Propensity score matched analysis of treatment outcomes in pediatric ureteropelvic junction obstruction: a comparison between horseshoe and non-horseshoe kidneys.

BACKGROUND: Pediatric hydronephrosis poses distinct challenges, particularly in cases involving horseshoe kidneys (HSK). This retrospective study compares treatment outcomes between HSK and non-horseshoe kidneys (NHSK) in pediatric ureteropelvic junction obstruction (UPJO) patients. METHODS: A retrospective cohort study included 35 patients with HSK and 790 patients with NHSK undergoing pyeloplasty. Preoperative, intraoperative, and postoperative parameters were evaluated. Propensity score matching (PSM) balanced patient characteristics in the NHSK group. RESULTS: In comparison with NHSK, HSK exhibited a higher crossing vessel incidence (51.6% vs. 5.12%, P < 0.001) and smaller preoperative anteroposterior pelvic diameter (APD). Post 6 and 12 months, NHSK maintained a larger APD, with a higher P/C ratio at 12 months. PSM retained significantly higher crossing vessel incidence in HSK (51.6 vs. 3.61%, P < 0.001). Laparoscopic pyeloplasty (LP) in HSK showed lower postoperative length of stay (LOS). Postoperative ultrasound parameters favored NHSK. In HSK and NHSK with crossing vessels, HSK demonstrated higher complications even post-PSM (38.5% vs. 0%, P = 0.039). CONCLUSIONS: The study emphasizes the importance of recognizing crossing vessels in HSK-related hydronephrosis. Surgical success, although comparable between HSK and NHSK, requires tailored approaches. This investigation contributes valuable insights to pediatric urology, emphasizing personalized management for optimal outcomes.

[A Case of Sigmoid Colon Cancer with Horseshoe Kidney].

We reported a case of sigmoid colon cancer with horseshoe kidney. A 79-year-old man had lower abdominal pain and underwent colonoscopy. The results of colonoscopy revealed sigmoid cancer. Preoperative computed tomography revealed horseshoe kidney. He underwent radical laparoscopic surgery. The histopathological diagnosis was pStage Ⅱa(The 9th Edition). He has not recurred 22 months later after operation. Surgery for colorectal cancer with congenital anomalies of the urinary tract requires attention to intraoperative secondary injuries. Therefore, preoperative evaluation using 3D-CT is useful tool for safety. Operating the proper dissecting normal layer would make safe laparoscopic operation possible without unexpected injuries.

Retrograde intrarenal surgery for stones associated with renal anomalies: caliceal diverticulum, horseshoe kidney, medullary sponge kidney, megacalycosis, pelvic kidney, uretero-pelvic junction obstruction.

PURPOSE OF REVIEW: Nowadays, due to the increase of imaging diagnosis, we identify easily renal anomalies, and we can choose between a wide range of armamentarium to treat symptomatic stones in those challenging cases. However, there is a lack of evidence and consensus on its use. The aim of this narrative review is to collect all the available data about safety and efficacity of retrograde intrarenal surgery (RIRS) in the treatment of kidney stones associated to a renal anomaly. RECENT FINDINGS: Renal anomalies are uncommon findings and even more if it has to be associated with renal stones. After a literature review of the past 2 years, there are a small number of studies that compare the outcomes in patients who have been treated with minimally invasive modalities and they are mainly focus on RIRS. SUMMARY: It is of extreme importance to know the advances on the stone treatment in anomalous kidneys. With the development of new laser technologies, RIRS is becoming a more interesting technique with high success rate and safety. Further studies are needed to make an accurate statement about the adequate surgical technique for each renal anomaly and also, clinical trials using new laser technologies.

Robot-assisted modified bilateral dismembered V-shaped flap pyeloplasty for ureteropelvic junction obstruction in horseshoe kidney using KangDuo-Surgical-Robot-01 system.

PURPOSE: Horseshoe kidney (HSK) is the most common renal fusion anomaly, occurring in 0.25% of the population (1). It presents technical obstacles to pyeloplasty for ureteropelvic junction obstruction (UPJO) despite robotic assistance (2, 3). KangDuo-Surgical-Robot-01 (KD-SR-01), an emerging robotic platform in China, has yielded satisfactory outcomes in pyeloplasty (4, 5). We first describe our modified technique of robotic bilateral pyeloplasty for UPJO in HSK using KD-SR-01 system in the Lithotomy Trendelenburg position. MATERIALS AND METHODS: A 36-year-old man with HSK and bilateral UPJO suffered right flank pain due to renal calculi (Figure-1). Repeated double-J stent insertion and ureteroscopy lithotripsy did not relieve his symptoms. A robot-assisted modified bilateral dismembered V-shaped flap pyeloplasty was performed using KD-SR-01 system in the Lithotomy Trendelenburg position. RESULTS: Total operative time was 298 minutes with 50 ml estimated blood loss. There was no conversion to laparoscopic or open surgery. A follow-up of 14 months showed relieving symptoms and stable renal function. Cine magnetic resonance urography and computed tomography urography revealed improved hydronephrosis and good drainage. No intraoperative or postoperative complications occurred. CONCLUSIONS: It is technically feasible to perform a KD-SR-01-assisted modified bilateral dismembered V-shaped flap pyeloplasty in the Lithotomy Trendelenburg position for HSK. This procedure achieves managing UPJO on both sides without redocking the system and provides a wider operative field. In addition, it may be associated with better ergonomics, better cosmetic outcomes, and less possibility of postoperative bowel adhesion. However, further investigation is still warranted to confirm its safety, efficacy, and advantages over traditional procedures.

Maximizing Nephron Mass in Horseshoe Kidney Transplantation Using Inferior Epigastric Artery: Case Report.

Due to the progressive shortage of donors, kidneys with congenital anomalies are considered for transplantation. We report a successful transplantation of a split horseshoe kidney from a deceased donor by using the inferior epigastric artery with an end-to-end anastomosis, supplying the isthmus. Thus, we preserved as much as possible the functional parenchyma for a good long-term outcome. The learning point is that the use of the right inferior epigastric artery seems to be a good solution to perfuse the lower artery in order to avoid its ligation, thus reducing the nephron mass of the graft.

Role of the three-dimensional printing technology incomplex laparoscopic renal surgery: a renal tumor in a horseshoe kidney.

PURPOSE: To report our initial experience using a patient-specific 3D-printed renal tumor model for the surgical planning of a complex heminephrectomy in a horseshoe kidney. MATERIALS AND METHODS: We selected a clinical case for a complex laparoscopic surgery consisting in a 53 year-old male presenting a local recurrence of a renal tumor in a horseshoe kidney with aberrant vascularisation previously treated with a laparoscopic partial nephrectomy. He is now proposed for a laparoscopic left heminephrectomy. Along with conventional imaging, a real-size 3D-printed renal model was used to plan de surgical approach. The perioperative experience of the surgical team was recorded. RESULTS: The surgical team found the patient-specifi c 3D printed model useful for a better understanding of the anatomy and an easier surgical planning. CONCLUSION: The use of patient-specifi c 3D-printed renal models seem to be helpful for the surgical planning in complex renal tumors.

[Horseshoe kidney tumor laparoscopic surgery. First 19 cases].

INTRODUCTION: Although horseshoe kidney (HSK) is the most common congenital anomaly of the upper urinary tract, renal cell cancer (RCC) in HSK develops extremely rarely. Until 2012 y. there were less than 200 cases of RCC in HSK published in PubMed. Only five cases of laparoscopic partial nephrectomies and some cases of heminephrectomies have been described in PubMed. AIM: To conduct a multicenter retrospective analysis of laparoscopic surgery for tumors in HSK. MATERIAL AND METHODS: From January 2013 to December 2018 a total of 19 conventional laparoscopic interventions were performed in patients with RCC in HSK, including 1 isthmusectomy, 5 partial nephrectomies and 13 heminefrectomies. In addition, 16 divisions of isthmus were done in 15 patients. The video describing our operation technique is available on: http://youtu.be/nk-WlbjNtIs . RESULTS: There were no conversions to open surgery and mortality as well as intra- and postoperative complications of Clavien grade 3 or higher. Warm ischemia time during partial nephrectomy didnt exceed 19 minutes. Operative time ranged from 110 to 270 min, while max estimated blood loss was 400 ml. All patients were followed for 6 month and no case of disease recurrence or progression was noted. CONCLUSIONS: The small number of laparoscopic interventions in patients with RCC in HSK doesnt allow to carry out a proper statistical analysis and draw certain conclusions. We presented the largest experience available in the literature and our results demonstrate the efficacy and safety of conventional laparoscopic technologies in the treatment of RCC in HSK.

Intraoperative utilization of advanced imaging modalities in a complex kidney stone case: a pilot case study.

PURPOSE: Despite the increasing use of advanced 3D imaging techniques and 3D printing, these techniques have not yet been comprehensively compared in a surgical setting. The purpose of this study is to explore the effectiveness of five different advanced imaging modalities during a complex renal surgical procedure. METHODS: A patient with a horseshoe kidney and multiple large, symptomatic stones that had failed Extracorporeal Shock Wave Lithotripsy (ESWL) and ureteroscopy treatment was used for this evaluation. CT data were used to generate five different imaging modalities, including a 3D printed model, three different volume rendered models, and a geometric CAD model. A survey was used to evaluate the quality and breadth of the imaging modalities during four different phases of the laparoscopic procedure. RESULTS: In the case of a complex kidney procedure, the CAD model, 3D print, volume render on an autostereoscopic 3D display, interactive and basic volume render models demonstrated added insight and complemented the surgical procedure. CAD manual segmentation allowed tissue layers and/or kidney stones to be made colorful and semi-transparent, allowing easier navigation through abnormal vasculature. The 3D print allowed for simultaneous visualization of renal pelvis and surrounding vasculature. CONCLUSIONS: Our preliminary exploration indicates that various advanced imaging modalities, when properly utilized and supported during surgery, can be useful in complementing the CT data and laparoscopic display. This study suggests that various imaging modalities, such as ones utilized in this case, can be beneficial intraoperatively depending on the surgical step involved and may be more helpful than 3D printed models. We also present factors to consider when evaluating advanced imaging modalities during complex surgery.

Head-to-Head Comparison of Modified Laparoscopic Pyeloplasty and Robot-Assisted Pyeloplasty for Ureteropelvic Junction Obstruction in China.

OBJECTIVE: To compare the outcomes of modified laparoscopic pyeloplasty (LP) and robot-assisted pyeloplasty (RLP) for ureteropelvic junction obstruction (UPJO) in China patients. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients who underwent modified LP and RLP using a transperitoneal laparoscopic approach at 2 different medical institutions between October 2009 and November 2017. RESULTS: Seventy-six patients underwent modified LP and 140 patients underwent RLP. No open conversion occurred. The mean operative time of RLP was shorter than that of modified LP (p = 0.042). For UPJO concomitant with renal calculi, there was no difference in operative time between 2 groups (p = 0.656). With RLP, the operative time for UPJO concomitant with horseshoe was shorter (p = 0.011). In terms of complication rate, there was no significant difference between 2 groups (p = 0.596). The postoperative hospital stay for modified LP was shorter than that for RLP (p < 0.05). The mean follow-up time for modified LP and RLP was 31.79 months and 10.85 months respectively (p < 0.05). The success rate was 96.05 and 97.86% for modified LP and RLP, respectively (p = 0.736). CONCLUSIONS: Modified LP and RLP are safe and efficient treatment for UPJO with similar success rates.

Organ-Preserving Surgical Treatment of a Horseshoe Kidney Occupied by a Large Renal Cell Carcinoma with Extensive Venous Invasion: A Case Report.

The horseshoe kidney is one of the most common congenital disorders affecting the urogenital system. Following a fusion of the lower kidney poles, which in turn lead to the formation of an isthmus, this anatomical variation is accompanied by other characteristic properties like an incomplete ascension, ventral rotation of the pelvices as well as atypical vascular supply. Even though renal carcinoids and Wilms tumors are more common in horseshoe kidneys, the incidence of renal cell carcinomas seems to be unaffected. Here we report the case of a locally advanced renal cell carcinoma with extensive venous invasion occurring in a horseshoe kidney and its complex surgical management. The whole primary tumor as well as a majority of venous tumor thrombi could be removed by a combination of 2/3 nephrectomy and cavotomy with thrombectomy. During 1 year of follow-up, the patient neither suffered from a tumor relapse, nor did he require renal replacement therapy. Thus, we conclude that even in cases of RCC where advanced disease is associated with complex anatomical situations, organ-preserving surgical treatment should be pursued to achieve excellent functional and oncological results.

Safety and efficacy of PNL vs RIRS in the management of stones located in horseshoe kidneys: A critical comparative evaluation.

AIM: To assess the efficacy and safety of two different techniques (Percutaneous nephrolithotomy (PNL) vs Retrograde intrarenal surgery (RIRS)) in the management of stones in patients with horseshoe kidneys (HSK). PATIENTS AND METHODS: Departmental files of 88 cases with radiopaque kidney stones in horseshoe kidneys undergoing two different approaches (PNL vs RIRS) were evaluated with respect to the success and complication rates of in a retrospective manner. In addition to the factors related with the procedures (success and complication rates, additional procedures), patient and stone characteristics were all well evaluated. Findings obtained in both groups were evaluated in a comparative manner with respect to the statistical significance. RESULTS: Stone free rates were comparable in both groups after 1-week period (81.6% PNL vs 80% RIRS). As well as 3 months evaluation (84.2% PNL and 82.0% RIRS). The percentage of the cases with residual fragments (> 4 mm) were similar in both groups and while all PNL procedures were completed in one session, mean number of RIRS sessions was higher (1.22 ± 0.05). Mean duration of the procedure was slightly higher in RIRS group and based on Clavien scoring system, despite a higher risk of Hb drop noted in patients treated with PNL, all complication rates were found to be similar in both groups. CONCLUSION: Our results demonstrate that of the available minimally invasive treatment alternatives, both PNL and RIRS could be safe and effective alternatives for renal stone removal in patients with HSK.

[High ureteral insertion as the cause of extreme hydronephrosis in a 5-year-old child with horseshoe kidney].

The incidence of horseshoe kidney is 1 per 400-800 live births. From 44-52% of the patients with horseshoe kidney have other coexisting abnormalities of the urinary tract, such as hydronephrosis, vesicoureteral reflux and a duplex collecting system. Our patient, a 5-year old boy, was admitted to a pediatric nephrology department because of abdominal pain and vomiting. He had ultrasonography of the abdomen performed for the first time at the age of 9-months and horseshoe kidney was shown. In a control ultrasonography, a mild dilatation of the pyelocalyceal system in the left kidney was described. On the day of admission, an abdominal ultrasound confirmed horseshoe kidney with large left hydronephrosis. Power Doppler ultrasonography showed two renal arteries to the left kidney and no arterial compression on the ureter. Dynamic scintigraphy (99mTc-EC) revealed left-sided hydronephrosis with high isotope intake up to 55% ERPF, a prolonged time of tissue perfusion and signs of subpelvic junction obstruction. Magnetic resonance urography presented an enlarged left kidney, with a diameter of up to 105 mm, a narrow renal cortex, a dilated renal pelvis up to 39 mm in diameter, dilated calyces up to 26-32 mm, and the high insertion of the ureter from the pelvis. The right kidney was normal. To facilitate drainage from the dilated collecting system of the left kidney, a double-J catheter was inserted. Pyeloplasty is planned as the next step of treatment. Conclusion: In a child with horseshoe kidney and a mild dilatation of the collecting system detected in infancy, long-term follow up is necessary, because of the increased risk of significant hydronephrosis in the future.

Laparoscopic Pyeloplasty in children with Horseshoe Kidney.

INTRODUCTION: Horseshoe kidney occurs in 1 per 400-800 live births and are more frequently observed in males (M:F 2:1). Ureteropelvic junction obstruction (UPJO) is commonly associated with horseshoe kidneys. The variable blood supply, presence of the isthmus and high insertion of the ureter contribute to this problem. CASE REPORT: An asymptomatic 6 year-old boy presented with antenatal hydronephrosis. Ultrasonography and CT scan demonstrated left UPJO associated with a horseshoe kidney. DMSA showed 33% of function on the left side. DTPA showed a flat curve and lack of washout. A left dismembered laparoscopic pyeloplasty was performed after identification of crossing vessels and abnormal implantation of the ureter. After one year, the child is asymptomatic. DTPA demonstrated a good washout curve. RESULTS: Our cohort consisted of six patients, five males and one female, with a mean age of 6 years (range 6m-17 years) and a mean follow-up of 3 years. Ureteropelvic junction obstruction was more common on the left side. Symptoms appeared only in 34% of the cases. Mean operative time was 198 minutes (range 120-270 minutes). Crossing vessels were common (observed in 50% patients). High implantation of ureter was seen in 67% patients and intrinsic obstruction in 83%. Surgical difficulties were found in two cases. Hospital stay was 4.3 days (3 to 6 days), with only one patient having a mild complication (pyelonephritis). All cases had clinical and radiologic improvement. CONCLUSION: Laparoscopic pyeloplasty is safe and feasible in children with UPJO in horseshoe kidneys, with good results and minimal morbidity.

Partial nephrectomy in horseshoe kidney: Primary carcinoid tumor.

Primary neuroendocrine carcinoma of the kidney is a rarely observed clinical condition because neuroendocrine cells are not found in kidney parenchyma. It's not clinically and radiologically possible to distinguish from other kidney tumors. Incidence with horseshoe kidney anomaly, it should be considered as a definitive diagnosis for the patients with this condition. In this case report, we reported about a carcinoid tumor in horseshoe kidney in a 37-year-old woman.

Partial and hemi-nephrectomy for renal malignancy in patients with horseshoe kidney.

INTRODUCTION: Horseshoe kidney is the most common congenital renal fusion anomaly, with an estimated incidence of 1.7 to 2.5 cases per 1000 live births. In these patients, nephron-sparing surgical management of renal tumors may be complicated by abnormal renal location, aberrant vasculature, and the presence of a renal isthmus. We present the largest known series of patients with renal malignancy in horseshoe kidneys managed by partial or hemi-nephrectomy with associated outcomes. MATERIALS AND METHODS: A retrospective review of our institution's electronic medical record was conducted to identify consecutive cases over an 11 year period. Pediatric patients and those who underwent surgery for benign indications were excluded from analysis. RESULTS: Eight patients with horseshoe kidney who underwent partial or hemi-nephrectomy for renal malignancy were identified. Median tumor size was 6.0 cm (IQR 3.7 cm-9.5 cm). Six patients had clear cell renal cell carcinoma (RCC), 1 patient had papillary RCC, and 1 patient had a renal carcinoid tumor with concurrent adenocarcinoma. Median length of stay was 4 days (IQR 2-.5.5 days). Median perioperative change in eGFR was -6 mL/min/1.73² (IQR -2.6-8.6 mL/min/1.73m²). One patient developed postoperative urine leak requiring percutaneous drainage and ureteral stent placement. Median follow up was 38.5 months, with a cancer-specific survival of 87.5% and an overall survival of 62.5%. CONCLUSION: Partial and hemi-nephrectomy for renal malignancy can safely be performed in patients with horseshoe kidney with acceptable operative and oncologic outcomes.

Retroperitoneoscopy Technique-Assisted Percutaneous Nephrolithotomy for Complexity Horseshoe Kidney with Renal Stones.

OBJECTIVE: To assess the safety and efficacy of retroperitoneoscopy technique-assisted percutaneous nephrolithotomy (PCNL) used in the treatment of complexity horseshoe kidney (HSK) with renal stones. METHODS: Between January 2012 and April 2015, 5 patients with renal stones in complexity HSK underwent retroperitoneoscopy technique-assisted PCNL. The perioperative data analyzed, included operation time, blood loss, incidence of complication rate, the stone-free rate (SFR), and so on. RESULTS: All the patients successfully completed the operation without need for an open surgery. The mean operative time in which this procedure was done was 77.5 ± 20.6 min, the mean hemoglobin that was reduced was 2.5 ± 0.8 g/dl, the mean time to remove nephrostomy tube and retroperitoneal tube were 3.0 ± 1.0, 3.5 ± 1.0 days, respectively. The mean hospital stay was 7.0 ± 1.5 days. The SFR of all the patients was 80% (4/5). One patient who had residual stones (6 × 5 mm) in the middle pole underwent additional shock wave lithotripsy after the operation and no serious perioperative complications were noticed. Study limitations include small sample size and short follow-up time. CONCLUSIONS: Retroperitoneoscopy technique-assisted PCNL is a feasible, safe, and an effective alternative to laparoscopic pyelolithotomy for treating complexity HSK with renal stones, especially in a situation where the HSK is tightly wrapped by the surrounding organs.

Comparison of shock wave lithotripsy (SWL) and retrograde intrarenal surgery (RIRS) for treatment of stone disease in horseshoe kidney patients.

OBJECTIVES: In this study it is aimed to compare the success and complication rates of SWL and RIRS in treatment of HSK stone disease. MATERIALS AND METHODS: In this retrospective study data of 67 patients treated with either SWL (n=44) or RIRS (n=23) for stone disease in HSK between May 2003 to August 2014 was investigated. age, gender, stone size and multiplicity, stone free status, renal colic episodes and complication rates of the SWL and RIRS groups were compared. RESULTS: Mean age of the population was 42.5±8.2 (range: 16-78) years and mean stone size was 16.9±4.1 mm. SWL and RIRS groups were similar with regard to demographic characteristics and stone related characteristics. SFR of the SWL and RIRS groups were 47.7%(21/44 patients) and 73.9% (17/23 patients) respectively (p=0.039). Renal colic episodes were observed in 3 and 16 patients in the RIRS and SWL groups respectively (p=0.024). No statistically significant complications were observed between the SWL (8/44 patients) and RIRS (4/23) groups (p=0.936). CONCLUSIONS: In HSK patients with stone disease, both SWL and RIRS are effective and safe treatment modalities. However RIRS seems to maintain higher SFRs with comparable complication rates.

[Laparoscopic pyeloplasty for hydronephrosis of horseshoe kidney].

AIM: Horseshoe kidney is often associated with other congenital abnormalities and obstruction of pyeloureteral segment (PUS). The aim of our study was to evaluate the results of laparoscopic pyeloplasty (LP) in patients with hydronephrosis of horseshoe kidney. MATERIALS AND METHODS: From February 2010 to March 2016, 130 patients underwent LP. Ten (7.7%) of them (6 men and 4 women) had a hydronephrosis of horseshoe kidney. Left and right PUS obstruction were diagnosed in 6 and 4 patients, respectively. All the patients underwent PL transperitoneally using the Anderson-Hynes method. In patients with left hydronephrosis, surgery was performed by transmesenteric access. RESULTS: There were no cases of conversion to open surgery and drainage urine leakage. Exacerbation of chronic pyelonephritis was observed in 2 cases. Operating time ranged from 125 to 160 minutes (median 130 minutes), time of performing pyeloureteral anastomosis - from 50 to 105 minutes. Patients were ambulated within the first day after surgery, the length of hospital stay was 3 - 4 days. One patient with recurrent strictures of PUS 8 months after the LP underwent retrograde endopyelotomy with the placement of endopyelotomy stent. The effectiveness of operations over a 6-38 month follow-up was 90%. CONCLUSION: LP is an effective and minimally invasive treatment for patients with hydronephrosis of horseshoe kidney. In a left PUS obstruction, pyeloplasty can be performed using transmesenteric access.