© 1991 S. Karger AG, Basel 0042-1138/91/0461 -0029Î2.75/0
Urol Int 1991;46:29-34
Multimodal Therapy for Stones in Pelvic Kidneys Patrizio Rigatti*d, Francesco Montorsib-d, Giorgio Guazzonic’d, Valerio di Girolamo a, Paolo Consonnia, Renzo Colombo a, Luigi Da Pozzo a, A Ido Bocciardia a Department of Urology, Institute S. Raffaele, bInstitute of Human Anatomy, University of Milan School of Medicine, c Institute of General Surgery and Surgical Oncology, University of Milan School of Medicine, and d Stone Center Clinic Citta di Milano, Milan, Italy
Key Words. Pelvic kidney • Kidney, ectopy • Extracorporeal shock wave lithotripsy ■Extracorporeal piezoelectric lithotripsy • Surgery • Ureteroscopy
Introduction The advent of extracorporeal lithotripsy and endou rology has dramatically changed the therapeutic strategy for reno-ureteral stone disease [1-3]. Anomalous anatomical conditions such as pelvic re nal ectopia had been initially considered as noneligible for treatment with these new procedures, the bony pelvis blocking shock wave transmission [4, 5], The develop ment of new procedures [6-11] has recently broadened the indications for these minimally invasive therapeutic modalities to stones overlying the sacroiliac skeleton. We hereby report the experience achieved at our insti tution in 16 patients with pelvic kidney stone disease successfully submitted to extracorporeal lithotripsy and combined procedures. Material and Methods From January 1988 to December 1989, 16 patients with stone disease in pelvic kidneys were admitted at our institution. The age of the patients ranged from 32 to 64 years (mean 41.5 years). Ten patients had stones in the renal pelvis (in 2 cases the stones were
radiolucent), 2 patients had renal calyceal stones, 2 patients had total staghorn stones, 1 patient had a ureteropyelic junction (UPJ) stenosis with a secondary stone in the renal pelvis, and, finally, 1 patient presented with a kidney autotransplanted in the right iliac fossa and a stone at the pyelovesical anastomotic site. Patients were evaluated preoperatively by history, physical ex amination, complete biochemistry, intravenous pyelogram and renovesical ultrasonography. The therapeutic modality was chosen according to the stone size. Stones with a maximum diameter < 2 cm (4 cases) were treated with a second generation piezoelectric lithotripter (Wolf Piezolith 2300) and neither analgesia nor sedation was necessary. Stones larger than 2 cm were treated with the modified low pressure gener ator Domier HM3 lithotripter [12] and intravenous sedation with 10 mg diazepam was used. Staghorn stones were approached with a debulking pyelolithotomy and following extracorporeal piezoelec tric lithotripsy (EPL) on the lithiasic remnants. An open pyeloplasty following the Anderson-Heynes technique was performed in the UPJ obstruction case. General anesthesia was used in the cases treated by open surgery. Ureteroscopy was applied for the stone in the autotransplanted kidney and intravenous sedation was used. All the patients submitted to extracorporeal lithotripsy and ure teroscopy were given antibiotic prophylaxis with aztreonam 3 g i.m. A full course of antibiotic therapy was used in the open surgery cases and when a preoperative urinary tract infection was detected. The mean stone size was 29 mm (range 11-48 mm). The mean number of shock waves used was 2,700 (range 2,200-3,000) for
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 12:20:26 AM
Abstract. Stones located in pelvic kidneys can be successfully treated by extracorporeal lithotripsy, either alone or in combination with endourology and open surgery. A multimodal approach was used in 16 patients with pelvic kidney stone disease and a 87.5% stone-free rate was achieved. The proper positioning of the patient on the lithotripter apparatus and the correct integration of the different therapeutic procedures were the real clues for obtaining a remarkable success rate with a minimally invasive approach.
Rigatti/Montorsi/Guazzoni/di Girolamo/Consonni/Colotnbo/Da Pozzo/Bocciardi
extracorporeal shock wave lithotripsy (ESWL) and 4,000 (range 3,200-4,500) for EPL. The mean energy of shock waves was 22 kV (20-24 kV) with the Domier HM3 while the highest level of shock wave energy (level 4; 1.020 bar) was always used with the piezoelec tric lithotripter [13]. The mean duration of each ESWL and EPL session was 45 and 42 min, respectively. All the stones were located within the pelvis projecting at the kidney, ureter, bladder (KUB) roentgenogram over the sacroiliac bone. This bony structure causes an acoustical impedance that greatly reduces the stone fragmenting capacity of shock waves when the patient is classically positioned supine. Moreover, focusing of stones with the patient in this position is generally impossible with the available lithotripters. These unfavorable conditions were by passed by prone-positioning the patients on the gantry of the Dor mer HM3 lithotripter that did not require any structural modifica tion [9, 10] and by using a modified prone position with the Wolf Piezolith 2300 (fig. 1). In stones larger than 2 cm a double J ureteral stent was inserted preoperatively with the double aim of making the stone focusing easier and preventing obstructive complications. Pre operative cystoscopic manipulations were not performed in EPL patients, the focusing of the stone being under sonographic guidance and the stone size being small. Open surgery was limited to a simple incision of the renal pelvis and extraction of the accessible stones. Outpatient follow-up consisted of a KUB roentgenogram and a renovesical ultrasound at postoperative months 1 and 3.
Results In the EPL series, 3 patients underwent a single ses sion (fig. 2, 3) and 1 required a second treatment in order to achieve a complete stone fragmentation. In the ESWL patients, 5 cases were submitted to one session and 5 required a second treatment (fig. 4, 5). Two ESWL pa tients had large radiolucent stones (fig. 6-9): a preopera tive retrograde pyelogram was thus performed to visual ize the calculi. At discharge from the hospital these patients were given an appropriate oral alkalinizing ther apy with sodium-potassium citrate to complete the dis solution of fragments. The mean hospitalization period after EPL and ESWL was 3.3 and 5.9 days respectively (range 2-5 and 2-7 days). The two debulking pyélolithotomies were uneventful: intraoperative blood loss was minimal (150 and 160 ml) and blood transfusions were not necessary. Patients sub mitted to a debulking pyelolithomy were discharged on the
Fig. 1. Modified prone position on the Wolf Piezolith 2300 litho tripter. Fig. 2,3. Pre- and postoperative intravenous pyelogram of a pyelic stone submitted to one EPL session: no fragments can be seen at the follow-up film.
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Stones in Pelvic Kidneys
31
Fig. 4, 5. KUB roentgenogram of 2 pelvic kidney stones: after one ESWL session 1 stone has been pulverized and discharged.
6
7
5th postoperative day and EPL was performed after 1 month (fig. 10-12). The open pyeloplasty patient was dis charged on the 9th postoperative day (fig. 13, 14) while the patient submitted to ureteroscopy was discharged 2 days after the procedure. The ureteral stents were removed as soon as the discharge of fragments was completed. Eleven out of 12 patients undergoing elective extra corporeal lithotripsy were stone-free at the 3-month fol low-up date. One patient still showed two small (< 3 mm) fragments which were deemed susceptible of
spontaneous discharge. One staghorn stone patient was stone-free 1 month after the postoperative EPL while the second patient still showed a small lithiasic fragment at the 3-month post-EPL follow-up. Patients undergoing open pyeloplasty and ureteroscopy were stone-free at discharge from the hospital. Overall, 14 patients (87.5%) were thus rendered stone-free at the 3-month follow-up date. No major complications were encountered. Fever (> 38.5 °C) occurred in 5 patients and was successfully treated by a specific antibiotic therapy.
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Fig. 6, 7. Pre- and postoperative in travenous pyelogram of a radiolucent pyelic stone submitted to ESWL and alkalinizing therapy.
Rigatti/Montorsi/Guazzoni/di Girolamo/Consonni/Colombo/Da Pozzo/Bocciardi
Discussion Renal ectopia has been first described by 16th century anatomists [14] but it became well known and was related to typical clinical syndromes only in more recent times due to the improvement of appropriate diagnostic techniques. The average occurrence among autopsy se ries and the incidence in hospitalized patients are almost comparable, about 1 in 900 [15]. Pelvic kidneys have been reported to occur once in 22,000 autopsies [16] and a recent review of the literature has recorded 165 cases of solitary pelvic kidneys [17]. Our study reports on 15 patients with ectopic pelvic kidneys and 1 patient with a kidney autotransplanted in the pelvis: as far as we know this is the largest pelvic kidney stone disease series found in the English literature. In our cases the controlateral kidneys were always normal and other anomalies of the genitourinary tract were not found. It is known that ectopic kidneys are more frequently involved in the development of hydronephrosis or urinary stone forma tion than normal kidneys. The anterior position of the renal pelvis and the kidney malrotation usually seen in this setting may lead to the impairment of the drainage of urine from a high UPJ; moreover, an anomalous ves sel can partially block one of the major calyces or the upper ureter. Only 1 case of our series presented with a primary anomaly of the UPJ and a consequent kidney
stone: 5 patients showed an anterior rotation of the pel vic kidney but the UPJ appeared normal in the intrave nous pyelogram. Extracorporeal lithotripsy has been increasingly gain ing space in the therapy of renoureteral stone disease. Since its first application to small renal stones the indi cations of this procedure have included stones in the proximal and distal (prevesical) ureter [18]. More re cently the successful application of ESWL for mid-ureteral stones overlying the pelvic bone has been reported [6 - 11].
In pelvic kidney stone disease the same anatomical setting is observed: the region of the sacroiliac joint acts as a barrier for shock waves delivered from the back, as it normally happens with the patient in the usual supine position. Not only the fragmenting effect of shock waves is greatly diminished by the bony pelvis but visualization of the stone in both the focusing points of the Dornier HM3 lithotripter is impossible. Treatment with the pa tient in the prone position avoids the bony obstacle and does not necessitate any modification of the lithotripter apparatus; the only technical requirement is the posi tioning of a ureteral targeting catheter as fluoroscopic guidance is used [8, 9], The sacroiliac region has always been considered a blind space for lithotripters using ultrasonography for stone focusing and calculi in the mid-ureter have never been considered as eligible for
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 12:20:26 AM
32
Fig. 10,11,12. Total staghorn stone: after debulking pyelolithotomy two residual calyceal fragments have been submitted to double EPL treatment. Fig. 13,14. Pre- (intravenous pyelogram) and postoperative (ul trasonography) view of UPJ stenosis and pyelic stone.
33
EPL [13, 19]. However, in case of stones in pelvic kid neys, we could easily detect the calculi under ultrasono graphic guidance by using a simple modified prone posi tion. In these patients cystoscopic manipulations could be avoided. The fragmentation and stone-free rate were extremely high with extracorporeal lithotripsy in the prone patient and our data can be compared to those reported by other authors [7, 8, 10]. None of the patients reported symptoms referable to intraabdominal damage thus confirming the safety of the procedure [7, 8, 10]. In pelvic kidneys a percutaneous approach is rendered impossible by the surrounding bony structures: thus, open surgery should still be con sidered when facing total and high burden staghorn stones that cannot be successfully treated by ESWL monotherapy [1, 20], At our institution the surgical act is limited to a small ‘V’ shaped incision in the renal pelvis in order to avoid any damage to the renal parenchyma. In case of small postoperative stone remnants, extracor-
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 12:20:26 AM
Stones in Pelvic Kidneys
Rigatti/Montorsi/Guazzoni/di Girolamo/Consonni/Colombo/Da Pozzo/Bocciardi
poreal lithotripsy is successfully used to render the kid ney free of disease. Again, open surgery should be per formed in case of anatomical anomalies of the urinary tract such as a UPJ stenosis. Ureteroscopy is considered the first choice therapy for kidneys transplanted in the iliac fossa and with a stone at the pyelovesical anastomotic site. In our patient the stone could be easily seen and pulverized by ultra sonic ureteroscopic lithotripsy thus avoiding any possi ble ESWL-induced damage to the renal parenchyma [21-23], The multivariate application of extracorporeal litho tripsy, endourological procedures and open surgery re presents a minimally invasive therapeutic approach that can achieve an extremely high success rate in patients with renal stone disease and anomalous anatomical con ditions. Acknowledgements The authors are indebted to Laura Galli, PhD, for her technical assistance.
References 1 Rigatti, P.; Francesca, F.; Montorsi, F.; Consonni, P.; Guazzoni, G.; Di Girolamo, V.: Extracorporeal lithotripsy and combined surgical procedures in the treatment of renoureteral stone dis ease: our experience with 2955 patients. World J. Surg. 13: 765— 775 (1989). 2 Chaussy, G.C.; Fuchs, G.J.: Current state and future develop ments of noninvasive treatment of human urinary stones with ESWL. J. Urol. 141: 782-789 (1989). 3 Finlayson, B.; Ackermann, D.: Overview of surgical treatment of urolithiasis with special reference to lithotripsy. J. Urol. 141: 778-779 (1989). 4 Mueller, S.; Wilbert, D.; Thuroff, J.; Aiken, P.: ESWL of ureteral stones: clinical experience and experimental findings. J. Urol. 135: 831-833 (1986). 5 Chaussy, C.: ESWL for kidney stones. An alternative to surgery? Urol. Radiol. 2: 80-85 (1984). 6 Bush, W.H.; Brannen, G.E.: ESWL of pelvic kidney calculus. Urology 29: 357-360 (1987). 7 Jenkins, A.D.; Gillenwater, J.Y.: ESWL in the prone position: treatment of stones in the distal ureter or anomalous kidney. J. Urol. 139: 911-915 (1988). 8 Tiselius, H.G.; Pettersson, B.; Ansersson, A.: ESWL of stones in the mid ureter. J. Urol. 141: 280-282 (1989).
9 Rigatti, P.; Montorsi, F.; Guazzoni, G.; Maffezzini, M.: ESWL: first choice therapy for ureteral stones. Scand. J. Urol. Nephrol. 23: 67-69 (1989). 10 Puppo, P.; Bottino, P.; Genninale, F.; Caviglia, C.; Ricciotti, G.: ESWL in the prone position for stones situated anteriorly. Eur. Urol. 15: 113-117 (1988). 11 Culkin, D.J.; Wheeler, J.S.; Karasis, M.; Nam, S.I.; Canning, J.R.: Treatment of renal calculus in inferior crossed renal ecto pia. Urology 32: 424-426 (1988). 12 Graff, J.; Schmidt, A.; Pastor, J.; Herberhold, D.; Rassweiler, J.; Hankemeier, U.: New generator for low pressure lithotripsy with the Domier HM3: preliminary experience of 2 centers. J. Urol. 139: 904-907 (1988). 13 Marberger, M.; Turk, C.; Steinkogler, I.: Painless piezoelectric extracorporeal lithotripsy. J. Urol. 139: 695-699 (1988). 14 Perlmutter, A.D.; Retik, A.B.; Bauer, S.B.: Anomalies of the upper urinary tract; in Walsh, Gittes, Perlmutter, Stamey, Campbell’s urology (Saunders, Philadelphia 1986). 15 Abeshouse, B.S.; Bhisitkul, I.: Crossed renal ectopia with and without fusion. Urol. Int. 9: 63-66 (1959). 16 Delson, B.: Ectopic kidney in obstetrics and gynecology. N.Y. State J. Med 75: 2522-2530 (1975). 17 Downs, R.A.; Lane, J.W.; Bums, E.: Solitary pelvic kidney: its clinical implications. Urology 1: 51-54 (1971). 18 Pettersson, B.; Tiselius, H.G.: ESWL of proximal and distal ure teral stones. Eur. Urol. 14: 184-188 (1988). 19 Vallancien, G.; Aviles, J.; Munoz, R.; Veillon, B.; Charton, M.; Brisset, J.M.: Piezoelectric extracorporeal lithotripsy by ultrashort waves with the EDAP LT01 device. J. Urol. 139: 689-694 (1988). 20 Winfield, H.N.; daym an, R.V.; Chaussy, C.G.; Weyman, P.J.; Fuchs, G.J.; Lupu, A.N.: Monotherapy of staghorn renal calculi: a comparative study between percutaneous nephrostolithotomy and ESWL. J. Urol. 139: 895-899 (1988). 21 Lingeman, J.E.; Woods, J.; Toth, P.D.; Evan, A.P.; McAteer, J.A.: The role of lithotripsy and its side effects. J. Urol. 141: 793-797 (1989). 22 Delius, M.: This month in investigative urology: effect of extra corporeal shock waves on the kidney. J. Urol. 140: 390 (1988). 23 Rigatti, P.; Colombo, R.; Centemero, A.; Francesca, F.; Di Giro lamo, V.; Montorsi, F.; Trabucchi, E.: Histological and ultrastructural evaluation of ESWL-induced acute renal lesions: pre liminary report. Eur. Urol. 16: 207-211 (1989).
Received: March 20, 1990 Accepted: May 23, 1990 Patrizio Rigatti, MD Divisione di Urologia Istituto San Raffaele Via Olgettina 60 1-20132 Milano (Italy)
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Urol Int 1991;46:29-34
Multimodal Therapy for Stones in Pelvic Kidneys Patrizio Rigatti*d, Francesco Montorsib-d, Giorgio Guazzonic’d, Valerio di Girolamo a, Paolo Consonnia, Renzo Colombo a, Luigi Da Pozzo a, A Ido Bocciardia a Department of Urology, Institute S. Raffaele, bInstitute of Human Anatomy, University of Milan School of Medicine, c Institute of General Surgery and Surgical Oncology, University of Milan School of Medicine, and d Stone Center Clinic Citta di Milano, Milan, Italy
Key Words. Pelvic kidney • Kidney, ectopy • Extracorporeal shock wave lithotripsy ■Extracorporeal piezoelectric lithotripsy • Surgery • Ureteroscopy
Introduction The advent of extracorporeal lithotripsy and endou rology has dramatically changed the therapeutic strategy for reno-ureteral stone disease [1-3]. Anomalous anatomical conditions such as pelvic re nal ectopia had been initially considered as noneligible for treatment with these new procedures, the bony pelvis blocking shock wave transmission [4, 5], The develop ment of new procedures [6-11] has recently broadened the indications for these minimally invasive therapeutic modalities to stones overlying the sacroiliac skeleton. We hereby report the experience achieved at our insti tution in 16 patients with pelvic kidney stone disease successfully submitted to extracorporeal lithotripsy and combined procedures. Material and Methods From January 1988 to December 1989, 16 patients with stone disease in pelvic kidneys were admitted at our institution. The age of the patients ranged from 32 to 64 years (mean 41.5 years). Ten patients had stones in the renal pelvis (in 2 cases the stones were
radiolucent), 2 patients had renal calyceal stones, 2 patients had total staghorn stones, 1 patient had a ureteropyelic junction (UPJ) stenosis with a secondary stone in the renal pelvis, and, finally, 1 patient presented with a kidney autotransplanted in the right iliac fossa and a stone at the pyelovesical anastomotic site. Patients were evaluated preoperatively by history, physical ex amination, complete biochemistry, intravenous pyelogram and renovesical ultrasonography. The therapeutic modality was chosen according to the stone size. Stones with a maximum diameter < 2 cm (4 cases) were treated with a second generation piezoelectric lithotripter (Wolf Piezolith 2300) and neither analgesia nor sedation was necessary. Stones larger than 2 cm were treated with the modified low pressure gener ator Domier HM3 lithotripter [12] and intravenous sedation with 10 mg diazepam was used. Staghorn stones were approached with a debulking pyelolithotomy and following extracorporeal piezoelec tric lithotripsy (EPL) on the lithiasic remnants. An open pyeloplasty following the Anderson-Heynes technique was performed in the UPJ obstruction case. General anesthesia was used in the cases treated by open surgery. Ureteroscopy was applied for the stone in the autotransplanted kidney and intravenous sedation was used. All the patients submitted to extracorporeal lithotripsy and ure teroscopy were given antibiotic prophylaxis with aztreonam 3 g i.m. A full course of antibiotic therapy was used in the open surgery cases and when a preoperative urinary tract infection was detected. The mean stone size was 29 mm (range 11-48 mm). The mean number of shock waves used was 2,700 (range 2,200-3,000) for
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 12:20:26 AM
Abstract. Stones located in pelvic kidneys can be successfully treated by extracorporeal lithotripsy, either alone or in combination with endourology and open surgery. A multimodal approach was used in 16 patients with pelvic kidney stone disease and a 87.5% stone-free rate was achieved. The proper positioning of the patient on the lithotripter apparatus and the correct integration of the different therapeutic procedures were the real clues for obtaining a remarkable success rate with a minimally invasive approach.
Rigatti/Montorsi/Guazzoni/di Girolamo/Consonni/Colotnbo/Da Pozzo/Bocciardi
extracorporeal shock wave lithotripsy (ESWL) and 4,000 (range 3,200-4,500) for EPL. The mean energy of shock waves was 22 kV (20-24 kV) with the Domier HM3 while the highest level of shock wave energy (level 4; 1.020 bar) was always used with the piezoelec tric lithotripter [13]. The mean duration of each ESWL and EPL session was 45 and 42 min, respectively. All the stones were located within the pelvis projecting at the kidney, ureter, bladder (KUB) roentgenogram over the sacroiliac bone. This bony structure causes an acoustical impedance that greatly reduces the stone fragmenting capacity of shock waves when the patient is classically positioned supine. Moreover, focusing of stones with the patient in this position is generally impossible with the available lithotripters. These unfavorable conditions were by passed by prone-positioning the patients on the gantry of the Dor mer HM3 lithotripter that did not require any structural modifica tion [9, 10] and by using a modified prone position with the Wolf Piezolith 2300 (fig. 1). In stones larger than 2 cm a double J ureteral stent was inserted preoperatively with the double aim of making the stone focusing easier and preventing obstructive complications. Pre operative cystoscopic manipulations were not performed in EPL patients, the focusing of the stone being under sonographic guidance and the stone size being small. Open surgery was limited to a simple incision of the renal pelvis and extraction of the accessible stones. Outpatient follow-up consisted of a KUB roentgenogram and a renovesical ultrasound at postoperative months 1 and 3.
Results In the EPL series, 3 patients underwent a single ses sion (fig. 2, 3) and 1 required a second treatment in order to achieve a complete stone fragmentation. In the ESWL patients, 5 cases were submitted to one session and 5 required a second treatment (fig. 4, 5). Two ESWL pa tients had large radiolucent stones (fig. 6-9): a preopera tive retrograde pyelogram was thus performed to visual ize the calculi. At discharge from the hospital these patients were given an appropriate oral alkalinizing ther apy with sodium-potassium citrate to complete the dis solution of fragments. The mean hospitalization period after EPL and ESWL was 3.3 and 5.9 days respectively (range 2-5 and 2-7 days). The two debulking pyélolithotomies were uneventful: intraoperative blood loss was minimal (150 and 160 ml) and blood transfusions were not necessary. Patients sub mitted to a debulking pyelolithomy were discharged on the
Fig. 1. Modified prone position on the Wolf Piezolith 2300 litho tripter. Fig. 2,3. Pre- and postoperative intravenous pyelogram of a pyelic stone submitted to one EPL session: no fragments can be seen at the follow-up film.
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30
Stones in Pelvic Kidneys
31
Fig. 4, 5. KUB roentgenogram of 2 pelvic kidney stones: after one ESWL session 1 stone has been pulverized and discharged.
6
7
5th postoperative day and EPL was performed after 1 month (fig. 10-12). The open pyeloplasty patient was dis charged on the 9th postoperative day (fig. 13, 14) while the patient submitted to ureteroscopy was discharged 2 days after the procedure. The ureteral stents were removed as soon as the discharge of fragments was completed. Eleven out of 12 patients undergoing elective extra corporeal lithotripsy were stone-free at the 3-month fol low-up date. One patient still showed two small (< 3 mm) fragments which were deemed susceptible of
spontaneous discharge. One staghorn stone patient was stone-free 1 month after the postoperative EPL while the second patient still showed a small lithiasic fragment at the 3-month post-EPL follow-up. Patients undergoing open pyeloplasty and ureteroscopy were stone-free at discharge from the hospital. Overall, 14 patients (87.5%) were thus rendered stone-free at the 3-month follow-up date. No major complications were encountered. Fever (> 38.5 °C) occurred in 5 patients and was successfully treated by a specific antibiotic therapy.
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Fig. 6, 7. Pre- and postoperative in travenous pyelogram of a radiolucent pyelic stone submitted to ESWL and alkalinizing therapy.
Rigatti/Montorsi/Guazzoni/di Girolamo/Consonni/Colombo/Da Pozzo/Bocciardi
Discussion Renal ectopia has been first described by 16th century anatomists [14] but it became well known and was related to typical clinical syndromes only in more recent times due to the improvement of appropriate diagnostic techniques. The average occurrence among autopsy se ries and the incidence in hospitalized patients are almost comparable, about 1 in 900 [15]. Pelvic kidneys have been reported to occur once in 22,000 autopsies [16] and a recent review of the literature has recorded 165 cases of solitary pelvic kidneys [17]. Our study reports on 15 patients with ectopic pelvic kidneys and 1 patient with a kidney autotransplanted in the pelvis: as far as we know this is the largest pelvic kidney stone disease series found in the English literature. In our cases the controlateral kidneys were always normal and other anomalies of the genitourinary tract were not found. It is known that ectopic kidneys are more frequently involved in the development of hydronephrosis or urinary stone forma tion than normal kidneys. The anterior position of the renal pelvis and the kidney malrotation usually seen in this setting may lead to the impairment of the drainage of urine from a high UPJ; moreover, an anomalous ves sel can partially block one of the major calyces or the upper ureter. Only 1 case of our series presented with a primary anomaly of the UPJ and a consequent kidney
stone: 5 patients showed an anterior rotation of the pel vic kidney but the UPJ appeared normal in the intrave nous pyelogram. Extracorporeal lithotripsy has been increasingly gain ing space in the therapy of renoureteral stone disease. Since its first application to small renal stones the indi cations of this procedure have included stones in the proximal and distal (prevesical) ureter [18]. More re cently the successful application of ESWL for mid-ureteral stones overlying the pelvic bone has been reported [6 - 11].
In pelvic kidney stone disease the same anatomical setting is observed: the region of the sacroiliac joint acts as a barrier for shock waves delivered from the back, as it normally happens with the patient in the usual supine position. Not only the fragmenting effect of shock waves is greatly diminished by the bony pelvis but visualization of the stone in both the focusing points of the Dornier HM3 lithotripter is impossible. Treatment with the pa tient in the prone position avoids the bony obstacle and does not necessitate any modification of the lithotripter apparatus; the only technical requirement is the posi tioning of a ureteral targeting catheter as fluoroscopic guidance is used [8, 9], The sacroiliac region has always been considered a blind space for lithotripters using ultrasonography for stone focusing and calculi in the mid-ureter have never been considered as eligible for
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 12:20:26 AM
32
Fig. 10,11,12. Total staghorn stone: after debulking pyelolithotomy two residual calyceal fragments have been submitted to double EPL treatment. Fig. 13,14. Pre- (intravenous pyelogram) and postoperative (ul trasonography) view of UPJ stenosis and pyelic stone.
33
EPL [13, 19]. However, in case of stones in pelvic kid neys, we could easily detect the calculi under ultrasono graphic guidance by using a simple modified prone posi tion. In these patients cystoscopic manipulations could be avoided. The fragmentation and stone-free rate were extremely high with extracorporeal lithotripsy in the prone patient and our data can be compared to those reported by other authors [7, 8, 10]. None of the patients reported symptoms referable to intraabdominal damage thus confirming the safety of the procedure [7, 8, 10]. In pelvic kidneys a percutaneous approach is rendered impossible by the surrounding bony structures: thus, open surgery should still be con sidered when facing total and high burden staghorn stones that cannot be successfully treated by ESWL monotherapy [1, 20], At our institution the surgical act is limited to a small ‘V’ shaped incision in the renal pelvis in order to avoid any damage to the renal parenchyma. In case of small postoperative stone remnants, extracor-
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 12:20:26 AM
Stones in Pelvic Kidneys
Rigatti/Montorsi/Guazzoni/di Girolamo/Consonni/Colombo/Da Pozzo/Bocciardi
poreal lithotripsy is successfully used to render the kid ney free of disease. Again, open surgery should be per formed in case of anatomical anomalies of the urinary tract such as a UPJ stenosis. Ureteroscopy is considered the first choice therapy for kidneys transplanted in the iliac fossa and with a stone at the pyelovesical anastomotic site. In our patient the stone could be easily seen and pulverized by ultra sonic ureteroscopic lithotripsy thus avoiding any possi ble ESWL-induced damage to the renal parenchyma [21-23], The multivariate application of extracorporeal litho tripsy, endourological procedures and open surgery re presents a minimally invasive therapeutic approach that can achieve an extremely high success rate in patients with renal stone disease and anomalous anatomical con ditions. Acknowledgements The authors are indebted to Laura Galli, PhD, for her technical assistance.
References 1 Rigatti, P.; Francesca, F.; Montorsi, F.; Consonni, P.; Guazzoni, G.; Di Girolamo, V.: Extracorporeal lithotripsy and combined surgical procedures in the treatment of renoureteral stone dis ease: our experience with 2955 patients. World J. Surg. 13: 765— 775 (1989). 2 Chaussy, G.C.; Fuchs, G.J.: Current state and future develop ments of noninvasive treatment of human urinary stones with ESWL. J. Urol. 141: 782-789 (1989). 3 Finlayson, B.; Ackermann, D.: Overview of surgical treatment of urolithiasis with special reference to lithotripsy. J. Urol. 141: 778-779 (1989). 4 Mueller, S.; Wilbert, D.; Thuroff, J.; Aiken, P.: ESWL of ureteral stones: clinical experience and experimental findings. J. Urol. 135: 831-833 (1986). 5 Chaussy, C.: ESWL for kidney stones. An alternative to surgery? Urol. Radiol. 2: 80-85 (1984). 6 Bush, W.H.; Brannen, G.E.: ESWL of pelvic kidney calculus. Urology 29: 357-360 (1987). 7 Jenkins, A.D.; Gillenwater, J.Y.: ESWL in the prone position: treatment of stones in the distal ureter or anomalous kidney. J. Urol. 139: 911-915 (1988). 8 Tiselius, H.G.; Pettersson, B.; Ansersson, A.: ESWL of stones in the mid ureter. J. Urol. 141: 280-282 (1989).
9 Rigatti, P.; Montorsi, F.; Guazzoni, G.; Maffezzini, M.: ESWL: first choice therapy for ureteral stones. Scand. J. Urol. Nephrol. 23: 67-69 (1989). 10 Puppo, P.; Bottino, P.; Genninale, F.; Caviglia, C.; Ricciotti, G.: ESWL in the prone position for stones situated anteriorly. Eur. Urol. 15: 113-117 (1988). 11 Culkin, D.J.; Wheeler, J.S.; Karasis, M.; Nam, S.I.; Canning, J.R.: Treatment of renal calculus in inferior crossed renal ecto pia. Urology 32: 424-426 (1988). 12 Graff, J.; Schmidt, A.; Pastor, J.; Herberhold, D.; Rassweiler, J.; Hankemeier, U.: New generator for low pressure lithotripsy with the Domier HM3: preliminary experience of 2 centers. J. Urol. 139: 904-907 (1988). 13 Marberger, M.; Turk, C.; Steinkogler, I.: Painless piezoelectric extracorporeal lithotripsy. J. Urol. 139: 695-699 (1988). 14 Perlmutter, A.D.; Retik, A.B.; Bauer, S.B.: Anomalies of the upper urinary tract; in Walsh, Gittes, Perlmutter, Stamey, Campbell’s urology (Saunders, Philadelphia 1986). 15 Abeshouse, B.S.; Bhisitkul, I.: Crossed renal ectopia with and without fusion. Urol. Int. 9: 63-66 (1959). 16 Delson, B.: Ectopic kidney in obstetrics and gynecology. N.Y. State J. Med 75: 2522-2530 (1975). 17 Downs, R.A.; Lane, J.W.; Bums, E.: Solitary pelvic kidney: its clinical implications. Urology 1: 51-54 (1971). 18 Pettersson, B.; Tiselius, H.G.: ESWL of proximal and distal ure teral stones. Eur. Urol. 14: 184-188 (1988). 19 Vallancien, G.; Aviles, J.; Munoz, R.; Veillon, B.; Charton, M.; Brisset, J.M.: Piezoelectric extracorporeal lithotripsy by ultrashort waves with the EDAP LT01 device. J. Urol. 139: 689-694 (1988). 20 Winfield, H.N.; daym an, R.V.; Chaussy, C.G.; Weyman, P.J.; Fuchs, G.J.; Lupu, A.N.: Monotherapy of staghorn renal calculi: a comparative study between percutaneous nephrostolithotomy and ESWL. J. Urol. 139: 895-899 (1988). 21 Lingeman, J.E.; Woods, J.; Toth, P.D.; Evan, A.P.; McAteer, J.A.: The role of lithotripsy and its side effects. J. Urol. 141: 793-797 (1989). 22 Delius, M.: This month in investigative urology: effect of extra corporeal shock waves on the kidney. J. Urol. 140: 390 (1988). 23 Rigatti, P.; Colombo, R.; Centemero, A.; Francesca, F.; Di Giro lamo, V.; Montorsi, F.; Trabucchi, E.: Histological and ultrastructural evaluation of ESWL-induced acute renal lesions: pre liminary report. Eur. Urol. 16: 207-211 (1989).
Received: March 20, 1990 Accepted: May 23, 1990 Patrizio Rigatti, MD Divisione di Urologia Istituto San Raffaele Via Olgettina 60 1-20132 Milano (Italy)
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