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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 1254-1257
Laparoscopic trans-peritoneal pyelolithotomy in a pelvic kidney


Department of Surgery, Government Medical College, Karan Nagar, Srinagar, India

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Date of Web Publication17-Nov-2012
 

   Abstract 

Urinary lithiasis is one of the most common and the oldest known afflictions of the urinary tract. The management of renal stones has undergone radical changes in recent years, the latest being the minimally invasive procedures like extra-corporeal shock wave lithotripsy and percutaneous nephrolithotomy, making the open surgical procedures relatively obsolete. However, there are situations where the above-mentioned minimally invasive procedures prove to be lacking in achieving the cure; laparoscopic pyelolithotomy caters to such group of patients, e.g. the presence of calculi in malrotated or malpositioned kidneys. Herein, we report a case of pelvic kidney with a large calculus managed by laparoscopic trans-peritoneal pyelolithotomy.

How to cite this article:
Ahangar S, Durrani AM, Qadri SJ, Patloo AM, Ganaie RG, Khan M. Laparoscopic trans-peritoneal pyelolithotomy in a pelvic kidney. Saudi J Kidney Dis Transpl 2012;23:1254-7

How to cite this URL:
Ahangar S, Durrani AM, Qadri SJ, Patloo AM, Ganaie RG, Khan M. Laparoscopic trans-peritoneal pyelolithotomy in a pelvic kidney. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Sep 30];23:1254-7. Available from: http://www.sjkdt.org/text.asp?2012/23/6/1254/103571

   Introduction Top


Laparoscopic urology has evolved rapidly over the last two decades. Although stone disease is one of the most common afflictions of modern society, it has been described since antiquity. In recent years, however, the site of stone formation has migrated from the lower to the upper urinary tract, and the disease once limited to men is increasingly gender blind.

Herein, we report a case of pelvic kidney with a large calculus managed by laparoscopic transperitoneal pyelolithotomy.


   Case Report Top


A 35-year-old female with no previous significant medical and/or surgical history presented with chief complaints of pain in the left lower quadrant of the abdomen for the last three months. The pain was deep, dull aching, constant type of pain and spreading toward the umbilicus. There was a history of recurrent episodes of urinary tract infections and few episodes of hematuria.

The patient was evaluated clinically and her investigations revealed the following: the hemogram, kidney function tests and serum electrolytes were normal. Urine examination was normal and urine culture was sterile. Plain X-ray of the abdomen revealed an elliptical, smooth, radio-opaque shadow in the lower abdomen in the midline [Figure 1]. Ultrasound scan of the abdomen showed normal right kidney, and the left kidney was located in the pelvis. Additionally, there was a large calculus measuring 3.7 mm × 1.2 mm in the left renal pelvis. Intravenous urography revealed normal excretion of contrast on both the sides, although it was slightly delayed on the left side.
Figure 1: Pre-operative X-ray of the abdomen showing a radioopaque shadow in the pelvis.

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It was confirmed that the left kidney was located in the pelvis and showed grade II hydronephrosis [Figure 2]. From the above data, an impression of ectopic left kidney with symptomatic nephrolithiasis was made and the patient was planned for laparoscopic trans-peritoneal pyelolithotomy. The stone was too big for extra-corporeal shock wave lithotripsy (ESWL) and its position was deemed too dangerous for percutaneous nephrolithotomy. Ureteroscopic removal of the stone was not feasible because the stone was too large for this procedure.
Figure 2: Pre-operative intravenous urogram showing a radioopaque shadow in the pelvis and a normal right kidney.

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The patient was initially placed supine for intravenous access, induction of general anesthesia, endotracheal intubation, bladder catheterization and nasogastric tube placement. The operating table was then given a Trendelenberg tilt of 20 degrees and a right lateral tilt of 30 degrees. A pneumo-peritoneum was established by a closed technique 1 cm above the umbilicus. Diagnostic laparoscopy was performed and the kidney was located. Additional trocars were placed under vision; a 10 mm port in the right iliac fossa, a 5 mm port to the left of the umbilicus in the mid-clavicular line and an accessory fourth trocar (5 mm) superomedial to the left anterior superior iliac spine [Figure 3]. Dissection started with incision of the peritoneum over the kidney, which was mobilized and dissecting out clear of the surrounding structures [Figure 4]. The renal sinus was found to be very wide and the pelvis was dilated with a stone in it. Pyelotomy was done with endo-scissors and the stone was retrieved [Figure 5]. A double-J stent was placed in retrograde fashion as it was difficult to place it in antegrade fashion [Figure 6]. The pyelotomy was closed using a four-zero poly-glactin in a continuous fashion. The kidney was reretroperitonalized and a tube drain was kept in the pelvis. The operative time was 110 min and there was no intra-operative complication. The post-operative period was uneventful. The Foley's catheter was removed on the second post-operative day, followed by removal of drain on the third post-operative day. A post-operative X-ray of the abdomen showed that the stent was in place. The patient was discharged home on the fourth post-operative day. The total duration of stay in the hospital was four days. The retrieved stone is shown in [Figure 7].
Figure 3: Port sites used for laparoscopic surgery.

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Figure 4: Clinical photograph showing pelvic location of the kidney.

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Figure 5: Intra-operative photograph showing the stone being removed from the left renal pelvis.

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Figure 6: Intra-operative photograph showing an antegrade stenting being performed.

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Figure 7: Photograph showing the retrieved stone.

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   Discussion Top


Laparoscopic urology has evolved rapidly over the last two decades. Although stone disease is one of the most common afflictions of modern society, it has been described since antiquity. In recent years, however, the site of stone formation has migrated from the lower to the upper urinary tract, and the disease once limited to men is increasingly gender blind. Revolutionary advances made in the field of minimally invasive and non-invasive management of stone disease over the past two decades have greatly facilitated the ease with which stones are removed. [1] Renal anomalies are usually at a higher risk of stone formation due to non-dependant drainage in most of the cases. [2] In a pelvic kidney with stones less than 2 cm in size and/or symptomatic renal pelvic stones, the initial treatment should be ESWL because, if successful, it eliminates the need for more invasive procedures. If it fails, laparoscopic management provides a very good alternative. [3] In our case, the stone was too big for ESWL and we decided to approach the kidney laparoscopically using a trans-peritoneal approach. The operative time was 110 min and we did not have any intra-operative complication. Retroperitoneal laparoscopic pyelolithotomy was performed by Gaur et al in eight cases and the stones were successfully removed in five (62.5%). [4] The first report of laparoscopic pyelolithotomy for calculus removal in a pelvic kidney was reported by William et al in 1996. [3]

 
   References Top

1.Wein, Kavoussi, Novick, Partin, Craig. Campbell-Walsh Urology. Philadelphia: Saunders Elsevier; 2007.  Back to cited text no. 1
    
2.Dretler SP, Olsson C, Mster RC. The anatomic, radiographic and clinical characteristics of the pelvic kidney: An analysis of 86 cases. J Urol 1971;105:623.  Back to cited text no. 2
    
3.Harmon WJ, Kleer E, Segura JW. Laparoscopic pyelolithotomy for calculus removal in a pelvic kidney. J Urol 1996;1:2019-20.  Back to cited text no. 3
    
4.Gaur DD, Agarwal DK, Purohit KC, Darshane AS. Retroperitoneal laparoscopic pyelolithotomy. J Urol 1994;151:927.  Back to cited text no. 4
[PUBMED]    

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Correspondence Address:
Shahnawaz Ahangar
Department of Surgery, Government Medical College, Karan Nagar, Srinagar
India
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DOI: 10.4103/1319-2442.103571

PMID: 23168860

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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    Abstract
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    References
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