Prevalence of renal uric acid stones in the adult.
Trinchieri Alberto,Montanari Emanuele
The aim of this study was to estimate uric acid renal stone prevalence rates of adults in different countries of the world. PubMed was searched for papers dealing with "urinary calculi and prevalence or composition" for the period from January 1996 to June 2016. Alternative searches were made to collect further information on specific topics. The prevalence rate of uric acid stones was computed by the general renal stone prevalence rate and the frequency of uric acid stones in each country. After the initial search, 2180 papers were extracted. Out of them, 79 papers were selected after the reading of the titles and of the abstracts. For ten countries, papers relating to both the renal stone prevalence in the general population and the frequency of uric stones were available. Additional search produced 13 papers that completed information on 11 more countries in 5 continents. Estimated prevalence rate of uric acid stones was >0.75% in Thailand, Pakistan, Saudi Arabia, Iran, South Africa (white population), United States and Australia; ranged 0.50-0.75% in Turkey, Israel, Italy, India (Southern), Spain, Taiwan, Germany, Brazil; and <0.50% in Tunisia, China, Korea, Japan, Caribe, South Africa (blacks), India (Northern). Climate and diet are major determinants of uric acid stone formation. A hot and dry climate increases fluid losses reducing urinary volume and urinary pH. A diet rich in meat protein causes low urinary pH and increased uric acid excretion. On the other hand, uric acid stone formation is frequently associated with obesity, metabolic syndrome and diabetes type 2 that are linked to dietary energy excess mainly from carbohydrate and saturated fat and also present with low urine pH values. An epidemic of uric acid stone formation could be if current nutritional trends will be maintained both in developed countries and in developing countries and the areas of greater climatic risk for the formation of uric acid stones will enlarge as result of the "global warming".
Evaluation of Deceased Kidney Donors for Renal Stone Disease: Is Computed Tomography Needed?
Tonyali Senol,Aydin Ahmet M
Objective:To investigate the clinical consequences of neglected risk of urolithiasis in deceased kidney donors in routine clinical practice, this study focused on different management options for transplanted allograft stones, and tried to find new solutions for more accurate detection of urolithiasis in deceased kidney donors prior to renal transplantation. Methods and Results:The overall prevalence of stone disease in endemic countries is between 7 and 29%. Because of the increased risk for stone disease in epidemic countries, screening renal grafts from deceased donors necessitates more sensitive imaging tests. Despite well established procedures on preoperative living related renal donor evaluation, there is no consensus on a preoperative imaging tool in cadaveric renal donor evaluation. The most commonly used imaging modality in deceased renal donors is ultrasonography. The overall sensitivity and specificity of ultrasonography for kidney stones are 45 and 88%, respectively. Use of a computed tomography scan for renal diseases, especially for urinary stones is now almost a routine test in clinical practice. Its sensitivity for renal stones < 3 mm is 85%, whereas for renal stones > 3 mm it is 100%. Conclusion:The use of radiological modalities i.e. computed tomography with higher sensitivity in deceased donors prior to renal transplantation seems reasonable in urinary stone epidemic countries.
Flexible Ureterorenoscopy Management of Calyceal Diverticular Calculi.
Yang Houmeng,Yao Xuping,Tang Chunbo,Shan Yuxi,Weng Guobin
OBJECTIVE:To introduce flexible ureterorenoscopy with holmium laser lithotripsy in the management of symptomatic caliceal diverticular calculi. MATERIALS AND METHODS:The records of 26 patients who underwent flexible ureterorenoscopy and lithotripsy with holmium laser to manage symptomatic caliceal diverticular calculi from January 2012 to June 2016 were retrospectively reviewed. RESULT:Flexible ureterorenoscopy lithotripsy was successfully placed in all 26 patients. Twenty-two cases accepted lithotripsy at the same time, and the success rate was 84.6%. The stone-free rate was 76.9%.The mean operative time was 48 ± 16 minutes. The mean hospital stay was 4.8 ± 1.6 days. There was no evidence of stone regrowth or recurrence at a mean follow-up of 11.5 months. CONCLUSION:Flexible ureterorenoscopy with holmium laser lithotripsy is safe and effective, and it can be offered as a first line therapy for symptomatic caliceal diverticular calculi.
[Percutaneous treatment of calyceal diverticulum associated with lithiasis].
Garrido Abad Pablo,Fernández González Inmaculada,Coloma Del Peso Almudena,Herranz Fernández Luis Miguel,Jiménez Gálvez Milagros,Fernández Arjona Manuel,Bocardo Fajardo Gloria,Herrero Torres Lorenzo,Pereira Sanz Ignacio
Archivos espanoles de urologia
OBJECTIVES:To report the case of a 47-years-old woman with several small stones located inside a calyceal diverticulum of the right kidney and to highlight the importance of minimally invasive endourological treatment in these cases. METHODS:Owing to the presence of diverticular calculi and clinical symptoms of recurrent infection, we decided to perform percutaneous nephrolithotomy (PNL). After Holmium-YAG laser calculi fragmentation and removal of all stone material, we fulgurated the diverticular lining and infundibulum with a resectoscope and a rollerball electrode. RESULTS:The patient is free of symptoms after 6 months follow-up. The disappearance of the calculi and diverticulum is confirmed with excretory urogram. CONCLUSIONS:Endourological approach for diverticular calculi, such as percutaneous nephrolithotomy (PNL), is a minimally invasive treatment with excellent results and low morbidity. Using this procedure we are able to perform stone removal and cavity fulguration. According to this, we think that endourological techniques, and specially PNL could be the first option for treatment in selected cases of this pathology.
Transitional cell carcinoma within a calyceal diverticulum associated with stone disease.
Zuckerman Jack M,Passman Corey,Assimos Dean G
Reviews in urology
We report a case of transitional cell carcinoma (TCC) discovered within a calyceal diverticulum at the time of percutaneous nephrolithotomy. The stones and tumor were endoscopically removed and the diverticular cavity fulgurated. Pathologic analysis demonstrated low-grade TCC. A subsequent laparoscopic radical nephroureterectomy was performed and high-grade TCC invading the parenchyma was found. This case demonstrates the potential for TCC to develop in stone-containing calyceal diverticula and also the potential for coexistence of different grades of TCC within the involved renal unit.
Calyceal diverticulum - a mimic of different pathologies on multiple imaging modalities.
Mullett Rebecca,Belfield Jane C,Vinjamuri Sobhan
Journal of radiology case reports
Calyceal diverticula are outpouchings of a renal calyx. Often found incidentally on radiological imaging, they are generally benign and usually asymptomatic, although complications include infection and stone formation. More importantly, calyceal diverticula may mimic other potentially more serious pathology on imaging, such as renal tumour or abscess on ultrasound or computed tomography and even rib metastasis on bone scintigraphy. We present a case of a patient with a calyceal diverticulum found incidentally on imaging, in which the diverticulum is demonstrated on ultrasound, computed tomography, intravenous urogram and bone scintigraphy, and discuss the potential differential diagnoses that need to be excluded in this condition.
Computed tomography urography for diagnosis of calyceal diverticulum complicated by urolithiasis: the accuracy and the effect of abdominal compression and prolongation of acquisition delay.
Lin Ningshu,Xie Liping,Zhang Peng,Min Yin,Yang Yuanqing,Wang Yongtao,Xia Ming
OBJECTIVE:To evaluate the accuracy of computed tomography urography (CTU) in the detection of caliceal diverticulum (CD) complicated with urolithiasis and the effect of compression and prolongation of acquisition delay. MATERIALS AND METHODS:All data were collected from a previous research between 2002 and 2011 at 3 hospitals. A total of 182 patients with evidence of renal parenchymal cystic lesion with calcific density were evaluated by CTU. Excretory phase imaging was acquired at 10 minutes and 60 minutes for each patient. Eighty-three patients received abdominal compression intervention during 10-minutes delay. RESULTS:CDs with stones were finally diagnosed in 41 patients (22.5%). Opacification within an apparent cyst was found in 31 patients (75.6%) when excretory phase images were acquired at 10 minutes and 38 patients (92.7%) at 60 minutes. The sensitivity and accuracy were significantly better with 60-minutes delay than with 10-minutes delay (92.7% vs 75.6%, P = .016 and 97.8% vs 94.0%, P = .016, respectively). The diagnostic results of compression group had significantly higher sensitivity and accuracy than that of the noncompression group (94.4% vs 60.9%, P = .025 and 98.8% vs 90.9%, P = .023, respectively). CONCLUSION:It is important to distinguish CD from other diseases such as complex cyst when diagnosing a renal parenchymal cystic lesion with wall calcification. CTU has high sensitivity and accuracy in the detection of CD. Abdominal compression and longer imaging delay can significantly improve the diagnostic effect of CTU.
Retrograde intrarenal surgery (RIRS) in the treatment of calyceal diverticulum with lithiasis.
Palmero Jose Luis,Miralles Jaume,Garau Carmen,Nuño de la Rosa Ines,Amoros Araceli,Benedicto Antonio
Archivos espanoles de urologia
OBJECTIVES:To evaluate the result of retrograde intrarenal surgery (RIRS) assisted by flexible ureterorenoscopy (FURS) and Holmium laser in the treatment of lithiasis within calyceal diverticula as a minimally invasive therapeutic option. METHODS:We retrospectively evaluated 11 cases of symptomatic lithiasis within calyceal diverticula treated between January 2010 and December 2011. We defined treatment success as absence of residual stones and absence/disappearance of symptomatology over the course of follow-up. We describe the RIRS technique and maneuvers for locating the diverticulum, opening the neck, and fragmenting intradiverticular lithiasis. RESULTS:The most frequently experienced symptom was flank pain (72.7%). The size of the lithiasis treated ranged from 7-20 mm. The overall success rate of RIRS was approximately 73% (absence of lithiasis and disappearance of symptoms) with an average follow-up of 13.3 months. Three cases were not solved by RIRS (2 due to unsuccessful location of the neck, 1 due to persistence of lithiasis and symptoms) . Cases of unsuccessful location were treated with laparoscopic surgery. CONCLUSION:RIRS assisted by FURS and Holmium laser is an effective and minimally invasive procedure for the treatment of lithiasis in the interior of the calyceal diverticulum. This treatment's efficacy improves upon the results from ESWL (extracorporeal shock wave lithotripsy( and equals that of the percutaneous method, exhibiting a lower rate of complications.
Calyceal diverticulum: a benign imitator of serious pathology.
Pareek Anuj,Laursen Christian B,Graumann Ole
BMJ case reports
A 72-year-old man with lung cancer underwent positron emission tomography CT (PET-CT) as a part of cancer staging. As an incidental finding, the PET-CT revealed a renal mass with metabolic and morphological characteristics of a malignant tumour. A diagnostic CT scan revealed a Bosniak III renal cyst, and malignancy could not be excluded. For correct Bosniak classification, a multiphasic contrast-enhanced CT was performed and the renal mass was finally diagnosed as a calyceal diverticulum. This case report summarises how calyceal diverticula may mimic serious pathology, leading to diagnostic difficulties.
Calyceal diverticulum mimicking simple parapelvic cyst: a case report.
Peng Yong-han,Zhang Wei,Gao Xiao-feng,Sun Ying-hao
Chinese medical sciences journal = Chung-kuo i hsueh k'o hsueh tsa chih
Calyceal diverticulum is a cystic intrarenal cavity lined by nonsecretory transitional epithelium that communicates with the collecting system via a narrow isthmus or infundibulum. It is a rare anatomic anomaly with an incidence of 0.2% to 0.6% in the patients undergoing renal imaging.1 Single imaging modality usually cannot differentiate calyceal diverticulum from other cystic renal diseases.2 Here, we report a 60-year-old male who was reliably diagnosed with calyceal diverticulum by retrograde urography combined with non-enhanced computed tomography (CT) and magnetic resonance urography (MRU).
Invasive urothelial carcinoma within a calyceal diverticulum associated with renal stones: A case report.
Nakano Taito,Kitagawa Yasuhide,Izumi Kouji,Ikeda Hiroko,Namiki Mikio
Calyceal diverticula are rare outpouchings of the upper collecting system lying within the renal parenchyma. These often contain stones, however, carcinoma within a calyceal diverticulum is uncommon. The present study reports a case of invasive urothelial carcinoma within a calyceal diverticulum associated with renal stones. A 70-year-old male with a left renal mass identified by abdominal computed tomography was referred to the Department of Urology, Kanazawa University Hospital. Pre-operative diagnosis was difficult owing to an atypical imaging finding of a hypovascular renal mass with calcification. A laparoscopic nephroureterectomy was performed, and the surgical specimens showed invasive high-grade urothelial carcinoma within a calyceal diverticulum, and the calcifications were renal stones consisting of 97% calcium oxalate. Urothelial carcinoma in calyceal diverticula is a rare condition, however, a pre-operative definite diagnosis is difficult and a high potential for invasion of the renal parenchyma is suspected in this disease.
Challenges in the diagnosis of calyceal diverticulum: A report of two cases and review of the literature.
Zhang Zejian,Zhang Yixiang,Wang Xisheng,Chen Dong,Peng Naixiong,Chen Jicheng,Bleyer Anthony,Wang Qinjun,Liu Yunfei,Zhang Yuanyuan
Journal of X-ray science and technology
BACKGROUND:Calyceal diverticula outpouchings that occur rarely in the upper collecting system of the kidney and is often difficult to detect. In this study, we present two cases of calyceal diverticula and discuss their clinical characteristics and radiologic features. PATIENTS AND METHODS:In the presented two cases, we applied several imaging examinations, including delayed intravenous pyelography, retrograde pyelography and axial computerized tomographic (CT) scanning of the kidneys with and without contrast. Serum creatinine levels in fluid withdrawn from the diverticula were found to be significantly higher than the simultaneous serum creatinine levels. Intravenous injection of methylene blue through a ureteral catheter was also aided in the diagnosis. Calyceal diverticulum neck dilatation was performed through a percutaneous nephroscope.ResultsThe two cases were diagnosed preoperatively and the operation was successful performed. The nephrostomy tube was removed seven days after surgery without complications. CT scans of the kidney after six months showed that the size of the calyceal diverticulum of two patients were considerably smaller than pre-surgery. There were no reports of pain in the lumbar region or other discomfort. COMMENTS:Diagnosis of calyceal diverticulum mainly depend on a variety of imaging examinations, including the delayed intravenous pyelography, retrograde pyelography, and kidney CT plain scan plus enhanced scan. If the patient cannot be diagnosed by above methods, cyst fluid can be aspirated percutaneously to measure the preoperative creatinine level. If it is significantly higher than the serum creatinine level, the cyst fluid is considered urine, which can assist in the diagnosis of calyceal diverticulum. A ureteral catheter should also be inserted before operation namely, intravenous injection of methylene blue through a ureteral catheter is helpful for diagnosis. The choice of surgical treatment is based on the size and location of calyceal diverticulum and clinical manifestations.
[Giant stone complicating calyceal diverticulum].
Touzani Mohammed Alae,Ziouziou Imad
The Pan African medical journal
Calyceal diverticulum is acystic cavity in the renal parenchyma, communicating with the collecting system via an infundibulum. In more than 40% of cases it is associated with a stone and in most cases appears as milk of calcium forming a fluid level or multiple small stones. We here report the case of an 82-year old patient with no previous history, presenting with mild and intermittent right flank pain lasting for 8 years. Clinical examination was normal. The patient first underwent X-ray of urinary tree without preparation showing a density of calcium projecting into the upper pole of the right kidney (A). The patient then underwent uroscanner showing giant stone measuring 28mm within a caliciel diverticulum of the upper pole directly communicating with the renal pelvis (B). No associated urinary tract infection or haematuria were detected. Given patient's age and that he was paucisymptomatic and uninfected, therapeutic abstention and monitoring were indicated. In accordance with the recommendations of the experts, only symptomatic intradiverticular stones must be treated. First, extracorporeal shockwave lithotripsy (ESWL) allows improvement to the symptoms in 1 patient out of 2 and no stone fragmentation in 1 patient out of 4. In second intention, flexible uretero-renoscopy should be performed. Percutaneous nephrolithotomy can be performed if the stone is located in the lower pole (rare). Finally, in case of failure, laparoscopic treatment or open surgery may be proposed.
The effects of acute and chronic JJ stent placement on upper urinary tract motility and calculus transit.
Ryan P C,Lennon G M,McLean P A,Fitzpatrick J M
British journal of urology
OBJECTIVE:To determine the pathophysiological changes in upper urinary tract motility and calculus transit which may occur following JJ stent insertion. MATERIALS AND METHODS:The acute and chronic effects of JJ stent placement were studied in 24 canine renal units. Intrarenal and intraureteric pressures and motility were measured, in addition to transit times for complete passage of synthetic calculi from the upper ureter into the bladder. RESULTS:Acute effects included raised renal intrapelvic pressure, reduced pelvic and ureteric motility and delayed calculus transit time. Prolonged JJ stent placement was associated with return of intrapelvic pressure to normal but persistent changes in both renal and ureteric motility and also calculus transit time. CONCLUSION:In situ JJ stents impair upper urinary tract motility and experimental calculus transit time and may delay passage of ureteric calculi or calculus fragments following extracorporeal shock wave lithotripsy.
Calyceal diverticula: a comprehensive review.
Waingankar Nikhil,Hayek Samih,Smith Arthur D,Okeke Zeph
Reviews in urology
Calyceal diverticula are rare outpouchings of the upper collecting system that likely have a congenital origin. Stones can be found in up to 50% of calyceal diverticula, although, over the combined reported series, 96% of patients presented with stones. Diagnosis is best made by intravenous urography or computed tomography urogram. Shock wave lithotripsy (SWL) is an option for first-line therapy in patients with stone-bearing diverticula that have radiologically patent necks in mid- to upper-pole diverticula and small stone burdens. Stone-free rates are the lowest with SWL, although patients report being asymptomatic following therapy in up to 75% of cases with extended follow-up. Ureteroscopy (URS) is best suited for management of anteriorly located mid- to upperpole diverticular stones. Drawbacks to URS include difficulty in identifying the ostium and low rate of obliteration. Percutaneous management is best used in posteriorly located mid- to lower-pole stones, and offers the ability to directly ablate the diverticulum. Percutaneous nephrolithotomy remains effective in the management of upperpole diverticula, but carries the risk of pulmonary complications unless subcostal access strategies such as triangulation or renal displacement are used. Laparoscopic surgery provides definitive management, but should be reserved for cases with large stones in anteriorly located diverticula with thin overlying parenchyma, and cases that are refractory to other treatment. This article reviews the current theories on the pathogenesis of calyceal diverticula. The current classification is examined in addition to the current diagnostic methods. Here we summarize an extensive review of the literature on the outcomes of the different treatment approaches.
The imaging appearances of calyceal diverticula complicated by uroliathasis.
Stunell H,McNeill G,Browne R F J,Grainger R,Torreggiani W C
The British journal of radiology
The presence of diverticula arising from the calyceal system is a relatively uncommon urological problem, occurring with an incidence of 2.1-4.5 per 1000 intravenous urogram (IVU) examinations. While the incidence of calyceal diverticula is low, the frequency of stone formation within them is high. We describe the aetiology and clinical presentation and describe the role of imaging with ultrasound, intravenous and retrograde pyelography and CT in diagnosis and planning treatment. We also describe the potential of fluid-sensitive magnetic resonance imaging techniques as a radiation-free alternative to the use of more conventional modalities, such as intravenous urography and retrograde pyelography, in delineating the anatomy of calyceal diverticula before surgical and radiological intervention especially in young patients and pregnant women.
Management of the bladder and calyceal diverticulum: options in the age of minimally invasive surgery.
Silay Mesrur Selcuk,Koh Chester J
The Urologic clinics of North America
Bladder and calyceal diverticula are rare clinical entities in the pediatric population. Most of these diverticula are asymptomatic, incidentally detected, and may not require surgical intervention. However, if surgery is indicated, there are minimally invasive treatment options available that have success rates comparable with those of traditional open surgery. In addition, they offer several advantages including reduced morbidity, decreased hospital length of stay, improved cosmesis, and reduced pain medication requirements. In this review, the minimally invasive surgical techniques in the management of bladder and calyceal diverticula are discussed.
Rupture of a Calyceal Diverticulum Secondary to Ureteroscopy: A Rare Complication.
Yamasaki Tomoya,Yoshioka Takashi,Imoto Masaya,Aoki Hiroshi,Fujio Kei,Uehara Shinya,Otsuki Hideo
Case reports in urology
We present a case of a 45-year-old female who experienced rupture of a right calyceal diverticulum caused by ureteroscopy. Fifteen hours after the operation, she had severe right flank pain and a high fever (38.9°C). Computed tomography revealed perinephric extravasation of urine and bleeding inside the diverticulum. We diagnosed rupture of a calyceal diverticulum; therefore, we continued antibiotic administration and pain relief medication. She became afebrile on postoperative day 4 and was discharged from the hospital on postoperative day 7. Owing to renal cortex thinning in the diverticula, ureteroscopy is associated with a risk of rupture of calyceal diverticula.
Squamous Cell Carcinoma in a Calyceal Diverticulum Detected by Percutaneous Nephroscopic Biopsy.
Mitome Taku,Tabei Tadashi,Tsuura Yukio,Kobayashi Kazuki
Case reports in oncological medicine
A 73-year-old woman was referred to our department with a complaint of asymptomatic gross hematuria. Dynamic computed tomography revealed a complicated (Bosniak type IIF) cyst in the upper pole of her right kidney, which was diagnosed as a calyceal diverticulum. The diagnosis was confirmed by ureteroscopy. The diverticulum was filled with a soft protein matrix that was difficult to completely remove from the inner surface of the calyceal diverticulum. Endoscopy combined with intrarenal surgery (ECIRS) was performed to completely remove the matrix. Percutaneous nephroscopy further revealed papillary lesions on the surface of the diverticulum, confirmed as squamous cell carcinoma on pathological assessment. A laparoscopic right radical nephroureterectomy was performed, with curative intent. Pathological assessment confirmed a high-grade squamous cell carcinoma with renal parenchymal invasion (pT3). Although carcinomas in a calyceal diverticulum are highly uncommon, when present, these tend to be high-grade neoplasms that deeply invade the parenchymal wall. As the effective management of these lesions is difficult, early-stage diagnosis is required for curative treatment. We report the case of squamous cell carcinoma in a calyceal diverticulum that was difficult to diagnose on preoperative computed tomography, urinal cytology examination, and ureteroscopy but was found during ECIRS.
Management of calyceal diverticular calculi: a comparison of percutaneous nephrolithotomy and flexible ureterorenoscopy.
Bas Okan,Ozyuvali Ekrem,Aydogmus Yasin,Sener Nevzat Can,Dede Onur,Ozgun Serhat,Hizli Fatih,Senocak Cagri,Bozkurt Omer Faruk,Basar Halil,Imamoglu Abdurrahim
To compare the outcomes in patients who have been treated with flexible ureterorenoscopy (f-URS) and percutaneous nephrolithotomy (PNL) in managing stone-bearing caliceal diverticula. Between April 2007 and October 2013, we performed a retrospective analysis of 54 evaluable patients (28 women and 26 men) with symptomatic stone-bearing caliceal diverticula, who underwent PNL (n = 29) or F-URS (n = 25) in four referral hospitals in Turkey. The groups were compared with respect to demographics, stone location/size, success rate, stone-free status, symptom-free status, complication rates, and hospital stay. The average stone burden preoperatively was significantly larger in patients who were treated with PNL, with the average size for f-URS being 154 ± 77 mm(2) and that for PNL being 211 ± 97 mm(2) (p = 0.023). Symptom-free rates, success rates, stone-free rates and clinically insignificant residual fragments were similar between the groups (p = 0.880 vs. p = 0.537 vs. p = 0.539, and p = 0.877, respectively). There was no statistical difference between the groups for minor complications (p = 0.521) but no major complication (Clavien III-V) occured in the f-URS group; although there were three major complications (10.3 %) (Clavien III) in the PNL group (p < 0.001). Hospitalization time per patient was 1.04 ± 0.20 days in the f-URS group, while it was 3.86 ± 1.94 days in the PNL group (p < 0.001). Even though this study clearly shows that both techniques have high overall success and symptom-free rates with similar complication rates for stone-bearing calyceal diverticulum, major complication rates may suggest consideration of the invasiveness of PNL. The f-URS procedure is advantageous with respect to a shorter hospital stay and absence of major complications. Therefore, it should be emphasized that the location of the stone and diverticula is an important factor for the selection of the procedure.
[Management of calyceal diverticular calculi with stenotic infundibulum by flexible ureteroscopic holmium laser infundibulectomy and lithotripsy].
Liu Ke,Xiao Chun-lei,Liu Yu-qing,Hao Yi-chang,Zhang Shu-dong,Tian Yu,Ma Lu-lin
Beijing da xue xue bao. Yi xue ban = Journal of Peking University. Health sciences
OBJECTIVE:To evaluate the efficacy and safety of flexible ureteroscopic holmium laser lithotripsy in treating calyceal diverticular calculi with stenotic infundibulum and to present our initial experience. METHODS:From Nov. 2012 to Nov. 2014, 10 patients with stone-bearing calyceal diverticulum and stenotic infundibulum underwent flexible ureteroscopic holmium laser lithotripsy in our hospital, including 3 female patients and 7 male patients with an average age of 36.9 years (range: 20 to 62 years). There were 6 patients with right side while 4 patients with left side calyceal diverticular calculi. The average cumulative stone size was (1.33±0.43) cm. Five patients underwent extracorporeal shock wave lithotripsy (ESWL) before hospital admission but no stone was discharged. All the patients received intravenous urography (IVU) and CT-urography (CTU) preoperatively and underwent double-J stents placement 2 weeks before operations. A digital-fiber flexible ureteroscopy and 200 μm holmium laser fiber were used for treatment. Surgeries began with routine flexible ureteroscopy and methylene blue injection was used to identify the small ostium of infundibulum. Then infundibulectomy followed by lithotripsy was performed. All the patients receive double-J stents placement and traditional Chinese medicine for 1 to 3 months after operations. The stone clearance was estimated by kidney ureter bladder (KUB) within 3 months' follow up. RESULTS:The locations of calyceal diverticulum were upper pole in 7 patients, and interpolar regions in 4 patients. The average operation time was (123.7±59.6) min, and the average estimated blood loss was (29.3±32.1) mL. Successful flexible ureteroscopic holmium laser infundibulectomies were performed in all the 10 patients. Success rate was 100%. The stone clearance rates for 1 and 3 months after surgery were 50.0% and 80.0%, respectively, which were observed by KUB follow-up. Two patients had serious post-operative fever (>38.0 °C) in coexistence with chills. The mobidity of urosepsis was 20.0%. No major complications were identified. CONCLUSION:In selected patients, calyceal diverticular calculi with stenotic infundibulum can be treated safely and efficiently with flexible ureteroscopic homium laser lithotripsy. CTU and IVU should be completed preoperatively for calyceal diverticulum location and technique difficulty prediction. Retrograde methylene blue injection can be used to identify the ostium during surgery. And prolonged post-operation stone clearance was observed.
Percutaneous Management of Stone Containing Calyceal Diverticula: Associated Factors and Outcomes.
Parkhomenko Egor,Tran Timothy,Thai Julie,Blum Kyle,Gupta Mantu
The Journal of urology
PURPOSE:We evaluated the outcomes of percutaneous treatment and metabolic evaluation of calyceal diverticula with associated stones. MATERIALS AND METHODS:We retrospectively identified 51 patients with a calyceal diverticulum in our prospectively maintained percutaneous nephrolithotomy database. Patients with complete data were separated into 14 with stones isolated to the diverticulum and 15 with renal stones in and outside the diverticulum. A total of 571 patients with renal stones but no diverticulum were used for comparison. Statistical differences were assessed using the chi-square test and the t-test. RESULTS:Patients with stones isolated to the diverticulum were younger (44 vs 54 years, p = 0.024), had a lower body mass index (23.2 vs 27 kg/m, p = 0.032) and were more often female (71% vs 44%, p = 0.046) compared to patients with renal stones but no diverticulum. Calyceal diverticula were anterior in 19 of 29 cases and in the upper pole in 15. Average diverticular size was 2.5 cm with a 1.5 cm stone burden. Percutaneous treatment was successful in 96% of patients with a 4% complication rate. The diverticular neck was dilated in 22 of 51 patients (43%). During 5-year followup in the 51 patients there was 1 stone recurrence, which was managed by ureteroscopy, while 46 and 5 patients showed complete absence and reduction of the diverticulum, respectively. Of the calyceal diverticular stones 82% contained calcium phosphate compared to only 33% in patients with renal stones but no diverticulum. All patients with a diverticulum had at least 1 metabolic derangement. CONCLUSIONS:Percutaneous treatment of calyceal diverticula is safe and effective regardless of size or location, including anterior diverticula. Infundibular neck dilation does not appear to be necessary. There are metabolic abnormalities in a significant proportion of patients with a calyceal diverticulum.
Pediatric calyceal diverticulum treatment: An experience with endoscopic and laparoscopic approaches.
Long C J,Weiss D A,Kolon T F,Srinivasan A K,Shukla A R
Journal of pediatric urology
INTRODUCTION:The symptomatic calyceal diverticulum is a rare event in the pediatric population. In adults, surgical options include ureteroscopy, percutaneous ablation, and laparoscopic decortication but there is a lack of experience in the literature with these techniques. OBJECTIVE:We present our experience with both the ureteroscopic and laparoscopic approach to treating the pediatric calyceal diverticulum. STUDY DESIGN:We performed a retrospective case series looking at patients who underwent treatment for calyceal diverticulum at our institution from January 2009 to May 2014. We reviewed patient demographics, indications for intervention, radiographic appearance, type of intervention, and perioperative outcomes. Ureteroscopic approach included dilation of infundibulum and ablation of diverticular cavity. Laparoscopic approach included ablation of the diverticulum with argon diathermy with or without surgical closure of the ostium. RESULTS:There were 13 patients who underwent 15 procedures for symptomatic calyceal diverticulum (Table). Median age was 11 years. Indications for intervention were: pain and increasing size of diverticulum (8/15, 55%), hematuria (3/15, 20%), UTI (3/15, 20%), and calculi (1/15, 5%). 11/15 (73%) procedures were managed endoscopically and 4/15 (27%) were managed with laparoscopic decortication. Ureteral stent was left in all patients for a mean duration of 51 days (15-120 days). Follow up imaging at median of 2.1 years (0.5-4 years) revealed an initial success rate of 85% (11/13 patients). Two patients failed initial intervention (persistent pain/increasing size) necessitating successful secondary minimally invasive procedures. There were 2 (13%) complications: a perinephric hematoma post endoscopic ablation which resolved spontaneously and a deep venous thrombosis in a patient with a coagulation disorder in the laparoscopic group. DISCUSSION:Limitations of our study include its retrospective design, lack of standardization of the treatment approach amongst the four treating surgeons, and the small number of patients requiring intervention for this relatively rare diagnosis. Our study is the largest to date in the pediatric population and is the first to report outcomes with ureteroscopic management of the calyceal diverticulum. CONCLUSIONS:We found that the pediatric calyceal diverticulum can be successfully treated in a minimally invasive manner. The endoscopic approach should be the first line option for patients with small, endophytic diverticula, particularly those located in the upper and mid pole. The laparoscopic approach is more invasive but should be considered for large diverticula that are exophytic with thin overlying parenchyma.
Retrospective Analysis of Ultrasound-guided Flexible Ureteroscopy in the Management of Calyceal Diverticular Calculi.
Zhang Ji-Qing,Wang Yong,Zhang Jun-Hui,Zhang Xiao-Dong,Xing Nian-Zeng
Chinese medical journal
BACKGROUND:Percutaneous nephrolithotomy (PCNL) is the most widely recommended treatment for calyceal diverticular calculi, providing excellent stone-free results. However, its invasiveness is not negligible considering its major complication rates. Flexible ureteroscopy (FURS) is currently used to treat calyceal diverticula. However, the greatest drawback of FURS is locating the diverticulum since its neck is narrow and concealed. In such a case, the FURS procedure must be converted to PCNL. The aim of this study was to evaluate ultrasound-guided flexible ureteroscopy (UFURS) identifying diverticulum and the management of calyceal diverticular calculi. METHODS:A retrospective analysis was conducted on 24 patients who had calyceal diverticular calculi. In all 12 patients in the UFURS group, direct FURS failed to find evidence of calyceal diverticula but were confirmed with imaging. The other 12 patients in the PCNL group received PCNL plus fulguration of the diverticular walls. RESULTS:Puncture of calyceal diverticulum was successful in all 12 UFURS patients. Two patients in this group had postoperative residual calculi and two patients developed fever. In the PCNL group, percutaneous renal access and lithotomy were successful in all 12 patients. One patient in this group had residual calculi, one had perirenal hematoma, and two patients developed fever. No significant difference was found in the operating time (UFURS vs. PCNL, 91.8 ± 24.2 vs. 86.3 ± 18.7 min), stone-free rate (UFURS vs. PCNL, 9/12 vs. 10/12), and rate of successful lithotripsy (UFURS vs. PCNL, 10/12 vs. 11/12) between the two groups (all P> 0.05). Postoperative pain scores in the FURS group were significantly lower than that in the PCNL group (2.7 ± 1.2 vs. 6.2 ± 1.5, P< 0.05). Hospital stay in the UFURS group was significantly shorter than that in the PCNL group (3.4 ± 0.8 vs. 5.4 ± 1.0 days, P< 0.05). All patients were symptom-free following surgery (UFURS vs. PCNL, 10/10 vs. 12/12). CONCLUSION:Ultrasound-guided puncture facilitates identification of calyceal diverticula during FURS and improves the success rate of FURS surgery.