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CASE REPORT
Year : 2021  |  Volume : 48  |  Issue : 3  |  Page : 213-214

Trifid pelvis with staghorn calculus managed by percutaneous nephrolithotomy


Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, JNMC Campus, Belagavi, Karnataka, India

Date of Submission10-May-2021
Date of Acceptance31-May-2021
Date of Web Publication28-Dec-2021

Correspondence Address:
Prof. Rajendra B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, JNMC Campus, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.jss_50_21

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  Abstract 


A trifid pelvis is an extremely rare anomaly. It represents either a peduncular arrangement or elongation of the major calyces in association with a rudimentary pelvis. This anomaly becomes significant only in the presence of pathological conditions. We report a case of left sided trifid pelvis with a staghorn calculus managed by percutaneous nephrolithotomy.

Keywords: Percutaneous nephrolithotomy, trifid pelvis, urolithiasis


How to cite this article:
Nerli RB, Chandra S, Patil SD, Rotti N. Trifid pelvis with staghorn calculus managed by percutaneous nephrolithotomy. J Sci Soc 2021;48:213-4

How to cite this URL:
Nerli RB, Chandra S, Patil SD, Rotti N. Trifid pelvis with staghorn calculus managed by percutaneous nephrolithotomy. J Sci Soc [serial online] 2021 [cited 2022 May 25];48:213-4. Available from: https://www.jscisociety.com/text.asp?2021/48/3/213/333848




  Introduction Top


It is believed that 10% of normal renal pelvis are bifid.[1] The renal pelvis divides to form two major calyces first at, or just within, its entrance to the kidney. A bifid pelvis is considered as a normal variant. Further, division of the renal pelvis can occur resulting in triplication of the pelvis. A trifid pelvis is an extremely rare anomaly.[1],[2] The ureteral bud arises from the mesonephric duct at the 5th week of embryological life. This structure then divides into two or three before reaching the metanephrogenic blastema.[3] In a case of a trifid pelvis, it may be difficult to decide whether the kidney represents a trifid pelvis, purely a peduncular arrangement, or elongation of the major calyces in association with a rudimentary pelvis.[2] In this article, we report a case of left-sided trifid pelvis with a staghorn calculus managed by percutaneous nephrolithotomy (PCNL).


  Case Report Top


A 22-year-old male presented with pain on the left side of the abdomen, associated with occasional vomiting. Ultrasonography revealed a left-sided staghorn calculus which was confirmed on a plain computed tomography (CT) [Figure 1]a and [Figure 1]b. The patient was taken up for PCNL.
Figure 1: (a) Plain X-ray kidneys, ureter, and bladder reveals a left side staghorn calculus (b) computed tomography imaging of a left side staghorn calculi (c) Plain X-ray kidneys, ureter, and bladder following first session of percutaneous nephrolithotomy. (d) Plain X-ray kidneys, ureter, and bladder 48 h after second session of percutaneous nephrolithotomy

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Using the bulls eye technique and under fluoroscopy guidance, an initial puncture was made into the upper posterior calyx. Another puncture was made into the middle posterior calyx. The tracts were dilated, and the nephroscope was introduced into the collecting system. The superior limb of the staghorn was first tackled. The bulk of the stone was cleared. Similarly, the limb of the stone extending into the middle calyx was cleared [Figure 1]c. The time taken for this partial removal was 90 min. The urine gradually darkened due to bleeding. It was decided to abandon the procedure at that stage. A nephrostomy was placed in both the tracts. Postoperatively, the patient had a smooth recovery.

The patient was taken up for a repeat PCNL, 72 h later. The stone fragments had got rearranged into the lower calyx and middle calyx. Another puncture was made into the lower calyx. With these three tracts, the staghorn calculi were cleared [Figure 1]d. No blood transfusions were required; however, the hemoglobin levels dropped by 2 gm%. Postoperatively, the patient recovered well, the nephrostomy tubes were removed after 48 h and the catheter after 72 h. A double J stent was left in place. The patient was discharged onm the 5th postoperative day. An initial retrograde pyelography revealed a trifid pelvis on the side (Left) of the stone with multiple calyces that appeared to be arranged in three rows, namely anterior, intermediate, and posterior [Figure 2].
Figure 2: Retrograde pyelography prior to first percutaneous nephrolithotomy. It shows Trifid pelvis with numerous calyces arranged in three rows

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  Discussion Top


A trifid renal pelvis is a very rare congenital malformations of the upper urinary tract. The triplication of renal pelvis is the result of the additional division of the ureteric branches that make the renal pelvis. This variation is known as triple or trifid renal pelvis. These anomalies become significant in the presence of pathological conditions. Pejcić et al.[4] reported on a 55-year-old man who was evaluated for papillary bladder cancer. Incidentally, on intravenous urogram, a bilateral trifid pelvis was noted which was further confirmed on CT.

The presence of a large renal calculi or staghorn calculi has not been reported in the available literature. Our case was that of a staghorn in a trifid pelvis system. With care, one can puncture select calyces so as to extract the stone. PCNL is a safe and effective option in the management of staghorn calculi in a patient with trifid pelvis.

Acknowledgment

The authors highly appreciate the support rendered by Mr. Neeraj S. Dixit, public relation in-charge of the Department of Urology, KLES Dr. Prabhakar Kore Hospital and MRC, Belagavi.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
VanderBrink BA, Reddy PP. Anomalies of the upper urinary tract. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, editors. Campbell-Walsh-Wein Urology. 12th ed. USA: Elsevier, Philadelphia; 2020. p. 737.  Back to cited text no. 1
    
2.
Kumar GA, Nerli RB, Devaraju S, Hiremath MB. A trifid pelvis in a patient with a solitary kidney with LUTS: An unusual presentation. Journal of the Scientific Society 2013;40:177.  Back to cited text no. 2
    
3.
Akkoç A, Yagli ÖF, Metin A, Eroglu M, Kandirali E. A case of trifid pelvis with ureteropelvic junction obstruction/Üreteropelvik bileske obstrüksiyonuyla birlikteligi olan trifid pelvis olgusu. Turkish Journal of Urology. 2011;37:272.  Back to cited text no. 3
    
4.
Pejcić T, Aćimović M, Dzamić Z, Maksimović H, Marković B, Hadzi-Djokić J. Bilateral triple renal pelvis: a case report. Vojnosanit Pregl 2015;72:185-7.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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