Pyelo-hepatic abscess caused by staghorn stone infection: a case report.

BACKGROUND: The most common source of pyogenic liver abscess is biliary tract infection. Other less common routes include the spread of bacteria from distant foci. However, direct extension of a perinephric infection focus to the liver is extremely rare. CASE REPORT: The patient was a non-diabetic, immunocompetent, 29-year-old woman of mixed race ancestry with a history of recurrent urinary tract infections who was referred to our hospital because of an ultrasound-detected liver abscess. She was initially treated with metronidazole for 20 days at the referring institution for suspected amebic abscess without improvement. On admission to our center, she was febrile and complained of a dull right upper quadrant pain. A POCUS ultrasound suggested a pyogenic abscess, probably from a staghorn calculus infection. She received meroperem and amikacin for 22 and 10 days, respectively. Repeat hemocultures showed no growth, but urine cultures were positive for Proteus sp. Complete remission of clinical and imaging findings was observed under antibiotics. The patient was referred to the urology outpatient clinic to discuss the option of radical nephrectomy. CONCLUSION : This case underlines the high morbidity of staghorn calculi.

[Results of percutaneous nephrolithotomy using two accesses in the treatment of patients with staghorn stones].

INTRODUCTION: In order to improve clinical efficiency and reduce the risk of postoperative complications in patients with staghorn stones, we compared the results of original technique of biportal percutaneous nephrolithotomy (PCNL) with the standard PCNL. MATERIALS AND METHODS: The total of 221 patients with staghorn stones of K3-K4 was included in the study. The biportal PCNL was used in 109 patients, while the control group consisted of 112 patients. Inclusion criteria were stone size more or equal 2 cm, age over 18 years, absence of coagulopathy and width of the renal parenchyma more or equal 1 cm. On 1st postoperative day, ultrasound or plain urography was performed, while in patient with radiolucent stones, multi-slice computed tomography was used. In addition, complete blood count and biochemical profile were done. The main difference from the standard PCNL with sequential renal tracts is the simultaneous creation of the main and additional accesses when performing biportal PCNL. This method allowed two surgeons to simultaneously and synergistically perform lithotripsy and stone extraction from two accesses using a standard nephroscope in the main tract of 24 Ch and a miniaturized nephroscope in the additional tract of 16.5 Ch. RESULTS: The stone-free rate in the group of biportal PCNL was 80.7% (n=88), compared to 72.3% in the control group (n=81). Secondary interventions and additional procedures were required in 29 (26.6%) and 40 (39.2%) cases, respectively. The total number of infectious and hemorrhagic complications was higher in the control group. DISCUSSION: According to our data, significant advantages are observed in the group of biportal PCNL compared to the standard technique. CONCLUSION: Biportal PCNL can be recommended as a promising advancement of the technique traditionally used in the clinical practice.

[Unilateral combination of staghorn stone with kidney tumor].

This manuscript provides an overview of the available literature about unilateral combination of nephrolithiasis and renal tumor. Analysis of publications has shown that ipsilateral staghorn calculus and kidney tumors are an extremely rare combination. The majority of these infrequent papers describe case reports where the method of treating such patients is limited by the capabilities and competence of the surgeon or clinic. Despite some messages of favorable outcomes of combined interventions, the effectiveness of simultaneous laparoscopic partial nephrectomy and pyelolithotomy has not been studied, and the technique of this procedure, tactics and criteria for choosing this method are not defined.

A Multi-institutional Review of Single-access Percutaneous Nephrolithotomy for Complex Staghorn Stones.

BACKGROUND: With the heterogeneous distribution of novel surgical technologies and variable physician training, there is a need to re-evaluate contemporary outcomes of percutaneous nephrolithotomy (PCNL) for complex staghorn stones. OBJECTIVE: To evaluate contemporary outcomes of guideline-supported treatment for patients with staghorn kidney stones using single-access PCNL in multiple North American centers. DESIGN, SETTING AND PARTICIPANTS: We performed a multi-institutional retrospective review of staghorn stones managed from January 1, 2017 to January 1, 2019, inclusive. We excluded patients with more than a single percutaneous access per renal unit and those who underwent a concomitant contralateral procedure. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Safety (Clavien-Dindo complications) and efficacy in terms of a strictly defined stone-free rate were examined for single-access PCNL performed on staghorn stones with a Guy's stone score of 3-4. RESULTS AND LIMITATIONS: We evaluated 301 patients meeting the inclusion criteria with an average age of 57 yr (range 18-87). All stones had a Guy's stone score of 3 (36.2%) or 4 (63.8%). The mean (± standard deviation) stone burden was 191.4 ± 49.8 mm2. Of the 297 patients (98.6%) who underwent computed tomography on postoperative day 1, 132 (44.4%) showed no residual stone, 111 (37.3%) had a largest fragment <4 mm, and 54 (18.2%) had a fragment ≥4 mm after primary single-access PCNL. Secondary procedures were performed in 117 patients (38.9%). Imaging at 3 mo demonstrated that 210/257 patients (82%) were stone-free. The overall complication rate was 17.9%, with 11 patients (3.7%) experiencing Clavien-Dindo grade ≥3 complications. CONCLUSIONS: Single-access PCNL for complex staghorn stones is safe and effective. High stone-free rates with minimal morbidity are achievable with current techniques. PATIENT SUMMARY: This study confirms that single-access percutaneous nephrolithotomy provides excellent outcomes in the treatment of complex kidney stones. This surgical technique has both safe and effective outcomes that are reproducible across multiple centers in North America.

How I Do It: Modification of technique to safely position patients with super obesity in dorsal lithotomy for ureteroscopic management of kidney stones.

Obesity is a known risk factor for recurrent nephrolithiasis and it can be challenging to provide safe surgical intervention in the super obese population. Despite high weight limits on surgical beds, these often do not take into account positioning the patient on the end of the bed for dorsal lithotomy, which can risk an unsteady bed. In addition, depending on patient habitus the leg stirrups may not accommodate. There is limited literature that discusses the technical approach for positioning super obese patients in dorsal lithotomy when the weight limit approaches or exceeds the capacity of equipment available. In this article, we present a modified positioning technique to improve bed stability, which also provides an alternative if the patient's legs are not supported by available leg stirrups. From our experience, this modified dorsal lithotomy positioning for ureteroscopy is feasible and safe in patients with super obesity. Surgical intervention on this population requires appropriate planning and teamwork to ensure safe positioning.

Staghorn renal stones: what the urologist needs to know

ABSTRACT Patients with staghorn renal stones are challenging cases, requiring careful preoperative evaluation and close follow-up to avoid stone recurrence. In this article we aim to discuss the main topics related to staghorn renal stones with focus on surgical approach. Most of staghorn renal stones are composed of struvite (magnesium ammonium phosphate) and are linked to urinary tract infection by urease-producing pathogens. Preoperative computed tomography scan and careful evaluation of all urine cultures made prior surgery are essential for a well-planning surgical approach and a right antibiotics choice. Gold standard surgical technique is the percutaneous nephrolithotomy (PCNL). In cases of impossible percutaneous renal access, anatrophic nephrolithotomy is an alternative. Shockwave lithotripsy and flexible ureteroscopy are useful tools to treat residual fragments that can be left after treatment of complete staghorn renal stone. PCNL can be performed in supine or prone position according to surgeon's experience. Tranexamic acid can be used to avoid bleeding. To check postoperative stone-free status, computed tomography is the most accurate imaging exam, but ultrasound combined to KUB is an option. Intra-operative high-resolution fluoroscopy and flexible nephroscopy have been described as an alternative for looking at residual fragments and save radiation exposure. The main goals of treatment are stone-free status, infection eradication, and recurrence prevention. Long-term or short-term antibiotic therapy is recommended and regular control imaging exams and urine culture should be done.

Staghorn renal stones: what the urologist needs to know.

Patients with staghorn renal stones are challenging cases, requiring careful preoperative evaluation and close follow-up to avoid stone recurrence. In this article we aim to discuss the main topics related to staghorn renal stones with focus on surgical approach. Most of staghorn renal stones are composed of struvite (magnesium ammonium phosphate) and are linked to urinary tract infection by urease-producing pathogens. Preoperative computed tomography scan and careful evaluation of all urine cultures made prior surgery are essential for a well-planning surgical approach and a right antibiotics choice. Gold standard surgical technique is the percutaneous nephrolithotomy (PCNL). In cases of impossible percutaneous renal access, anatrophic nephrolithotomy is an alternative. Shockwave lithotripsy and flexible ureteroscopy are useful tools to treat residual fragments that can be left after treatment of complete staghorn renal stone. PCNL can be performed in supine or prone position according to surgeon's experience. Tranexamic acid can be used to avoid bleeding. To check postoperative stone-free status, computed tomography is the most accurate imaging exam, but ultrasound combined to KUB is an option. Intra-operative high-resolution fluoroscopy and flexible nephroscopy have been described as an alternative for looking at residual fragments and save radiation exposure. The main goals of treatment are stone-free status, infection eradication, and recurrence prevention. Long-term or short-term antibiotic therapy is recommended and regular control imaging exams and urine culture should be done.

Use 3D printing technology to enhance stone free rate in single tract percutaneous nephrolithotomy for the treatment of staghorn stones.

This study assesses the feasibility and effectiveness of using a three-dimensional (3D) printing model for preoperative planning in the treatment of full staghorn stones, specifically in the selection of the most optimal calyx for puncture. Twelve patients were enrolled in this trial. A preoperative CT taken in prone position was performed on each of the patients. 3D models were reconstructed using digital imaging and 3D printers. Three identical models were printed for each patient. Three puncture sites from the upper-, middle-, and lower-pole calyces of the kidney models were selected for simulation of percutaneous nephrolithotomy. The stone-free rates were recorded after each of the simulations. The puncture site that yielded the maximum SFR was translated to the patient for the actual procedure. CT was performed postoperatively on both patients and simulation models. The SFR of patients and simulation models was compared. Correlation analysis and consistency analysis suggested that there was a high degree of consistency between patients and 3D-printed models. The Pearson product-moment correlation coefficient r for the postoperative stone volume of the patients (PoSVP) and postoperative stone volume of the models (PoSVM) was 0.972 (P < 0.001, 95% CI = 0.900-0.992). The Bland-Altman plot of PoSVP to PoSVM showed an icon of 95% consistency 205.8(- 725.5 ~ 1137.1), and 100% of the points were within the 95% limits of agreement. 3D-printed models can potentially be used for preoperative planning in the treatment of full staghorn stones, especially in the selection of the most optimal calyx for puncture.

Squamous cell carcinoma of the renal pelvis presenting as an integumentary neoplasm of the flank: A case report.

RATIONALE: Although chronic pyelonephritis and urolithiasis are established risk factors for squamous cell carcinoma (SCC), only a minority of patients with chronic urolithiasis eventually develop SCC. It is believed that the chronic irritation leads to squamous cell metaplasia that may subsequently develop into SCC. Although studies show that SSC generally spreads locally with associated symptoms of lymphadenopathy, metastasis to the lungs and liver have also been reported. However, cases spreading to the flank have yet to be reported. Therefore, the use of reconstructive techniques for the repair of extensive soft tissue defects in the flank region after extended retroperitoneal resection, is unknown. PATIENT CONCERNS: We report a 54-year-old man who presented with a 1-month history of an enlarged skin mass on the right flank. DIAGNOSES: The patient was subsequently diagnosed with metastatic SCC involving the patient's integumentary system near the flank region proximal to the right kidney following percutaneous nephrostomy. INTERVENTIONS: The skin mass and the surrounding muscle tissue of the right flank were excised with a wide resection margin including radial nephrectomy. The soft tissue defect after resection was reconstructed using a unilateral gluteus maximus myocutaneous V-Y advancement flap. OUTCOMES: No recurrence of the SSC was found on follow-up CT performed 12 months postoperatively. LESSONS: In patients with long-standing nephrolithiasis complicated by staghorn stone-related infections, biopsies from suspicious lesions detected during percutaneous nephrolithotomy may facilitate early diagnosis. The modified gluteus maximus V-Y advancement flap may be a useful technique for the reconstruction of extensive soft-tissue defects involving the flank region.

Litiasis coraliforme / Coraliform litiasis

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Robotic Pyelolithotomy for the Intact Removal of a Complete Staghorn Calculus: A Feasible Approach Even After a Previous Open Pyelolithotomy.

OBJECTIVE: To describe the steps and technique of a robotic pyelolithotomy for complete removal of a left staghorn stone after a previous open pyelolithotomy. METHODS: The patient is placed in a left modified flank position with 4 laparoscopic ports placed: 12mm port for camera paramedian to the left of the midline, 8mm robotic port left lower quadrant at the level of the umbilicus, 8mm robotic port midclavicular line 2 finger breaths below the costal margin, 12mm Airseal assistant port paramedian infraumbilical. The white line of Toldt was incised and the colon was mobilized medially. Anterior Gerota's fascia was opened and tacked to the lateral abdominal wall exposing renal pelvis and parenchyma. An intraoperative ultrasound confirmed the underlying stone. A V-shaped Gil-Vernet pyelolithotomy incision was made and Prograsp forceps were used to manipulate the stone out of the renal pelvis. The collecting system was inspected and irrigated using the robotic lens. The pyelotomy was closed with 4-0 Monocryl suture on a TF needle in 2 lengths of suture, superiorly and inferiorly. Gerota's fascia was closed over the renal pelvis and the kidney was re-retroperitonealized by tacking the colon to the white line of Toldt. The specimen was retrieved through a mini-Pfannenstiel incision via a specimen bag. The patient was discharged on postoperative day 1 and seen in clinic 5 weeks later for stent removal. CONCLUSIONS: Robotic pyelolithotomy is a minimally invasive alternative that can be offered to patients with complete staghorn stones even after major open stone surgery. However case selection for this approach relies on the stone burden primarily in a dilated renal pelvis with limited calyceal projections. It is imperative to review preoperative imaging to understand the calyceal anatomy and the rotation required to free the stone from the collecting system.

Long-term effects of anatrophic nephrolithotomy on selective renal function.

To evaluate the long-term changes of selective renal function after anatrophic nephrolithotomy (ANL). A retrospective study was conducted for patients who underwent ANL between January 1995 and December 2016. Inclusion criteria were availability of preoperative and follow-up (1 year or more) radio-isotopic renal scans. Stone-free status was evaluated after 1 month with KUB and ultrasonography or NCCT. Renal isotope scans using 99mTc MAG3 were performed to measure the changes in selective function of the affected kidney (GFR%). Eligible patients were classified into two groups, group 1 patients with stable or improved function and group 2 patients with deteriorated function (> 5% decrease in GFR%). Univariate and multivariate analyses were performed to determine risk factors for deterioration of renal function. The cutoff value for any significant variable was determined using ROC curve. The study included 50 patients with mean age 43.8 + 13.9 years. Complications developed in 26 patients (52%), and stone-free status was documented in 42 patients (84%). After a median follow-up of 2.7 years (range 1-11), mean GFR% of all cases significantly decreased from preoperative value of 52.7% + SD 20 to 45.4% + SD 25% during follow-up (P < 0.001). Deterioration of GFR% was documented in 21 kidneys (42%). Cold ischemia time with a cutoff value 50 min was the independent risk factor (RR 3.986, 95% CI 1.069-14.869, P 0.039). The results of this study support limiting ANL to a selected group of patients and taking all the possible efforts to minimize cold ischemia time below 50 min.

Suctioning Minimally Invasive Percutaneous Nephrolithotomy with a Patented System Is Effective to Treat Renal Staghorn Calculi: A Prospective Multicenter Study.

OBJECTIVES: To investigate the safety, efficacy, and practicability of minimally invasive percutaneous nephrolithotomy (MPCNL) with the aid of a patented irrigation clearance system in treating renal staghorn calculi. METHODS: From August 2009 to July 2014, 4 hospitals had executed a prospective multicenter study with a total of 912 cases. The patients were randomly divided into 3 groups: suctioning MPCNL, standard percutaneous nephrolithotomy (PCNL), and traditional MPCNL groups. Multiple operative and perioperative parameters were compared. RESULTS: Blood loss and intrapelvic pressure in the suctioning MPCNL group were significantly less than those in the standard PCNL group. The average operation time, intrapelvic pressure, and amount of bleeding in the suctioning MPCNL group were better than those in the traditional MPCNL group. The suctioning MPCNL used one tract more frequently and 2 or 3 tracts less frequently than the standard MPCNL and traditional MPCNL groups. The stone-free rate by one surgery in the suctioning MPCNL group was significantly higher than that in standard PCNL and traditional MPNCL groups. CONCLUSIONS: Suctioning MPCNL using our patented system shows several advantages in treating renal staghorn calculi, including minimal invasion, shorter operation time, lower intrapelvic pressure, less bleeding and the need for a smaller number of -percutaneous tracts, and higher stone clearance rate by one -surgery.

A Gastric Duplication Cyst Initially Mimicking Staghorn Calculus.

Gastric duplication cyst is an uncommon anomaly typically found in the greater curvature of the stomach. It is usually diagnosed in children and quite difficult to diagnose in adult because of variable presentation. We present a 76-year woman who was admitted for abdominal pain of few weeks' duration. Her X-ray showed calcification in the region of left kidney, and she was subsequently managed with a presumptive diagnosis of staghorn calculus. Computerized Tomography (CT) scan of her abdomen disclosed calcification in the gastric wall for which an endoscopic ultrasound and biopsy was done. Findings were consistent with the presence of gastric epithelium and a diagnosis of gastric duplication cyst was made. Surgery was the continuation of care. The presence of symptomatic gastric cyst in an elderly patient is very rare. This is the first case in which gastric duplication cyst mimicked staghorn calculus on abdominal X-ray. Consequently, this diagnosis, though rare, should be considered in the differentials of upper abdominal pain.

Giant Urethral Calculus without Acute Urinary Retention.

A 46-year gentleman presented with a left-sided lumbar region pain without fever or dysuria. He denied episodes of acute urinary retention. There was a hard mass at the distal urethra with normal laboratory blood tests. Computed tomography urogram revealed a concurrent left renal staghorn calculus and large distal urethral stone. The urethral stone was fragmented via endourologic technique successfully. We report a case of a non-obstructing large urethral calculus in a gentleman with concurrent left renal staghorn calculus and discuss the literature review.

Prostatic abscess: a rare complication of staghorn calculi.

A staghorn calculus is a calculus accommodating the majority of a renal calyx extending into the renal pelvis. A conservative approach to its treatment may lead to high morbidity and mortality rates. Such morbidity usually manifests with renal failure, obstructed upper urinary tractand/or life-threatening sepsis. Prostatic abscesses have never been associated with staghorn calculi in the literature. We report a case of a 70-year-old man who presented with sepsis, which was found to originate from a complex prostatic abscess. The patient had no history of urinary tract infections or risk factors. The authors believe that the incidentally identified staghorn calculi promoted the growth of Proteus mirabilis which led to the development of the prostatic abscess. The patient underwent a transurethral resection and drainage of the abscess following a failed course of antibiotic therapy. This case also highlights the paucity of guidelines available in treating prostatic abscesses.

Laparoscopic Pyelolithotomy for Management of Complete Staghorn Stone of An Ectopic Pelvic Kidney.

A 40-year-old man was referred to our urology clinic due to vague abdominal pain and hematuria. Computed tomography (CT) without contrast material visualized an ectopic kidney in the left iliac fossa with a complete staghorn stone. Under general anesthesia, operation was done in supine position with a gentle lateral elevation on the right side. The surgeon stands on the right side of the patient. First, a 12 mm port was inserted at the umbilicus using the Hasson technique. After creation of pneumoperitoneum, operation was done by three 5 mm trocars were arranges as paraumbilical, the point between umbilicus and inguinal canal at left and right side.A vertical pyelotomy incision was made over the anterior pelvic wall and then extended to a cross figure. The stone extracted intact with a laparoscopic stone grasper and placed in endobag. A short double J stent was placed via the pyelotomy incision and renal pelvis was closed using continuous 4.0 vicryl sutures. He was discharged from hospital after 3 days without any complication.