Laparoscopic assisted transmesocolonic percutaneous nephrolithotripsy in ectopic iliac kidney.
Sohail N, Albodour A, Abdelrahman K.
Alkhor hospital Urology section, Hamad Medical Corporation. Qatar
Urology Case Reports (2016), pp. 48-50 DOI information: 10.1016/j.eucr.2016.04.005
We report a case of 15 years old female who presented with recurrent lower abdominal pain treated three times with ESWL previously. She was diagnosed as having right ectopic kidney with a 4 cm renal stone in renal pelvis and involving lower and mid calyx. She was treated successfully with laparoscopic assisted transmesocolonic percutaneous nephrolithotripsy. Procedure resulted in complete stone clearance without any perioperative or post-operative complication. Patient stayed in hospital for 72 hours with no drains or stents after day 5, post operatively.
Laparoscopy, Ectopic Kidney, percutaneous nephrolithotripsy, transmesocolonic, renal stones
Percutaneous nephrolithotomy was first introduced in 1976 (1). Since then it went through different phases of evolutions (2). Managing stones in ectopic kidney remains challenge. Open surgical procedures, SWL and retrograde endoscopic procedures can be an option but these procedures might have some limitations. Laparoscopic surgery is an alternative (3, 4).
We are presenting a case of renal calculi in ectopic kidney located in the iliac region treated successfully by laparoscopic assisted percutaneous nephrolithotripsy.
A 15 years old girl presented with recurrent abdominal pain, diagnosed with right renal calculi and underwent three sessions of ESWL. CT abdomen showed malrotated right kidney located at L4-5 region with multiple stones in renal pelvis and lower and mid calyx (Figure-1). Laparoscopic guided percutaneous nephrolihtotripsy was planned. In modified Valdivia position, cystoscopy was performed and Retrograde ureteric catheter was inserted. Through umbilical incision 12mm trocar was inserted. Secondary trocars introduced at both iliac fossa 10mm at right and 5mm at left side. Minimal dissection of the mesocolon performed to expose kidney parenchyma without mobilizing large bowel. Contrast used retrogradely to opacify renal system under fluoroscopy. Through the port in right side, fluoroscopy guidance puncture of renal calyx performed (Figure 2). Guide wire insertion and tract dilatation were monitored by laparoscopic video and fluoroscopy. The right laparoscopic port removed and replaced by amplantz dilator and Sheath (Figure 3). A 26French nephroscope connected to separate video monitor used. Stone fragmented using ultrasonic lithoclast. Flexible scope and dormia used for further clearance. Retrograde insertion of JJstent with string performed. A drain was placed and was removed on day 1. Patient discharged home on day 2. JJ stent removed in clinic on day 5.
According to Campbell’s urology 11th edition, Ectopic kidney can be found in pelvic, iliac, abdominal, thoracic, and contralateral or crossed position. Its incidence varies from 1 in 500 to 1 in 1200, with an average occurrence of about 1 in 900 (5).
Renal stones in ectopic kidney are difficult to treat. ESWL, flexible RIRS or PCNL and open surgery have limitations. Laparoscopic assisted PCNL is a reasonable option. 1st laparoscopic assisted PCNL was reported by Esghi and colleagues in 1985 (3).
Later Alesse R and associates (6) and Mousavi-Bahar SH and associates (7) also performed similar procedure. Goel R and his colleagues operated on two cases with stone in ectopic kidney. One of their patients had same location of kidney as of our case. They removed stones successfully by entering kidney parenchyma through transmesocolonic approach with minimal dissection to the bowel (8).
Our patient underwent a successful surgery, complete stone clearance (Figure 4), shorter hospital stay, smooth recovery with no further procedure for removing JJ stent.
Laparoscopic assisted transmesocolonic percutaneous nephrolithotrispy can be considered safe and effective treatment option in cases of ectopic kidney with stone disease. We gave special consideration to transmesocolonic approach for calyceal. It needs minimal dissection and mobilization of the mesocolon and colon avoiding bowel related complications.
1). Fernstrom I, Johansson B. Percutaneous pyelolithotomy. A new extraction technique. Scand J Urol Nephrol 1976; 10: 257-259
2). Cracco CM, Scoffone CM, Scarpa RM. New developments in percutaneous techniques for simple and complex renal stones. Curr Opinion Urol. 2011; 21(2): 154-60
3). Eshghi AM, Roth JS, Smith AD. Percutaneous transperitoneal approachto a pelvic kidney for endourological removal of staghorn calculus. J.Urol. 1985; 134: 525–7.
4). Holman E, Toth C. Laparoscopically assisted percutaneoustransperitoneal nephrolithotomy in pelvic dystopic kidneys: Experience in 15 successful cases. J. Laparoendosc. Adv. Surg. Tech. A 1998; 8:431–5.
5). Shapiro E, Telegrafi S, editors. Anomalies of upper urinary tract. Philadelphia: Elsevier; c2016. 2975 p. (Mc Dougal WS, Wein AJ, Kavoussi LR, Partin AW, Peters CA. Cambell-Walsh Urology 11th rev. ed).
6). Alesse R. Dos Santos, Deloson C.RochaFilho, Lluis C.F.Tajra. Management of lithiasis in pelvic kidney through laparoscopic guided percutaneous transperitoneal nephrolithotripsy. Int Braz J Urol. 2004; 30(1): 32-34
7). Mousavi-Bahar SH, Amir-Zaqar MA, Gholamrezaie HR. Laparoscopic assisted percutaneous nephrolithotomy in ectopic pelvic kidneys. Int J Urol. 2008; 15(3): 276-8
8). Goel R, Yadav R, Gupta NP, Aron M. Laparoscopic Assisted Percutaneous Nephrolithotomy (PCNL) in Ectopic Kidneys: Two Different Techniques. Int Urol Nephrol. 2006, Volume 38(1): 75-78