Full text of DOI:10.1089/end.2000.14.715

JOURNAL OF ENDOUROLOGY
Volume 14, Number 9, November 2000
Mary Ann
Liebert, Inc.
Controversial Cases in
Endourology
STEPHEN Y.
M.D., AND YOSHINARI ONO, M.D.
NARADA,
Section Editors
CASE PRESENTATION
If the stone is in
a
caliceal diverticulum, it is difficult, and
to eradicate it
SWL alone.
sometimes
ment
impossible,
is made
using
Frag¬
WOMAN
flank
to the office with
She had an abdominal ra¬
a
3-
difficult if the diverticulum
presents
pain.
passage
particularly
A36-YEAR-OL
o
D
f
is in
a
Even if the stone
the
year history
right
dependent position.
fragments well,
that result often do not to the outside because of the
pass
a
1-cm stone over the
diograph demonstrating
right kidney (Fig.
pieces
1
), and
a
subsequent intravenous urogram demonstrated that the
small lumen of the neck of the diverticulum.
is an in this circumstance as well. The
stone was in the
She underwent Shockwave
collecting system.
Ureteroscopy
option
without success and
a
here would be to
the
to the diver¬
Next,
the neck of the di¬
lithotripsy
nephrolithotomy through a lower-pole
was not seen
subsequent percutaneous
approach
identify
opening
access in which the stone
ticulum and
pass a
wire
it.
through
and flexible
She re¬
verticulum is balloon dilated to allow access to the stone for
despite rigid
non-contrast CT scan
nephroscopy.
She continues to
turns with
have
pain,
a
with the holmium laser.
are washed or basketed
the stone
of the di¬
(
Fig. 2).
fragmentation
Optimally,
and her abdominal
remains
out,
and the
radiograph
unchanged.
fragments
verticulum is
lining
She is thin and otherwise
of this stone.
and insistent on eradication
to obliterate the diverticulum and
healthy
fulgurated
vent future stone formation. This
pre¬
is tedious and
process
but it can be effective. If the
requires
patience,
cutaneous tube is not
approach
works,
a
per¬
A
double-J stent should be
necessary.
EXPERT OPINIONS
at the termination of the
placed
procedure.
percutaneous-retrograde approach.
I
would use
a
combined
No.
1
First, with the patient in the prone position,
a
flexible uretero-
The
to confirm its
The first
I
would do is to review the
and
of reasons
is
into the
thing
urogram
try
scope
guided up
pelvocaliceal system.
opening
to
where the stone lies. There are
a
to the diverticulum is identified and is
clarify
couple
opacified
the stone
not have been seen at the time of
in relation to the stone.
I
then advance
a
or 15-
might
percutaneous
not
position
mm
5-, 10-,
For
the
Nitinol snare into the diverticulum to
access. This maneuver is
nephroscopy.
example,
pelvocaliceal system may
Amplatz gooseneck
have been examined
all of the
In
the likelihood of serve as
a
for
completely.
general,
is little less when the
In most cases, the lower
target
percutaneous
very
of
a
when stones are not
seeing
pelvocaliceal system
helpful
particularly opaque.
by placing
is advanced
access tract is in the lower
Percutaneous access is then obtained
the
pole.
pole
factor that can make ma¬
tip
is more anterior than the
upper pole, a
the access needle in the snare.
Sometimes, it the snare via the needle. The snare is then
A
guidewire
though
of the flexible
down on
the
nipulation
endoscope challenging.
snugged
is
not
to examine all the calices from
a
the
and the wire is
down the
simply
possible
single
wire,
pulled
ureter, through
access tract. It
to
contrast medium and use flu-
and out the urethra. Tract dilation can then be done in
important inject
bladder,
to determine that all of the
standard fashion
the
dilator of choice.
oroscopy during nephroscopy
sys¬
using
urologist's
the stone can be
tem has been examined.
On
into the
ultrasonic
entry
diverticulum,
with
fragmented
removal of the
However, the most likely reason that the stone was not seen
is that it is in
caliceal diverticulum. In almost all circum¬
using
pieces.
lithotripsy
subsequent
the interior of the diverticulum
a
I would then
fulgurate
stances, the neck of the diverticulum can be seen
using a
with the intent of
it. I would dilate the neck of the
obliterating
ureteroscopic approach.
diverticulum and fulgurate it as well.
A
nephrostomy tube (e.g.,
If the stone
offer the
taneous
to be in
a
calix or the the
SWL
I
would
14F
is in the renal
At
a
later
an
proves
the
pelvis,
Cope loop)
antegrade nephrostogram
date,
placed
pelvis.
of
a
treatment, percu¬
is done to ensure that the
is
patient
option
repeat
patient
or
with holmium laser
stone free and that there is no obstruction of the ureter. The
nephrolithotomy,
ureteroscopy
If the stone is
hard
calcium ox¬
tube
then be removed.
lithotripsy.
particularly
(e.g.,
may
alate), it may respond to another Shockwave treatment. Opti¬
the would be treated with
a
Dornier HM-3 or Sie¬
Robert C.
Newman,
M.D.
mally,
patient
mans Lithostar with shock tube C, with the
of
University of Florida College of
Medicine
Florida
goal
delivering
the maximum amount of
energy possible.
Gainesville,
715

716
NARADA AND ONO
No.
2
This
has
a
1-cm stone in the
of her
patient
posterior portion
which is the
cause of her
assume that she has not been having
flank
right kidney,
probable
right
pain.
I
with urinary
problems
tract infection, as this was not mentioned in the clinical intro¬
duction. Shockwave
was not successful, and
stone
nephrolitho¬
a
lithotripsy
was not seen at the time of
attempted percutaneous
The aforementioned
suggest an associated col¬
tomy.
lecting system abnormality
The renal
findings
such as
a
caliceal diverticulum.
anatomy needs to be defined in
renal function is normal, she should
which should include pos-
collecting system
this case. If the
patient's
intravenous
undergo
urography,
teroanterior, lateral, and oblique images with delayed
films. If
anatomic information or
this
the
does not
study
patient
provide adequate
has renal insufficiency, retrograde pyelography
us¬
similar directional
should be undertaken.
Ifthis stone is demonstrated to be in
ing
imaging
a
caliceal diverticulum,
I
would recommend that percutaneous nephrolithotomy be un¬
dertaken
the stone with subsequent ful-
by directly accessing
of the
be
after stone removal. This procedure could
guration
probably
cavity
via an infracostal access if the nee¬
accomplished
dle was inserted into the
I
would
week and
cavity
during deep inspiration.
leave
a
tube in the diverticular cavity for about
1
would not
The
to insert it into the
system proper.
attempt
collecting
technique
results with this
are excellent: stone-
reported
free rates >90%, resolution of symptoms in >90% of patients,
and correction of the
anatomic abnormality in al¬
underlying
most 90% of individuals.112
ureteroscopic approach is another option. The
A
retrograde
diverticular ostium is usually
easy to see and can be di¬
fairly
FIG. 1. Abdominal film
kidney.
showing 1-cm stone
overlying right
lated with
quate access
a
12F balloon. This dilation
ade¬
usually provides
stone, allowing intracorporeal lithotripsy,
to the
FIG. 2.
slice from non-contrast CT scan demonstrating 1-cm stone within right kidney.
Representative

CONTROVERSIAL CASES IN ENDOUROLOGY
717
the holmium laser
free rates with this
tool of choice. The
are
stone-
be evoked
means of valve-like action of the stone itself and
being my
approach
reported
by
60%.13,14 Other could be relieved
if stone removal was successful.
approximately
only
treatment
for such cases include
with ablation of the diverticular
or
Such calculi are difficult to
with SWL and to vi¬
The best treat¬
options
open
laparoscopic
fragment
Ultra-
sualize via
ment is to make
nephrolithotripsy
a
nephrolithotomy
cavity.
lower-pole nephroscopic approach.
can be used to
are
locate the stone. These more
however.
a
direct
and
to the stone
percutaneous
sonography
help
approach
it
by
invasive
the Ho:YAG laser.
techniques
rarely necessary,
fragment using
If this stone were demonstrated to be in the
The success of percutaneous treatment is dependent mainly
collecting sys¬
tem
I
would consider
on
the best tract
to the stone. It is easy to
proper,
directly accessing
the
the best chance of
percutaneous nephrolithotomy by
making
directly
the
calix, as this would
achieve direct puncture under ultrasound
However,
stone-containing
give
guidance.
case with
long epidural needle
puncture needle. An epidural nee¬
stone free and limit the frus¬
dilatation of the tract is very difficult in such
a
a
small
patient
being
multiple
would be
tration that is associated with
treatment failures. An¬
space around the stone.
I
prefer to use
a
other
in this
ureterorenoscopy
rather than
a
standard
option
and holmium laser
setting
lithotripsy.
retrograde
long
dle is stiffer than the standard one, and its tip is designed to
control the direction of the
For dilatation of the tract,
and the dilatation
guidewire.
of dilator is
Dean G. Assimos, M.D.
Wake Forest University School Medicine
a
metal antenna
type
performed gently, keeping
Winston-Salem, North Carolina of the dilator all the time.
preferable,
should be
the stone
feeling at
the tip
of
Once the stone can be observed,
is not so dif¬
in the visual field. Gentle
For stone
fragmentation
ficult unless one misses the
movement of the
target
nephroscope
is
mandatory.
frag¬
REFERENCES
mentation,
stone looks
tation is
I
recommend
the Ho:YAG laser because this
using
hard on CT scan, and
of the
stone
very
elegant
fragmen¬
limited around
space
1.
Bellman GC, Silverstein JI, Blickensderfer S, et al:
and
Technique
of caliceal diverticula.
mandatory because
very
of
follow-up
percutaneous management
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Urology 1993;42:21.
It is unclear whether the narrow neck of the calix or caliceal
diverticulum needs to be dilated after stone removal.
2
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Ellis JH, Patterson SK, Sonda LP, et al: Stones and infection in re¬
nal caliceal diverticula: Treatment with
percutaneous procedures.
AJR Am
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Roentgenol
1991;156:995.
Yoshihiko Hirao, M.D.
Nara Medical University
Nara, Japan
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M,
W, Fernandez R, et al: Percutaneous (endo) in-
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Hedelin H, Geterud K, Grenabo L, et al: Percutaneous surgery for
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pyelocaliceal
5.
Hendriks AJM, Bierkens AF, Bos R, et al: Treatment of stones in
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caliceal diverticula:
shock wave
lithotripsy versus
Extracorporeal
Br
J Urol 1992;70:478.
percutaneous nephrolitholapaxy.
review
First,
I
would
was
go
back to basics. We need to do
(or
6.
Hulbert JC,
fulguration
S,
large
PK, et al: Percutaneous
Lapointe
Reddy
volume caliceal diverticulum.
endoscopic
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if the
done)
a
careful
study
previously
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of
a
to make sure where this stone is
We also must
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gram
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1
38:116.
assess whether the calix the stone is in is
excluded from the
partially completely
7
.
Hulbert JC,
PK, Hunter DW, et al: Percutaneous
Reddy
techniques
the
it is
for the
of caliceal diverticula
calculi.
J
Urol
collecting system. Despite
urogram
possible
management
containing
the stone to be in the
1
986;135:225.
showing
collecting system,
8
.
Jones JA,
JE, Steidle CP: The roles of
and
that the infundibulum of the calix is so narrow that it was in¬
Lingeman
extracorporeal
in the
shock wave
missed on flexible intrarenal
endoscopy at
the time
lithotripsy
percutaneous nephrostolithotomy
advertently
of
diverticula.
J
Urol 1991; 146:724.
was carried out.
also be
management
pyelocaliceal
the percutaneous procedure
9
.
EK: Percutaneous
of ca-
1991; 181:
Lang
infundibuloplasty: Management
Plain renal
in some cases
tomography may
helpful
diverticula and infundibular stenosis.
lyceal
Radiology
to delineate
the location of the stone. Careful
exactly
of the stone location is essential to the creation of
mapping
871.
a
successful
10.
EK, Glorioso LW:
percutaneous access routes to
Lang
multiple calculi, calculi
culi.
1986;158:211.
Multiple
of attack that will solve the
in detail to the
I would then
the situation and the likelihood
plan
explain
patient's problem.
in caliceal diverticula, and
staghorn cal¬
patient
Radiology
caliceal diverticula
of success with
of
a
number of
However, SWL or
1. Shalhav AL, Soble JJ, Nakada SY, et al: Long-term outcome of
any
options.
1
indirect access
are both
to fail
a sec¬
following percutaneous endosurgical manage¬
Urol 1998;160:1635.
2. Thomas R,
M, Castaneda WR:
repeat
nephroscopy
likely
ment.
J
ond time if tried again. Direct access percutaneous therapy is
1
1
1
management of the
to the sympto¬
most
to achieve success.
Monga
diverticulum.
3. Batter SJ, Dretler SP:
Optimum
option
The best solution for
access to the stone and into the affected
likely
J
Urol 1997;158:709.
a
stone
of this
is
a
direct
in
calyceal
problem
type
Ureterorenoscopic approach
matic caliceal diverticulum. Urol 1997;158:709.
4. Grasso M:
with the holmium laser as an endoscopic
percutaneous
the This
region
ac¬
J
entail
a
or an
kidney.
may
mid-kidney
upper-pole
Experience
1996;48:199.
cess. These routes will often be above the 12th, ll*, or even
lithotrite.
Urology
the 10th rib. However,
I
have
found it
renal stone.
risk of
to
rarely
necessary
go
than the 11th rib to access
a
Although these
higher
high
No.
3
accesses
carry a slightly greater
such
complications
The calculus seems to be
verticulum. The
in the calix or caliceal di¬
of
as pneumothorax, the probability of success is much higher than
via
with an access.
lodged
right flank pain might
a
persistent symptom
approach
lower-pole

718
NARADA AND ONO
A
B
!
9>5<>t2
RI URETER05C0PV
FIG. 3.
obtained
flexible
(A)
Ureteroscope
deflected onto stone. (B) Flexible uretero¬
Fluoroscopic images
during
ureteroscopy.
inside excluded diverticulum after laser incision.
scope
it is
to coil
easy
a
wire (i.e., Glidewire) in an oc¬ Editor's Note
Generally,
cluded calix and create
a
direct access to the stone via standard
If the infundibulum is in¬
We thank Dr. Ono for
Dr. Hirao of Nara Medical
inviting
percutaneous puncture techniques.
to comment on this case. As
the
verticular stones remains
judged by the responses
University
deed occluded, it
infundibuloplasty
be
to
an
may
necessary
perform
endoscopic
from our
of caliceal di¬
experts,
endourologic management
via the direct access. This can include bal¬
loon dilation or incision of the affected stenotic area.
In
technically complex.
any patient
renal stone,
A
percu¬
who has failed
multiple
treatments for
that an
a
solitary
taneous tube and
ureteral catheter or stent should be
antegrade
the
should
anatomic ab¬
urologist
suspect
unrecognized
left in
place as
needed.
is
normality
present.
The treatment
was to
plan
perform retrograde ureteroscopic
calix or
Joseph Macaluso, Jr., M.D.
access and laser lithotripsy of the stone in either
a
a
The
Institute
New Orleans
caliceal diverticulum. It was belief from the
Urologic
of
my
layered ap¬
Gretna, Louisiana
pearance of the stone on the preoperative CT scan that it was
B
FIG. 4.
views
(A)
to stone location on
(B) Inside of
Endoscopic
during surgery.
Papilla corresponding
fluoroscopic images.
excluded diverticulum with few
stone
which were
fragments,
removed.
remaining
subsequently

CONTROVERSIAL CASES IN ENDOUROLOGY
719
in
a
caliceal diverticulum. If
was
was unsuccessful,
removed. The
stone disease or
he is interested in
is otherwise
with no
of
and
ureteroscopy
planned
patient
healthy,
history
in that same session.
He works as
minimally invasive solution.
a
percutaneous therapy
urologic surgery.
carpenter,
we found that when the
at the stone
of the flexible
the same
a
Intraoperatively,
tip
was
ureteroscope
pointed
fluoroscopically,
was in view
was seen
3A and 4A). No diverticular neck or
throughout
papilla
(Figs.
the
an
opening
collecting system despite
exhaustive search. We elected to incise the
the
READERS' RESPONSES
papilla using
holmium laser and found an excluded calix full of stone
frag¬
ments
3B and 4B). The
were
and re¬
for our readers:
(Figs.
fragments
irrigated
Questions
moved, and the incision was enlarged to allow ample drainage
of this now "included" diverticulum. The
patient's symptoms
1. How would
2. What are the best alternatives?
and
you proceed
why?
resolved
immediately postoperatively.
Y. Nakada, M.D.
SlG]Stephen
[
University of Wisconsin Hospital and Clinics
Madison, Wisconsin
Please return
responses:
•
Mail:
Controversial Cases in
Endourology
UPCOMING CASE PRESENTATION
c/o
Y. Nakada, M.D.
Stephen
of
Division of
Department
University
Surgery,
Urology
A
flank
old man
He underwent stent
tion for acute obstruction, which verified the
with
a
2-month
of left
of Wisconsin Medical School
4
8-year
presents
history
at an outside institu¬
G5/343 Clinical Science Center
pain.
placement
of
a
600
Avenue
presence
Highland
Madison, WI 53792
horseshoe
and
Fol¬
kidney
ureteropelvic junction configuration.
CT
reveals
a
left-sided 1-cm renal
low-up spiral
pelvic
angiography
•
•
stone and no anterior
vessels
5).
A
diuretic
E-mail:
crossing
(Fig.
nakada@surgery.wisc.edu
renal scan reveals
function
and
ob¬
good
bilaterally
significant
struction, with
a
half-time clearance of 26 minutes with the stent
Fax: 608/262-6453
FIG. 5.
no anterior
CT
with three-dimensional reconstruction
horseshoe
left ureteral stent, and
Spiral
crossing
angiography
demonstrating
kidney,
vessels. Stone is not seen
clearly in this image but is present.