Pelvicaliceal anatomical variation between stone bearing and normal contralateral kidneys--does it have an impact on stone formation in pediatric patients with a solitary lower caliceal stone?

PURPOSE: We aimed to investigate the probable effect of pelvicaliceal anatomical differences between stone bearing and normal contralateral kidneys on the etiology of stone formation in children with a solitary lower pole caliceal stone. MATERIALS AND METHODS: We reviewed the clinical records of 25 pediatric patients who underwent SWL for a solitary lower caliceal stone and 15 healthy pediatric patients who served as controls. Lower pole IPA, IL and IW, together with other caliceal variables obtained from the pelvicaliceal anatomy of the stone bearing and contralateral normal kidneys of patients with urolithiasis, and both kidneys of the control group were measured based on excretory urography. Also, total pelvicaliceal volume for both kidneys was calculated. RESULTS: Mean LIPAs of stone bearing kidneys compared to the normal contralateral kidneys was more acute, equal and wider in 52%, 16% and 32% of the patients, respectively. Mean pelvicaliceal volumes of the stone forming and normal kidneys were 1,553.8 mm(3) (range 242 to 7,107) and 581.0 mm(3) (90 to 2,662), respectively, and there was statistical significance only in pelvicaliceal volumes between the stone bearing and contralateral normal kidneys (p <0.001). CONCLUSIONS: Our results reveal that IPA, IL and IW of calices do not have an effect on stone formation in pediatric patients. However, large pelvicaliceal volume seems to be a significant risk factor for stone formation in the lower calix, probably because it creates abnormal urodynamic and morphological features, especially when accompanied by other metabolic abnormalities.     

Combination of laparoscopy and nephroscopy for treatment of stones in pelvic ectopic kidneys

PURPOSE: To present the combination of laparoscopy and nephroscopy for the treatment of stones in pelvic ectopic kidneys. PATIENTS AND METHODS: The series included seven male and four female patients (mean age 43 +/- 9 years). Laparoscopy-assisted percutaneous nephrolithotomy (PCNL) was performed for caliceal stones in five patients after failure of shockwave lithotripsy, while laparoscopic pyelolithotomy was performed for large or branched renal pelvic stones in six patients. RESULTS: The mean operative time was 164 +/- 30 minutes. There were neither complications nor conversions to open surgery. The stone-free rate was 91% (10 patients). One patient had a residual caliceal fragment that was treated with shockwave lithotripsy. The mean hospital stay was 3.5 +/- 0.7 days. CONCLUSION: The combination of laparoscopy and nephroscopy is feasible, safe, and effective for the treatment of stones in pelvic kidneys.     

Small caliceal stones: is extracorporeal shock wave lithotripsy justified?

Of 446 patients treated by extracorporeal shock wave lithotripsy 22 had small nonobstructive caliceal stones associated with lumbar or flank pain. Size (less than 1 cm.) and location of the stone did not explain the severity of the symptoms, nor would they have been an indication for open or percutaneous stone removal. Followup consisted of a sonogram and a film of the kidneys, ureters and bladder on postoperative day 1, a film of the kidneys, ureters and bladder 2 weeks after treatment, and a film of the kidneys, ureters and bladder and/or excretory urography after 3 months for patients with residual stone fragments. All patients were interviewed 3 to 15 months after treatment to ascertain the resolution or persistence of the symptoms. After extracorporeal shock wave lithotripsy, 3 of 22 patients had persistent stone fragments for more than 3 months: 2 reported no change and 1 had marked improvement of the symptoms. Of the remaining 19 patients 15 (79 per cent) had complete resolution of the pain and 4 (21 per cent) had significant symptomatic improvement. Thus, 20 of 22 patients (91 per cent) achieved complete or significant relief of pain. The only complication was a perirenal hematoma that resolved spontaneously. These results indicate that small, nonobstructive caliceal stones can be responsible for persistent, severe flank pain. Extracorporeal shock wave lithotripsy is an effective, noninvasive treatment for caliceal stones and it can be justified as therapeutic treatment when the correlation between a small caliceal stone and persistent flank pain is indeterminable.     

Percutaneous nephrolithotomy in horseshoe kidneys. Applied anatomy and clinical experience

The arterial supply of horseshoe kidneys was studied in 6 anatomical specimens to establish whether there is a risk of haemorrhage when performing percutaneous nephrolithotomy. The anatomy of the collecting system was studied on patients' X-rays, taken in different planes to obtain a three-dimensional view. It was found that there is no increased risk of arterial bleeding in horseshoe kidneys compared with normal kidneys. The orientation of the collecting system offers good access. Eight patients with horseshoe kidneys and 1 with a malrotated kidney were treated with percutaneous nephrolithotomy because of solitary or multiple renal pelvic and caliceal stones and 1 ureteric stone. Four patients had had previous operations for calculi. All of the stones were removed without complications.     

Extracorporeal shock wave lithotripsy in the prone position for stones situated anteriorly

Stones situated anteriorly cannot be satisfactorily reached with extracorporeal shock wave lithotripsy (ESWL) in the supine position. By assuming the prone position, patients with stones in horseshoe or ectopic kidneys or in the iliac ureter can be treated by ESWL with the same success rate as patients with posterior stones. This new technique has been used in 30 patients with iliac ureteral stones, 5 patients with caliceal stones in horseshoe kidneys and 1 patient with a pyelic stone in a sacral kidney.     

Percutaneous nephrolithotomy in the spinal cord injury population

We evaluated 23 male spinal cord injury patients who underwent percutaneous nephrolithotomy for the success rate of stone removal and the incidence of operative complications. There were 18 quadriplegic and 5 paraplegic patients, and 5 had bilateral procedures. Of the kidneys 7 had staghorn calculi, 8 had pelvic and caliceal combinations, 6 had large multiple caliceal stones, 4 had large (more than 2.5 cm.) pelvic stones and 3 had pelvic stones less than 2.5 cm. Placement of a nephrostomy tube and stone extraction were performed as a single procedure with the use of general anesthesia in all but 4 patients. Our results showed that 19 of 21 compliant patients (90.4 per cent) were free of stone, with an average of 2.04 procedures per patient. A total of 47 procedures was performed, with an average operative time of 1 hour 45 minutes. Major complications were associated with 4 of the 47 procedures (8.5 per cent), and consisted of a respiratory arrest, 2 perirenal abscesses and a hydrothorax. Minor complications included fever (more than 101.5F) in 64.3 per cent and retained stones in 14.3 per cent of the kidneys operated upon, dislodged nephrostomy tubes in 12.6 per cent of the procedures (21.4 per cent of the kidneys operated upon), and anemia requiring transfusion in 17.0 per cent (8 of 47) of the procedures (27.8 per cent of the kidneys operated upon). The presence of infected stones, prior operative procedures and medical complexity of these patients make complications more frequent. Nevertheless, percutaneous nephrolithotomy is a safe and effective procedure for the spinal cord injury population.     

Pediatric renal pelvic fullness: an ultrasonographic dilemma

PURPOSE: We conducted a prospective study to define normal renal pelvic size in children. MATERIALS AND METHODS: Institutional Review Board approved consent was obtained to perform renal ultrasound during excretory urography (IVP) scheduled for medical management. Mean patient age (17 females, 11 males) was 5.2 years. Renal ultrasound was conducted concurrent with 10-minute IVP. RESULTS: Fifty kidneys were imaged with 51 collecting systems. IVP defined 44 collecting systems as normal. Mean anteroposterior pelvic diameter on sonography for these 44 systems was 3.3 mm. One normal collecting system on IVP had a diameter greater than 10 mm on ultrasound (14 mm). No sonographic caliceal dilatation was seen in any kidney appearing normal on IVP. The 7 dilated systems on IVP had a mean ultrasound diameter of 17.1 mm. Two dilated collecting systems smaller than 10 mm in diameter on sonography had caliceal distention on ultrasound. CONCLUSIONS: Normal renal pelvis threshold diameter was 10 mm in asymptomatic children. We recommend further evaluation in children with caliceal dilatation and/or dilatation of the anteroposterior renal pelvis greater than 10 mm. Using these criteria, no system appearing abnormal on IVP would have been missed.     

The residual calculi in conservative operation for renal calculi

One hundred and three kidneys with calculi in 100 patients, were treated by conservative renal surgery from Jan., 1980 to Dec., 1982. The operative technique consisted of pyelolithotomy, extended pyelolithotomy, dismembered pyelolithotomy, nephrolithotomy (bivalve or anatrophic nephrolithotomy) partial nephrectomy and pyelo-nephrolithotomy. Intraoperative X-ray and coagulum lithotomy were employed when pyelolithotomy was performed. Thirty-five residual calculi in 20 kidneys were observed on postoperative X-ray film. The rate of residual calculi was 19.4%. Factors causing residual calculi, were analysed on these 103 kidneys. The factors were as follows; the shape of calculi: staghorn calculus with multiple small calculi, the shape of the renal collecting system: narrow pelvis with narrow caliceal neck and dilatated calices, and the operative technique: nephrolithotomy. These results suggested that it would be necessary to minimize residual calculi when performing nephrolithotomy.     

Intrapelvic pressure and caliceal dilatation in the evaluation of intermittent hydronephrosis

We investigated 10 patients with suspected unilateral hydronephrosis and normal or minimal widening of the calices or renal pelvis on routine urography by high rate perfusion of the renal pelvis and simultaneous intrapelvic pressure measurement. All affected kidneys had reduced renal function (26 +/- 7 ml. per minute per 1.73 body surface area) evaluated from total and separate glomerular filtration rate studies using 51chromium-ethylenediaminetetraacetic acid clearance technique and isotope renography. Four patients without signs of obstruction operated upon because of renal calculi were used as controls with separate glomerular filtration rates greater than 40 ml. per minute per 1.73 body surface area bilaterally. The drainage function of the renal pelvis was studied by diuresis renography, simultaneous intrapelvic pressure measurement and fluoroscopy during infusion of roentgen contrast medium at a constant rate of 10.5 ml. per minute. The caliceal dilatation was calculated from planimetrical measurement of defined calices. The intrapelvic pressure gradually increased in all kidneys to a maximum value varying from 25 to 81 cm. water (average 47 +/- 15). In the control kidneys the intrapelvic pressure varied from 10 to 18 cm. water (average 14 +/- 3). Significant dilatation of the caliceal system did not occur until intrapelvic pressure values above 25 cm. water were measured. Caliceal dilatation and maximal intrapelvic pressure were correlated significantly to each other at a correlation coefficient of 0.95. Intrapelvic pressure flow measurement with contrast medium and roentgen film exposure at the time of increased pressure proved to be a useful method to diagnose outflow obstruction. The test was of particular value in cases of clinically suspected intermittent hydronephrosis, giving more reliable information than conventional renography and diuretic urography. The test could be used even when the glomerular filtration rate was decreased, thereby providing information on the presence of obstruction in cases when conventional renography and diuresis urography sometimes fail.     

Adjunct controlled inversion therapy following extracorporeal shock wave lithotripsy for lower pole caliceal stones

The lower calix is responsible for a significant number of kidneys with residual stone fragments after extracorporeal shock wave lithotripsy (ESWL*). To compare the effectiveness of controlled inversion therapy as an adjunctive method to the elimination of calculous fragments, 42 patients who had undergone treatment for lower caliceal stones with a Siemens Lithostar lithotriptor were reviewed. Of the patients 25 had no adjunctive therapy and 17 underwent controlled inversion therapy. The success rate, effectiveness quotient and complication rate were analyzed. Followup consisted of ultrasound and a nephrotomogram 1 day and 1 to 3 months postoperatively. Complete removal of all stone fragments was achieved in 84% of the patients without an adjunctive maneuver and in 64.7% of those treated with controlled inversion therapy. The effectiveness quotient was 72.4% and 35.5%, respectively. The group treated without adjunctive therapy had fewer retreatment sessions and a lower complication rate. There were no complications related to the controlled inversion therapy and patient acceptance was generally enthusiastic. We conclude that controlled inversion therapy did not improve the results of ESWL for lower pole caliceal calculi.     

Percutaneous nephrolithotomy of transplanted kidney

Urinary lithiasis after renal transplantation is a relatively uncommon disease; the predisposing factors and the composition of calculi are identical to those of patients with native kidneys. We present a case of a 45-year-old woman with a staghorn stone in a left-sided transplanted kidney who was treated successfully by percutaneous nephrolithotomy (PCNL). After reviewing the literature, we conclude that PCNL in transplanted kidney is a feasible and safe procedure. The technical aspects of the procedure, such as patient position and the use of the ultrasound-guided caliceal puncture, are stressed.     

CT analysis of caliceal anatomy in the supine and prone positions

PURPOSE: To assess the effect of patient positioning on the position of the kidneys and their consequent projection onto plain radiographs, thus ascertaining the need for special preoperative imaging. PATIENTS AND METHODS: Fourteen patients were studied by obtaining fine (5-mm)-cut contrast-enhanced CT scans in the pyelogram phase in both the supine and prone position. The orientation of the kidneys relative to the midsagittal plane of the body and the orientation of the anterior and posterior calices relative to the axis of the kidney were measured from hardcopy images. Comparison was made between prone and supine positions for left and right kidneys separately, as well as overall. RESULTS: The position of the patient had a small effect on the orientation of the kidneys, with the mean angle changing from 56.6 degrees when supine to 61.6 degrees when prone (p < 0.05). However, no significant change in caliceal orientation or the relative projection of the anterior and posterior calices occurred as a result. CONCLUSION: There is no need to carry out special preoperative imaging in the operative or prone position.     

Percutaneous catheter dissolution of cystine calculi

In 11 kidneys with presumed cystine stones that were symptomatic and obstructing, percutaneous nephrostomy and stone lavage with either acetylcysteine-bicarbonate solution or tromethamine-E were performed. There were 7 complete stone dissolutions: 2 of 6 attempts with acetylcysteine-bicarbonate alone, 3 of 5 with tromethamine-E, 1 partial with acetylcysteine-bicarbonate, which was completed with tromethamine-E, and 1 proved mixed stone (cystine and calcium phosphate) that required acetylcysteine-bicarbonate and hemiacidrin. In 1 case tromethamine-E irrigation was 97 per cent complete but a few tiny caliceal fragments remained. There were 3 failures of chemolysis: 2 pure cystine stones (1 each acetylcysteine-bicarbonate and tromethamine-E) and 1 mixed calculus with a surface shell of calcium oxalate. Irrigation time was 6 to 42 days for the 7 unoperated kidneys. Tromethamine-E appears to be a more effective agent for cystine stone dissolution. Percutaneous nephrostomy and dissolution are an alternative to an operation in patients with cystine calculous disease.     

ESWL: stone-free efficacy based upon stone size and location

Summary Extracorporeal shock wave lithotripsy was used for the treatment of 1060 patients or 1128 kidneys with solitary stones. There were 528 pelvic stones, 82 upper caliceal stones, 120 middle caliceal stones and 398 lower caliceal stones. These groups were divided into two subgroups of large (>15 mm) and small (15 mm) stones. A total of 1232 treatments were carried out (1.16/patient or 1.09/kidney) and 91% of the patients underwent a single treatment. Auxiliary procedures were required in 5% of the patients and the complication rate was 3%. Overall, 74% of the patients were stone-free after 3 months of follow-up. Of the 26% with residual stones, 18% had sand (2 mm fragments) or match-heads (4 mm), 6% had fragments (5 mm) and 2% had no fragmentation at all. A stone-free result occurred in approximately 87% with small pelvic and upper caliceal stones, whereas large stones in these locations became stone-free in approximately 70% of cases. Both large and small stones in the lower half of the kidney (mid and lower calices) become stone-free less frequently (to a statistically significant degree) than do similar stones located in the pelvis or upper calices.     

Caliceal diverticula developing into simple renal cyst

Although common in adults simple cortical renal cysts are rare in children. Caliceal diverticula are rare in adults and children. A case of a caliceal diverticulum apparently sealing off and becoming an isolated simple cyst in the renal parenchyma has been reported as an unusual complication of caliceal diverticula. There have been 2 other cases of caliceal diverticula becoming sealed off reported in the literature, although neither progressed to frank cysts. We report 2 cases of definite caliceal diverticula progressing to simple renal cortical cysts.     

Renal calculi in lower pole calices: what is the best method of treatment?

Percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy (ESWL*) can be used in the treatment of lower pole caliceal calculi. In a retrospective analysis these 2 therapies were compared for treatment of solitary lower pole caliceal calculi to evaluate morbidity. During a 2-year period 23 patients treated with percutaneous nephrolithotomy and 24 who underwent ESWL with the Siemens Lithostar were analyzed in regard to the success rate, effectiveness quotient, complication rate, length of hospitalization and disability period. Followup consisted of ultrasound and/or a plain film of the kidneys, ureters and bladder 1 day and 1 to 3 months postoperatively. A nephrotomogram was included in the ESWL group. Complete removal of all stone fragments was achieved in 93.6% of the patients treated percutaneously without retreatment. In the ESWL group the success rate was 79.2% with a 41.6% retreatment rate. On the other hand, the ESWL group had a shorter hospitalization and an earlier return to normal physical activities. Among the patients who underwent a percutaneous operation 13% had complications compared to 4.1% in the ESWL group. The recurrence rate was higher in the former group (13% within a median of 18 months, compared to 8.3% within a median of 11 months in the ESWL group). The mean stone diameter was 1.42 cm. in the percutaneous group and 1.22 cm. in the ESWL group. Stone composition was similar in both groups. Since ESWL is an effective noninvasive procedure without the need for routine anesthesia and hospitalization, and with prompt return of the patient to a normal life it must be considered the method of choice for lower caliceal stones less than 2 cm. in diameter. However, percutaneous nephrolithotomy will continue to have a primary role in the management of larger stones.     

Laparoscopic surgery for renal urolithiasis: pyelolithotomy, caliceal diverticulectomy, and treatment of stones in a pelvic kidney

Laparoscopic techniques may be considered for the uncommon patient in whom open stone surgery is considered. Stones in caliceal diverticula not accessible percutaneously may be approached transperitoneally. Pelvic stones in ectopic kidneys can be retrieved laparoscopically through a pyelotomy created with scissors or a knife. Percutaneous nephrolithotomy under laparoscopic guidance can be used if the stone extends beyond the renal pelvis. In the patient with difficult stone disease, laparoscopy does not replace other minimally invasive techniques but rather complements them. It should be the rare patient in the future who needs open surgery for stone removal regardless of its location or the presence of anatomic variants.     

Small caliceal stones: what is the best method of treatment?

In a retrospective analysis classical radial nephrolithotomy, percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy for symptomatic small nonobstructive caliceal stones were compared to evaluate morbidity. Size (less than 1 cm.) and location of the stone (caliceal and nonobstructive) did not explain the severity of the symptoms nor would they have been an indication for an operation. In 8 patients treated by an open operation, 16 treated percutaneously and 6 who underwent extracorporeal shock wave lithotripsy the procedure time, success rate, complication rate and length of hospitalization were analyzed. Followup consisted of ultrasound and/or a plain film of the kidneys, ureters and bladder 1 day and 3 months postoperatively. A nephrotomogram was included in group 3 patients. Of 30 patients 3 had persistent stone fragments for more than 3 months: 2 underwent percutaneous nephrolithotomy and 1 was treated by extracorporeal shock wave lithotripsy. A total of 28 patients (93.3 per cent) achieved complete or significant relief of pain. In the percutaneous group both patients with persistent fragments were symptomatic in contrast with the extracorporeal shock wave lithotripsy group, in which 1 patient presented with stone fragments but was free of pain. The group treated percutaneously had a shorter procedure time (60 minutes) and the shock wave group had a shorter hospitalization. On the other hand, the open operation group had a better success rate as well as relief of pain. These observations showed that small, nonobstructive caliceal stones can be responsible for persistent, severe flank pain. Since extracorporeal shock wave lithotripsy is an effective noninvasive procedure that does not require routine anesthesia and hospitalization, with prompt return of the patient to normal life, it must be considered the method of choice in these particular patients.     

MECHANICAL PERCUSSION, INVERSION AND DIURESIS FOR RESIDUAL LOWER POLE FRAGMENTS AFTER SHOCK WAVE LITHOTRIPSY: A PROSPECTIVE, SINGLE BLIND, RANDOMIZED CONTROLLED TRIAL

PURPOSE: We compare the effectiveness of mechanical percussion and inversion with observation for eliminating lower caliceal fragments 3 months after shock wave lithotripsy. MATERIALS AND METHODS: At 3 months after shock wave lithotripsy 69 patients with residual lower caliceal fragments 4 mm. or less were randomized to receive either mechanical percussion and inversion or observation for 1 month. The observation group then received crossover mechanical percussion and inversion if fragments persisted. All patients were followed with plain film of the kidneys, ureters and bladder to assess the stone area and stone-free status, and renal tomography or noncontrast spiral computerized tomography to confirm stone-free status. A blinded radiologist reviewed all films. Patients were treated with a mechanical chest percussor applied to the flank while inverted to greater than 60 degrees after receiving 20 mg. furosemide. RESULTS: A total of 35 patients were randomized to receive immediate mechanical percussion and inversion therapy and 34 observation. Of the patients in the observation group 28 subsequently received mechanical percussion and inversion after completing the observation period. The groups were not different in gender, body mass index, side affected, stone location or renal anatomical features. The mechanical percussion and inversion group had a substantially higher stone-free rate than the observation group (40% versus 3%, respectively, p <0.001). The mechanical percussion and inversion group also had a greater improvement in total stone area than controls (-63.3% versus +2.7%, respectively, p <0.001). No significant adverse effects were noted in the mechanical percussion and inversion group. CONCLUSIONS: Mechanical percussion and inversion is a safe and effective treatment option for residual lower caliceal fragments 3 months after shock wave lithotripsy. Nearly 50% of patients become stone-free, and stone burden is decreased by 50% in the remainder.     

肾盏憩室及其并发症的外科处理

目的 探讨肾盏憩室合并结石、感染的诊治特点及方法.方法肾盏憩室患者29例.男11例,女18例.平均年龄26(18～61)岁.其中单纯性肾盏憩室3例,合并感染14例(其中3例外院以肾囊肿行去顶减压术后漏尿转入),合并结石12例.行开放手术治疗10例,憩室去顶,并缝合憩室开口;行腹腔镜下手术8例,憩室处理同开放手术,2例合并结石者同时行取石术;行经皮肾镜取石术(PCNL)11例,取出结石并扩张憩室盏颈,留置肾造瘘管,其中1例中转开放.结果开放及腹腔镜下手术均取得成功,腹腔镜术后1例漏尿予患侧放置双J管1个月后治愈;1例行PCNL术失败中转开放.取石术后1周复查KUB平片无结石残留.29例平均随访14(6～24)个月,患者症状明显改善,无再发感染及结石.结论肾盏憩室常合并结石及感染,采用腹腔镜及PCNL等手术治疗安全可行,疗效确切.术前确诊、术前准备及术中证实是确保手术成功的重要环节.

Abstract：

Objective To analyze the diagnosis and treatment for complications of renal caliceal diverticulum with calculi or infection. Methods A retrospective investigation was performed on 29 cases with renal caliceal diverticulum. The 29 cases included 11 males and 18 females aged 18 to 61 years. Among the study group, 3 cases were simple renal caliceal diverticulum, 12 cases were diagnosed as diverticular calculi and 14 cases presented recurrent urinary tract infections including 3 cases with urinary fistula after unroofing and decompression as renal simple cyst from another hospital. Ten cases underwent an open operation that unroofed and decompressed the cyst, and sutured the diverticular neck. Eight cases underwent laparoscopic operation similar to the open operation, including lithotomy in caliceal diverticulum in 2 cases. Eleven cases diagnosed with caliceal diverticular calculi were taken one-stage percutaneous nephrolithotomy including dilating the diverticular neck, remaining the nephrostomy catheter and Double-J ureteral stents, and 1 case was transferred to open operation.Results The open and laparoscopic operations were performed successfully. One case was cured by Double-J ureteral stenting after postoperative urinary leakage. One case was transferred to open operation for the failure of percutaneous puncturation. X-ray examination revealed that there were no remaining stones after the operation. All the patients were followed up for 6 to 24 months without calculi and infection recurrence. Conclusions Stones and infection are common that complications of renal caliceal diverticulum. Percutaneous nephrolithotomy, laparoscopy and other operations were effective and feasible treatment options for cases with complications of renal caliceal diverticulum. Exact diagnosis was very important for treatment of renal caliceal diverticulum before operation.