Renal artery pseudoaneurysm: complication of minimally invasive kidney surgery.

PURPOSE: We retrospectively reviewed the charts of patients with renal artery pseudoaneurysms (RAPs) to document their clinical presentation, surgical background, and outcome. MATERIALS AND METHODS: In all, 7 of the 1965 patients who underwent percutaneous stone surgery and 3 of the 25 patients who underwent laparoscopic nephron-sparing surgery had a diagnosis of RAP and were treated accordingly. The most common symptom was hematuria, which was classified as early or delayed according to the time of presentation, as mild, moderate, or severe according to the hemodynamics of the patient. In addition, angiographic images were reviewed, and the correlation between the clinical presentation of RAP and its location was investigated. RESULTS: In the percutaneous stone surgery group, four patients experienced early mild to moderate hematuria and three experienced late moderate hematuria. All of the RAPs were located on the interlobar and arcuate arteries. In the laparoscopic nephron-sparing surgery group, one patient was asymptomatic, with diagnosis of renal-cell cancer recurrence at the 3-month follow-up, and had radical nephrectomy. Two patients presented with delayed moderate hematuria with lesions that were located on the interlobar, arcuate, and segmentary arteries. Two sessions of embolization were sufficient to stop bleeding in one patient with a segmentary artery aneurysm that had unfortunately lost kidney function during follow-up. CONCLUSION: There is no predictive factor for patients undergoing percutaneous nephrolithotomy procedure yet, but laparoscopic partial nephrectomy for tumors localized in the central portion of kidney may end up with RAP especially if no adjuvant sealing agents are used. The outcome of RAPs depends primarily on early recognition and a high index of suspicion, which facilitates correct diagnosis and appropriate management. Selective angiography and embolization together is the gold standard, both for diagnosis and treatment.

Horseshoe kidney: does it really have any negative impact on surgical outcomes of percutaneous nephrolithotomy?

OBJECTIVES: To compare the stone-free rate and complications between horseshoe and normal kidneys. METHODS: Between December 1997 and June 2008, a total of 2401 patients with 2618 renal units underwent percutaneous nephrolithotomy (PCNL). During this period, we retrospectively reviewed the data of 46 patients with 50 (1.9%) renal units with horseshoe kidneys treated by PCNL. We compared the success and complication rate in horseshoe kidney and normal kidney. RESULTS: Fifty PCNL were performed in the above-mentioned 46 patients with a mean age of 41.6 years. The average stone burden ranged from 100 to 4900 mm(2) (mean, 644 +/- 135 mm(2)). The stones were located in the renal pelvis in 13 (26%), calices in 17 (34%), and in both in 11 kidneys (22%). A single tract was used in 42 kidneys (84%), and 2 tracts were created in the remaining 8 (16%). Major complications were seen in 8 PCNL procedures (16%). A detailed comparison between horseshoe and normal kidneys showed that stone burden, operation time, stone-free rates, and auxiliary procedure rates were similar. The only statistically significant difference was detected in the number of access, which is more in normal kidneys. Logistic regression analysis did not reveal that horseshoe kidney did not have any negative effect on success after PCNL. CONCLUSIONS: Despite the anatomic abnormalities, PCNL is a safe and effective treatment option for calculi both in the horseshoe kidney and the normal kidney with the similar success and complications rates.

Percutaneous renal surgery in children with complex stones.

OBJECTIVE: We report our experience with percutaneous nephrolithotomy (PNL) therapy for staghorn or complex pediatric renal calculi. PATIENTS AND METHODS: We retrospectively analyzed the case records of 105 patients younger than 17 years who underwent PNL. The cases included 53 complex calculi analyzed in 51 patients. We defined complex calculi as either staghorn or those with a stone bulk larger than 300 mm(2), involving more than one calix, the upper ureter or stone in anomalous kidney. RESULTS: Mean age of patients with complex calculi was 9.7+/-0.7 years and stone burden was 654+/-92.4mm(2). The median duration of PNL was 90+/-4.7 (30-220) min. Complete clearance was achieved in 39 patients (73.6%). Of these, 32 (60.4%) required a single tract, while 21 (39.6%) required multiple tracts. With subsequent shock wave lithotripsy and PNL, the clearance rate increased to 86.8%. The average hemoglobin drop was 1.6+/-0.16 g/dL. Assessing the factors affecting the hemoglobin drop, the number of tracts (P=0.01) and size of tracts (P=0.002) were found to be significant. The mean change in serum creatinine concentration between preoperative and postoperative measurements was -0.01+/-0.02 mg/dL, for both patients with a single tract and those with multiple tracts. CONCLUSIONS: PNL is safe and effective in the management of staghorn and complex renal calculi in children. Tract dilatation and number of tracts are important factors in reducing blood loss.

Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease.

BACKGROUND AND PURPOSE: We investigated the impact of percutaneous renal procedures on estimated glomerular filtration rate (GFR) of patients with chronic kidney disease (CKD). PATIENTS AND METHODS: The GFRs of adult patients were calculated using the Modification of Diet in Renal Disease formula, and the patients were staged according to the Kidney Disease Outcome Quality Initiative CKD classification system. The study included 185 patients with preoperative GFR values less than 60 mL/min/1.73 m(2). The impact of percutaneous nephrolithotomy (PCNL) on GFR was analyzed by comparing the preoperative GFR with the GFR before discharge and at postoperative month 3. RESULTS: Patients with CKD had a significant increase in the GFR after the procedure. In postoperative month 3, the mean GFR was more than 60 mL/min/1.73 m(2) in 25% of the patients with CKD and less than 60 mL/min/1.73 m(2) in 75%. While all patients with stage 5 CKD improved to better stages, some other patients' conditions declined to stage 5 from better stages at the end of postoperative month 3. No patient needed dialysis. The presence of urinary tract infections tended to affect GFR negatively. CONCLUSION: Estimated GFR, as a better indicator of renal function, is significantly affected by the PCNL procedure. While significant improvement was observed in late-stage patients with CKD, unexpected deterioration could occur in patients at earlier stages.