|Year : 2018 | Volume
| Issue : 3 | Page : 113-115
Laparoscopic-assisted percutaneous nephrolithotomy in ectopic kidney
Shreyas Bhadranavar1, RB Nerli1, Shridhar C Ghagane2, Murigendra B Hiremath3
1 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belagavi, Karnataka, India
2 Department of Urology, ES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and MRC, Belagavi, Karnataka, India
3 Department of Biotechnology and Microbiology, Karnatak University, Dharwad, Karnataka, India
|Date of Web Publication||28-Jun-2019|
Dr. R B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), JNMC Campus, Nehru Nagar, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Renal calculi pose challenges to the health of a person with a normal anatomically positioned kidney. If renal stones occur in a pelvic ectopic kidney, then the health risk it poses is even higher and challenging for urologists. Various approaches have been suggested for the treatment of diverse forms of kidney stones and grounded on the stone distribution and location. The elimination rate of those kidney stones depends principally on the size of the stones, position, and the success of prior attempts. In patients with ectopic kidneys, laparoscopic-assisted percutaneous nephrolithotomy (PCNL) is an option. In this paper, we have reviewed the findings from various studies and have arrived at the same conclusion that PCNL is safe and effective in managing pelvic renal kidney stones when it is done alongside laparoscopy.
Keywords: Ectopic kidney, laparoscopy, pelvic kidney calculi, percutaneous nephrolithotomy
|How to cite this article:|
Bhadranavar S, Nerli R B, Ghagane SC, Hiremath MB. Laparoscopic-assisted percutaneous nephrolithotomy in ectopic kidney. J Sci Soc 2018;45:113-5
| Introduction|| |
When the mature kidney fails to reach its normal location in the ''renal'' fossa, the condition is known as renal ectopia. The incidence of ectopic kidneys at autopsy is approximately 1:900 live births with female predilection. Pelvic ectopia has been estimated to occur in 1 of 2100–3000 autopsies. A solitary ectopic kidney occurs in 1 of 22,000 autopsies. Bilateral ectopic kidneys are more rarely observed and account for only 10% of all patients with renal ectopia. Ectopic kidneys occur slightly more commonly on the left side. The location of an ectopic kidney can be pelvic, iliac (lumbar), abdominal, and thoracic or crossed/crossed fused. For ectopic kidneys, ureteropelvic junction obstruction and stone formation incidence are higher than the general population. This is most likely due to abnormal rotation and anatomy as well as the aberrant vasculature of these kidneys. The renal pelvis is usually anterior to the parenchyma because the kidney has incompletely rotated. As a result, 56% of ectopic kidneys have a hydronephrotic collecting system. Half of these cases are due to obstruction of the ureteropelvic or the ureterovesical junction (70% and 30%, respectively), 25% from reflux Grade III or greater, and 25% from the malrotation alone.
| Stones in Ectopic Kidney|| |
Most ectopic kidneys are asymptomatic. Vague abdominal complaints and ureteral colic secondary to an obstructing stone are the most frequent symptoms leading to the diagnosis of an ectopic kidney shown in a study conducted by Agrawal et al. [Figure 1]. The therapeutic approaches for kidney stones in structurally normal kidneys are well documented; however, there is no consensus on the best guidelines for the management of malrotation or ectopic kidneys as the morphology is inconstant, and consequently, choices have to be made on a case-by-case ground. This relies on the position and size of the stones, the age of the patient, position and structure of the kidney unit, as well as anatomical challenges in the patient. Stone disease in pelvic ectopic kidneys can present unique challenges to the endourologist. There are a variety of approaches which can be used to treat stones in ectopic kidneys including open surgery, retrograde intrarenal surgery (RIRS), extracorporeal shock wave lithotripsy (ESWL), and percutaneous nephrolithotomy (PCNL).,,, While open surgery escalates the risk of morbidity and mortality following manipulation of the bowel, bigger scars compared to other techniques, and unfathomable pain, However, ESWL has proven to pose 55%–69% success rates and is less effective because of the adjacent; ESWL has proven to pose 55%–69% success rates and is less effective because of the adjacent bone and bowel, high insertion of ureter with an associated chance of reduced morbidity which can substantially hinder the elimination of the renal stones.,
| Percutaneous Nephrolithotomy in Ectopic Kidney|| |
Although PCNL is an accepted treatment modality in anatomically normal kidneys, ectopic and transplanted pelvic kidneys require a different and more complicated approach for PCNL., The ectopic pelvic kidney is in the retroperitoneum and anterior to the sacrum interposing bowel loops between anterior abdominal wall and pelvic kidney. Thus, a blind percutaneous transperitoneal approach to a pelvic kidney should be avoided because of the high risk of injuring the bowel and vessels.
This paper analyses ten past studies to establish the efficacy of PCNL in the treatment of pelvic ectopic kidney. Most of the investigators commend laparoscopic means as an optimal choice to open operation. Sohail et al. in 2016 presented a case of 15 years old who was treated three times with ESWL after presenting with a diagnosed right ectopic pelvic kidney and a 4-cm kidney stone. The authors used transmesocolic percutaneous nephrolithotripsy aided by laparoscopic technique which led to complete clearance of the renal stone without any peri- and postoperative complications; however, the mobilization of the colon was found to be a safer approach to reveal the kidney pelvis and also decreases the time for the surgical procedure.
Kramer et al. in 2007 assert that the transmesocolic technique or colon mobilization with the exposure of the retroperitoneal cavity should be chosen founded on the anatomical specificities. In Gandhi et al. perspective, the transmesocolic method was expedient following the good position of the pelvic ectopic kidney. In a similar study, the pyelon was advanced through the mesocolon following the small fat quantities in the mesocolon that ensured an easy way of spotting the colic vessels.
Aquil et al. found that in patients with ectopic pelvic kidney, the employment of PCNL to treat renal calculi escalated the danger of intra-abdominal hemorrhage in addition to leakage of urine due to the unusual position of the pelvic kidney, as well as the irregular and erratic supply of blood to the ectopic kidney, the mesenteric vascular vessels, and the adjacent bowel loops, hence, the need for laparoscopic-assisted PCNL.
El-Kappany et al. is an example of a large time series study that involved 11 patients in testing the combination of nephroscopy and laparoscopy for the management of kidney stones in ectopic pelvic kidneys. The study treated 5 patients with laparoscopic (LAP) and noted a rate of 80% clearance of kidney stones. Even though LAP embodies an efficient alternative for the patients, it also had the benefit of preventing vascular complications in case of puncture of kidney parenchyma. Nonetheless, it is technically complex and time-consuming.
Vartak and Salvi in 2017 present a case of 2 patients suffering from large renal calculi in the ectopic pelvic kidney which completely cleared following the use laparoscopic-aided less aggressive PCNL and a laser. The technique is thought to be an excellent alternative for treating large calculi in pelvic ectopic kidneys.
Shadpour et al. present a case report of 3 patients who were diagnosed with ectopic pelvic kidney filled with renal calculi of 3 cm in size. The clinicians used laparoscopic pyelolithotomy to treat the stones. Unlike previously discussed studies, Shadpour et al. offered an entirely disparate advance to percutaneous pyelolithotomy by employing laparoscopy to direct nephroscopy straightforwardly into the kidney pelvis through a dilated perforation. In this study, colon mobilization that is required to conduct a perforation in the transabdominal route was completed through laparoscopic graspers under vision. This ensured that there was no mesenteric or bowel wound during the perforation of the kidney. The authors warned that the necessity for a nephrostomy catheter and the probable outflow of blood and urine into the abdominal cavity could be the likely complications. These could be reduced by performing a mini-PCNL that uses a smaller caliber sheath compared to standard PCNL as seen in D'souza et al.
In D'souza et al., whose objective was to establish an efficient and effective approach to address kidney stones in 9 patients who had been found with the ectopic pelvic kidney. The urologists used mini-PCNL after bowel and peritoneum mobilization followed by renal perforation using a rigid mini-nephroscope. The authors concluded that mini-PCNL with laser dusting offered benefits in pelvic ectopic in accomplishing a clearance of the stones, particularly in patients who had received unsuccessful ESWL or those with large renal calculi. In the retrospective study, 3 patients had >20 mm of the stones and preferred primary percutaneous technique. All the three had unsuccessful RIRS and ESWL previously. The authors noted that pelvic kidney was a predominant urological anomaly which was further complicated by unusual catheter insertion, rotation abnormalities, and shifting positions of the kidney, thus making the treatment difficult.
Otano et al. reported on their experience with the use of ultrasonography (USG) for puncture guidance while performing PCNL in ectopic pelvic kidneys. They performed PCNL in 26 patients with USG-guided punctures. The stones were solitary in 15 patients (58%) and multiple in 11 patients (42%). The mean stone size was 22 mm (range, 10–50 mm), including three staghorn calculi. All procedures were performed in an oblique supine position. The mean operative time was 93 min, achieving complete stone clearance in 22 (88%) patients. One of the patients had urine leakage after removing nephrostomy, needing postoperative double-J stenting. One patient had significant intraoperative bleeding requiring staging of the procedure and blood transfusion. The authors concluded that USG-guided puncture was a safe and effective approach to the collecting system even in renal anomalies like in pelvic ectopic kidneys.
In an editorial letter, Resorlu et al. attest that PCNL is safe, Procedure, and has produced best results if it is used along with laparoscopic approaches to manage renal calculi in ectopic pelvic kidneys, as well as kidney access, can be done straightforwardly into the calyx or kidney pelvis. The authors concur with Micali et al. who note that the technique is best for clearance of pelvic renal stones for which other less intrusive techniques have failed. Similarly, Nerli et al.,,, reported that the residents/junior consultants should undergo structured apprenticeship training in PCNL so that one can tackle stones in unusual positions with the help of PCNL.
| Conclusion|| |
From the reviewed case series, it can be confirmed that laparoscopic-assisted PCNL is an efficient and successful technique for the elimination of renal calculi in patients with a pelvic ectopic kidney. The current study suggests further research to establish the efficacy of laparoscopic-assisted PCNL using a larger sample as well as using randomized control trials which are known to be the golden standard in surgical and treatment research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shapiro E, Chow JS. Anomalies of the upper urinary tract. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh Urology. 10th
ed. Philadelphia, PA: Elsevier; 2011. p. 3123-60.
Agrawal S, Chipde SS, Kalathia J, Agrawal R. Renal stone in crossed fused renal ectopia and its laparoscopic management: Case report and review of literature. Urol Ann 2016;8:236-8.
] [Full text]
Aquil S, Rana M, Zaidi Z. Laparoscopic assisted percutaneous nephrolithotomy (PCNL) in ectopic pelvic kidney. J Pak Med Assoc 2006;56:381-3.
D'souza N, Verma A, Rai A. Laparoscopic-assisted mini percutaneous nephrolithotomy in the ectopic pelvic kidney: Outcomes with the laser dusting technique. Urol Ann 2016;8:87-90.
Patwardhan SK, Shelke UR, Patil BP, Pamecha YR. Laparoscopic assisted percutaneous nephrolithotomy in chronic kidney disease patients with ectopic pelvic kidney. Urol Ann 2017;9:257-60.
] [Full text]
El-Kappany HA, El-Nahas AR, Shoma AM, El-Tabey NA, Eraky I, El-Kenawy MR, et al.
Combination of laparoscopy and nephroscopy for treatment of stones in pelvic ectopic kidneys. J Endourol 2007;21:1131-6.
Dodia BV, Mahajan A, Patil M, Bathe S, Darakh P. Laparoscopy guided PCNL in a stone holding previously operated ectopic pelvic kidney. Int J Curr Microbiol Appl Sci 2017;6:975-9.
Gandhi HR, Thomas A, Nair B, Pooleri G. Laparoscopic pyelolithotomy: An emerging tool for complex staghorn nephrolithiasis in high-risk patients. Arab J Urol 2015;13:139-45.
Tóth C, Holman E, Pásztor I, Khan AM. Laparoscopically controlled and assisted percutaneous transperitoneal nephrolithotomy in a pelvic dystopic kidney. J Endourol 1993;7:303-5.
Stein RJ, Desai MM. Management of urolithiasis in the congenitally abnormal kidney (horseshoe and ectopic). Curr Opin Urol 2007;17:125-31.
Rifaioglu MM, Berger AD, Pengune W, Stoller ML. Percutaneous management of stones in transplanted kidneys. Urology 2008;72:508-12.
Matlaga BR, Kim SC, Watkins SL, Kuo RL, Munch LC, Lingeman JE. Percutaneous nephrolithotomy for ectopic kidneys: Over, around, or through. Urology 2006;67:513-7.
Sohail N, Albodour A, Abdelrahman K. Laparoscopic assisted transmesocolonic percutaneous nephrolithotripsy in ectopic iliac kidney. Urol Case Rep 2016;7:48-50.
Kramer BA, Hammond L, Schwartz BF. Laparoscopic pyelolithotomy: Indications and technique. J Endourol 2007;21:860-1.
Vartak KP, Salvi PH. Laparoscopic-assisted mini percutaneous nephrolithotomy for treatment of large calculi in pelvic ectopic kidney. Urol Ann 2017;9:174-6.
] [Full text]
Shadpour P, Maghsoudi R, Etemadian M, Mehravaran K. Laparoscopically assisted percutaneous pyelolithotomy in pelvic kidneys: A different approach. Urol J 2010;7:194-8.
Otaño N, Jairath A, Mishra S, Ganpule A, Sabnis R, Desai M. Percutaneous nephrolithotomy in pelvic kidneys: Is the ultrasound-guided puncture safe? Urology 2015;85:55-8.
Resorlu B, Karakan T, Kilinc MF, Kabar M, Doluoglu OG. Laparoscopic-assisted percutaneous nephrolithotomy in malrotated and ectopic pelvic kidneys: Calyceal or direct pelvic access? Ren Fail 2015;37:742-3.
Micali S, Moore RG, Averch TD, Adams JB, Kavoussi LR. The role of laparoscopy in the treatment of renal and ureteral calculi. J Urol 1997;157:463-6.
Nerli RB, Reddy MN, Devaraju S, Hiremath MB. Percutaneous nephrolithotomy in patients on chronic anticoagulant/antiplatelet therapy. Chonnam Med J 2012;48:103-7.
Nerli RB, Devaraju S, Hiremath MB. Training in percutaneous nephrolithotomy: A structured apprenticeship program. J Sci Soc 2014;41:26. [Full text]