal function is particularly not degraded in the medium or the long term.