Category: Stones: PCNL
Introduction & Objective :
Nepholitihiasis in a transplanted kidney is an uncommon complication, with an incidence from 0.2 to 1.7%.
Management should look for a complete resolution with morbidity as low as possible.
We describe the tecnique in case of kidney transplantation and nephrolithiasis treated with mini percutaneous (mini-PCNL), and impossible retrograde access.
A 35 years old male with a transplanted and urolithiasis was admitted to our department for mini-PCNL. The kidney was trasplanted in the right iliac fossa, and the urether was anastomosed following Lich-Gregoir Technique.
Images control showed the presence of 3 lithiasis. The biggest one located in renal pelvis is about 12x8mm long asociated with obstructive uropathy, and 2 smaller stones in the upper caliceal group. There is no repercusion in renal function.
The mini-PCNL treatment was carried out in Supine Lithotomy Position and general anesthesia. Flexible Cystoscope revealed trasplanted kidney meatus is in the bladder dome. Fail attempt of retrograde catheterization. A pure ultrasound-guided punction was inserted in the upper caliceal group, to make easy the access to the urether. And anterograde pielography was performed. The guide wire was inserted into the pelvicaliceal system and dilatation was performed using a single metal dilator (15/16-Ch operating sheath Karl Storz).
Holmium:YAG laser lithotripsy using 365 µm laser fiber was performed and Stones fragments were removed with a 1.9 Fr nitinol basket. Endoscopic revision of the rest of the cavities, ureter and bladder was realized by Karl Storz digital flexible ureteroscope through renal access. Antegrade placement of a ureteral stent and nephrostomy were positioned in the renal pelvis. The postoperative course was uneventful. The nephrostomy was removed 48 hours after surgery and the ureteral catheter 3 weeks later.
The stone analyses showed that it was mixed from calcium oxalate and calcium phosphate. Three months after mini-PCNL kidney function parameters were normal, and the graft is stone free.
Ureterovesical anastomosis is usually located at the bladder apex, making ureteral intubation and entry in the ureter very difficult. The ultrasound-guided puncture of a transplanted kidney in the iliac fossa is a relatively simple procedure because the graft is situated just below the muscles of the anterior abdominal wall. Also, the distance from skin to kidney is small. The miniaturized percutaneous nephrolithotomy is an excellent choice that minimize the complications and renal repercussions from a conventional percutaneous surgery in patients where a good functional reserve is a must for the future survival.
Juan Francisco Sánchez García– Faculty urology, hospital Álvaro Cunqueiro, Santiago de Compostela, Galicia, Spain
Jorge Sánchez Ramos– Vigo, Galicia, Spain
Jose María Díaz Álvarez– Vigo, Galicia, Spain
Miguel Pérez Schoch– Vigo, Galicia, Spain
Rubén Montero Fabuena– Vigo, Galicia, Spain
Sheila Almúster Domínguez– Vigo, Galicia, Spain
María Elena López Díez– Vigo, Galicia, Spain
Manuel Carballo Quintá– Urology consultant, Complejo Hospitalario Universitario de Vigo, Vigo, Galicia, Spain
Jose Manuel Barros Rodríguez– Vigo, Galicia, Spain
Antonio Ojea Calvo– Vigo, Galicia, Spain
hospital Álvaro Cunqueiro
Santiago de Compostela, Galicia, Spain
Consultant Urologist Hospital Álvaro Cunqueiro de Vigo (Pontevedra). Galicia. Spain.
Complejo Hospitalario Universitario de Vigo
Vigo, Galicia, Spain