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1.  Retrospective Analysis of Ultrasound-guided Flexible Ureteroscopy in the Management of Calyceal Diverticular Calculi 
Chinese Medical Journal  2016;129(17):2067-2073.
Background:
Percutaneous nephrolithotomy (PCNL) is the most widely recommended treatment for calyceal diverticular calculi, providing excellent stone-free results. However, its invasiveness is not negligible considering its major complication rates. Flexible ureteroscopy (FURS) is currently used to treat calyceal diverticula. However, the greatest drawback of FURS is locating the diverticulum since its neck is narrow and concealed. In such a case, the FURS procedure must be converted to PCNL. The aim of this study was to evaluate ultrasound-guided flexible ureteroscopy (UFURS) identifying diverticulum and the management of calyceal diverticular calculi.
Methods:
A retrospective analysis was conducted on 24 patients who had calyceal diverticular calculi. In all 12 patients in the UFURS group, direct FURS failed to find evidence of calyceal diverticula but were confirmed with imaging. The other 12 patients in the PCNL group received PCNL plus fulguration of the diverticular walls.
Results:
Puncture of calyceal diverticulum was successful in all 12 UFURS patients. Two patients in this group had postoperative residual calculi and two patients developed fever. In the PCNL group, percutaneous renal access and lithotomy were successful in all 12 patients. One patient in this group had residual calculi, one had perirenal hematoma, and two patients developed fever. No significant difference was found in the operating time (UFURS vs. PCNL, 91.8 ± 24.2 vs. 86.3 ± 18.7 min), stone-free rate (UFURS vs. PCNL, 9/12 vs. 10/12), and rate of successful lithotripsy (UFURS vs. PCNL, 10/12 vs. 11/12) between the two groups (all P > 0.05). Postoperative pain scores in the FURS group were significantly lower than that in the PCNL group (2.7 ± 1.2 vs. 6.2 ± 1.5, P < 0.05). Hospital stay in the UFURS group was significantly shorter than that in the PCNL group (3.4 ± 0.8 vs. 5.4 ± 1.0 days, P < 0.05). All patients were symptom-free following surgery (UFURS vs. PCNL, 10/10 vs. 12/12).
Conclusion:
Ultrasound-guided puncture facilitates identification of calyceal diverticula during FURS and improves the success rate of FURS surgery.
doi:10.4103/0366-6999.189060
PMCID: PMC5009590  PMID: 27569233
Calyceal Diverticulum; Calyceal Diverticulum Calculi; Flexible Ureteroscope; Percutaneous Nephrolithotomy; Puncture; Ultrasound
2.  AB095. Five concerns need to be pay attention to in percutaneous nephrolithotomy 
Translational Andrology and Urology  2015;4(Suppl 1):AB095.
Objective
To recommend our clinical experiences in five important concerns which common to be met in percutaneous nephrolithotomy (PCNL), helping the beginners easy to handle this kind of procedures.
Methods
Review PCNL in ten years in our hospital, we analyzed five important aspects which could influence the results of operations. Include selection of access site, loss of percutaneous access while dilation, different methods of stone fragmentation, controlling pressure of irrigation in PCNL, and management of complications.
Results
(I) Selection of access site. Because there are less blood vessels in most posterior lower or upper middle calyces, renal puncture through these two calyces would bleed less. It does not need to set up the third access, because of accessorial application of ESWL and RIRS. If necessary, puncture residual stone in calyx may be needed. (II) Loss of percutaneous access while dilation. If the guidewire was out of upper urinary tract collecting system, most of time it needs repeating puncture. If the sheath was not deep enough, the guidewire was still in collecting system, push the nephroscope into calyx along the guidewire, then advancing the sheath. (III) Different methods of stone fragmentation. The usual methods of stone fragmentation are pneumatic lithotripsy, ultrasonic lithotripsy and holmium laser lithotripsy. Pneumatic lithotripsy is efficacy and inexpensive. Almost all kinds of stones could be broken, except a few stones such as calcium oxalate monohydrate. It is too rigid that to be broken is very difficult. The speed of lithotripsy is slow, and the debris of stone should be clear off one by one. The ultrasonic lithotripsy could sucked away the debris of stone at same time of lithotripsy. The speed of lithotripsy is high. But bigger access has to be used, and it is difficult to break the stiffer stones. All kinds of stones could be broken by holmium laser, especially high power holmium laser, the debris of stone is less and speed of lithotripsy is higher than pneumatic lithotripter. But there is no stone removal function. (IV) Controlling pressure of irrigation in PCNL. It is very important to keep the sheath unobstructed, there is a relatively high pressure in mini PCNL with pneumatic or laser lithotripsy, a relatively lower pressure in collecting system in standard PCNL with ultrasonic lithotripsy. The irrigation pressure and flow rate could be changed according to the view and whether need to flush out the stone debris or not. (V) Management of severe complications. Review the experiences of damage of pleura, super selective renal arterial embolization for hemorrhage after PCNL, the use of antibiotics and management of respiratory and circulatory function for treatment of high fever and urosepsis, the management of injury of colon and stone combine with renal pelvic tumor.
Conclusions
The details would determine the results of PCNL. Any mistakes would result in failure of the procedure and damage of kidney, sometimes will be lethal for the patient. Pay attention to the details is the key of successful finishing the operations.
doi:10.3978/j.issn.2223-4683.2015.s095
PMCID: PMC4708791
Percutaneous nephrolithotomy (PCNL); stone; kidney
3.  Percutaneous management of renal caliceal diverticular stones: Ten-year experience of a tertiary care center with different techniques to deal with diverticula after stone extraction 
Introduction:
Caliceal diverticulae are a frequent surgical problem. We present our experience with caliceal diverticular stones (CDS) managed with percutaneous nephrolithotomy (PCNL) and describe the two different techniques to deal with diverticula after stone retrieval.
Materials and Methods:
We retrospectively analyzed 10-year data of 44 consecutive patients who underwent PCNL for CDS. During PCNL, if the guide wire could be negoted through the neck of the diverticula, we dilated and stented it. If we couldnot find the neck, we fulgurated the diverticular walls. Follow-up included intravenous urogram at 3 months and annual plain films thereafter. We analyzed the outcome, complications, and recurrence rate.
Results:
Total stone clearance was obtained in 40 (90.90%) patients. We dilated and stented the diverticula in 35 (79.5%) patients and fulgurated the walls in nine (20.5%) patients. Complications occurred in three patients. The postoperative intravenous urogram showed obliteration of diverticula in seven patients and the improved drainage in 37 patients. At the average follow-up of 2 years, 41 (93.18%) patients were asymptomatic and two (4.5%) patients showed the recurrence of stone.
Conclusions:
PCNL can clear calculi from caliceal diverticula in most cases with minimal morbidity. After stone retrieval, the diverticula may be drained into the pyelocaliceal system, if the neck is negotiable and fulgurated if the neck cannot be dilated.
doi:10.4103/0970-1591.120091
PMCID: PMC3822340  PMID: 24235786
Caliceal diverticula; Caliceal diverticular stones; percutaneous nephrolithotomy
4.  A Major Complication in Micropercutaneous Nephrolithotomy: Upper Calyceal Perforation with Extrarenal Migration of Stone Fragments due to Increased Intrarenal Pelvic Pressure 
Case Reports in Urology  2015;2015:792780.
Micropercutaneous nephrolithotomy is a safe and efficient technique for appropriate sized stones. It is performed through a 4.85 Fr all-seeing needle and stones are fragmented into dust, without the need for tract dilatation, unlike other percutaneous nephrolithotomy types. Even though micropercutaneous nephrolithotomy has many advantages, increase in intrapelvic pressure during surgery may cause rare but serious complications. Herein we report a case of micropercutaneous nephrolithotomy in a 20-year-old woman with a 20 mm right renal pelvis stone and present an undesired outcome of this complication, upper calyceal perforation. Right lower calyceal access was performed with 4.85 Fr all-seeing needle and 2 cm renal pelvis stone was fragmented by 272 μm Holmium-Yag laser system. Upper calyceal perforation and infrahepatic accumulation of stone fragments were detected by fluoroscopy during the surgery. Postoperative imagings revealed perirenal urinoma, perirenal and infrahepatic stone fragments, and lower calyceal stone fragments inside the system. On second postoperative day, minipercutaneous nephrolithotomy and double J catheter insertion procedures were applied for effective drainage and stone clearance. Risk of calyceal perforation and urinoma formation, due to increased intrapelvic pressure during micropercutaneous nephrolithotomy, should be kept in mind.
doi:10.1155/2015/792780
PMCID: PMC4516833  PMID: 26257977
5.  Percutaneous endoscopic treatment for urinary stones in pediatric patients: where we are now 
Translational Pediatrics  2016;5(4):266-274.
Background
Percutaneous nephrolithotomy (PCNL) has been adopted for pyelo-calyceal stones treatment in pediatric patients, starting from the 90’s. Very recently, miniaturization of endoscopic instruments allowed less invasive procedures with low complication rate. We reviewed our experience on upper tract stone treatment utilizing two different percutaneous accesses, focusing on the recent new miniaturized devices offered for pediatric renal stones.
Methods
Patients presenting upper tract urinary stones observed from January 2011 to December 2015 and treated by percutaneous renal access were prospectively evaluated: age, sex, metabolic issues, associated abnormalities, treatment modalities, hospital stay and complication rate were recorded in a specific database. Two different endourological percutaneous modalities were adopted, depending to the stone size and position. PCNL was performed through a direct calyceal puncture under ultrasonographic and fluoroscopic guidance and Amplatz access dilatation till 24 Fr. Ballistic energy was used for fragmentation. Micropercutaneous (Microperc) procedure was recently offered utilizing a 4.85 Fr metallic needle and Holmium:YAG laser lithotripsy under direct vision through a 0.9 mm high resolution optic flexible wire connected with a telescope.
Results
Thirty-eight percutaneous access to pyelo-calyceal renal stones were performed on a total of 108 children treated for upper tract stones, aged 4 to 18 years (mean age 7.5 years). The overall number of procedures was 144 (36 repeated procedures). Cystinuria was diagnosed in 5 patients. PCNL was adopted in 28 patients, Microperc was utilized in 8 patients. Hemoglobin dropdown was limited to 1.20±0.80 mg% in PCNL and was not significant in Microperc. No blood transfusion was needed. No significant complications were observed. Stone free rate or minimal not significant residuals were achieved in 82% of PCNL and in 87.5% of Microperc, after a single procedure.
Conclusions
Percutaneous endoscopic treatment of renal calculi is feasible in pediatric age, with high success rate in a single step. Advanced miniaturized endoscopic devices as Microperc guarantee high efficacy and reduced complication rate, but endo-urological experience and adequate learning curve are required, especially in small body weight children. Centralization of these patients in Pediatric Stone Centers is welcomed to optimize results and reduce risks.
doi:10.21037/tp.2016.09.03
PMCID: PMC5107374  PMID: 27867851
Percutaneous nephrolithotomy (PCNL); micropercutaneous (Microperc); renal stones; children; endoscopy
6.  Percutaneous Nephroscopic Surgery 
Korean Journal of Urology  2010;51(5):298-307.
With the development of techniques for percutaneous access and equipment to disintegrate calculi, percutaneous nephroscopic surgery is currently used by many urologists and is the procedure of choice for the removal of large renal calculi and the management of diverticula, intrarenal strictures, and urothelial cancer. Although it is more invasive than shock wave lithotripsy and retrograde ureteroscopic surgery, percutaneous nephroscopic surgery has been successfully performed with high efficiency and low morbidity in difficult renal anatomies and patient conditions. These advantages of minimal invasiveness were rapidly perceived and applied to the management of ureteropelvic junction obstruction, calyceal diverticulum, infundibular stenosis, and urothelial cancer. The basic principle of endopyelotomy is a full-thickness incision of the narrow segment followed by prolonged stenting and drainage to allow regeneration of an adequate caliber ureter. The preferred technique for a calyceal diverticulum continues to be debated. Excellent long-term success has been reported with percutaneous, ureteroscopic, and laparoscopic techniques. Each approach is based on the location and size of the diverticulum. So far, percutaneous ablation of the calyceal diverticulum is the most established minimally invasive technique. Infundibular stenosis is an acquired condition usually associated with inflammation or stones. Reported series of percutaneously treated infundibular stenosis are few. In contrast with a calyceal diverticulum, infundibular stenosis is a more difficult entity to treat with only a 50-76% success rate by percutaneous techniques. Currently, percutaneous nephroscopic resection of transitional cell carcinoma in the renal calyx can be applied in indicated cases.
doi:10.4111/kju.2010.51.5.298
PMCID: PMC2873882  PMID: 20495691
Diverticulum; Hydrocalycosis; Percutaneous nephrostomy; Transitional cell carcinoma; Urinary calculi
7.  Single puncture percutaneous nephrolithomy for management of complex renal stones 
BMC Research Notes  2009;2:62.
Background
The purpose of this report is to assess the safety and efficacy of single lower pole access for multiple and branched renal calculi. A prospective non randomized clinical study included 26 patients with complex renal stones (9 patients had branched renal stones and the other 17 had multiple renal stones) in the period from May 2003 to May 2004. Mean patient age was 42 years ± 13.2 (range 18 to 67 years). All patients underwent percutaneous nephrolithotomy (PCNL) via a single lower calyceal puncture. Small stones were intactly extracted by a range of stone graspers while large stones (smallest diameter more than 1 cm) were disintegrated using either the pneumatic EMS Swiss lithoclast or Holmium YAG laser. Flexible nephroscope was used for stones inaccessible by the rigid instruments.
Findings
Overall stone-free rate was 74.8%. Patients with residual stones were managed by one session of shock wave lithotripsy (SWL). Mean operative time was (80 minutes ± 27.4) for branched stones and (49.1 minutes ± 15.9) for multiple stones. No significant blood loss reported. Perforation of pelvicalyceal system occurred in 2 patients (11.5%) with no serious sequelae. Only 1 patient developed secondary hemorrhage which necessitated blood transfusion and selective angio-embolization.
Conclusion
In our hands, the efficacy and safety of single lower calyceal puncture PCNL in management of complex renal stones are comparable to those of the general procedure stated in literature.
doi:10.1186/1756-0500-2-62
PMCID: PMC2679047  PMID: 19379503
8.  Retrograde upper-pole calyceal access for percutaneous nephrolithotripsy of stones in the lower-pole calyx 
Arab Journal of Urology  2012;10(4):353-357.
Objective
To present the results of upper calyceal access during percutaneous nephrolithotripsy (PCNL) for stones in the lower calyx, as PCNL is considered the most effective minimally invasive surgery for managing lower calyceal stones, with percutaneous access either directly to the lower calyx or through an upper or middle calyx.
Patients and methods
The study included 76 patients with single (51) and multiple (25) stones in the lower calyx, and stones in the lower calyx plus renal pelvis (six) and associated pelvi-ureteric junction obstruction (PUJO, five). They were managed by PCNL using retrograde access through the upper-pole calyx in addition to laser endopyelotomy for the PUJO.
Results
The mean duration required for establishing the retrograde nephrostomy tract was 14.4 min, and for completing the procedure was 40 min. The mean fluoroscopy exposure time was 3.2 min. Access from the upper calyx allowed easy and rapid advancement of the nephroscope to the lower calyx. The stones varied in size, at 10–25 mm. Stones were cleared completely in 70 of the 76 patients (92%); the stone-free rate was 100%. The residual stone fragments (2–4 mm) in the remaining six patients (8%) were considered insignificant. Complications were minor in four patients (5%), and included pleural effusion in two, bleeding in one and an arteriovenous fistula in one.
Conclusions
Upper-pole calyceal access for PCNL provides easy and effective clearance of stones in the lower calyx. This access should be considered for PCNL of single or multiple stones in the lower calyx.
doi:10.1016/j.aju.2012.08.002
PMCID: PMC4442947  PMID: 26558049
PCNL, percutaneous nephrolithotripsy; PUJO, PUJ obstruction; Retrograde nephrostomy; Access; Percutaneous nephrolithotripsy; Lower calyx; Stone
9.  Invasive urothelial carcinoma within a calyceal diverticulum associated with renal stones: A case report 
Oncology Letters  2015;10(4):2439-2441.
Calyceal diverticula are rare outpouchings of the upper collecting system lying within the renal parenchyma. These often contain stones, however, carcinoma within a calyceal diverticulum is uncommon. The present study reports a case of invasive urothelial carcinoma within a calyceal diverticulum associated with renal stones. A 70-year-old male with a left renal mass identified by abdominal computed tomography was referred to the Department of Urology, Kanazawa University Hospital. Pre-operative diagnosis was difficult owing to an atypical imaging finding of a hypovascular renal mass with calcification. A laparoscopic nephroureterectomy was performed, and the surgical specimens showed invasive high-grade urothelial carcinoma within a calyceal diverticulum, and the calcifications were renal stones consisting of 97% calcium oxalate. Urothelial carcinoma in calyceal diverticula is a rare condition, however, a pre-operative definite diagnosis is difficult and a high potential for invasion of the renal parenchyma is suspected in this disease.
doi:10.3892/ol.2015.3590
PMCID: PMC4580019  PMID: 26622866
invasive urothelial carcinoma; calyceal diverticula; renal stone
10.  Robotic-assisted laparoscopic management of a caliceal diverticular calculus 
BMJ Case Reports  2014;2014:bcr2014205437.
Purpose
To report the first case of robotic-assisted laparoscopic management of a symptomatic caliceal diverticular calculus and review the literature on laparoscopic treatment for this condition.
Case report
A 33-year-old obese woman with a 2×1 cm calculus within an anterior caliceal diverticulum located in the middle pole of the left kidney was referred to our service. She had already undergone two flexible ureterorenoscopies without success. We considered that a percutaneous approach would be very challenging due to stone location, thus we elected to perform a robotic-assisted laparoscopic procedure for stone removal and diverticulum fulguration. The procedure was uneventfully performed with no intraoperative or postoperative complications. The patient was discharged from the hospital on the second postoperative day and after 1.5 years of follow-up she is asymptomatic with no recurrence.
Conclusions
The robotic-assisted laparoscopic approach to caliceal diverticular calculi is feasible and safe, providing one more option for treatment of stones in challenging locations.
doi:10.1136/bcr-2014-205437
PMCID: PMC4154007  PMID: 25188925
11.  Percutaneous nephrolithotomy for isolated calyceal stones: How important is the stone location? 
Turkish Journal of Urology  2015;41(4):171-176.
Objective
To evaluate the effect of percutaneous access site on the success and complication rates of isolated calyceal stones.
Material and methods
We retrospectively evaluated 2700 patients who underwent percutaneous nephrolithotomy (PNL) in our clinic between October 2002 and August 2014. We selected only the patients with isolated lower, middle or upper calyceal stones and we grouped the patients according to the location of their stones. Successful operation was defined as complete stone clearence or retention of stone fragments smaller than 4 mm which do not lead to infection, obstruction or pain requiring treatment. Intraoperative and postoperative complications were also recorded.
Results
Totally 360 patients underwent PNL for their isolated upper, middle and lower calyceal stones. Access sites for those patients were selected based on stone location. The stones were localized in the lower (n=304), middle (n=14), and upper (n=42) calices. There was no statistically significant difference between the groups with respect to operation and scopy times. Hemoglobin drop was seen more frequently in the upper calyceal access group, without any significant intergroup difference. Thoracic complications including hemothorax, pneumothorax and pleural effusion were more common in the upper calyceal access group (11.9%; p<0.001). Complete stone clerance was accomplished in 81.9%, 92.9% and 78.6% of the patients with lower, middle and upper calyceal stones respectively without any significant intergroup difference (p=0.537).
Conclusion
PNL is an effective and safe treatment modality for isolated calyceal kidney stones and upper calyceal access causes thoracic complications more than other access sites.
doi:10.5152/tud.2015.06787
PMCID: PMC4621143  PMID: 26623144
Isolated calyceal stones; kidney calculi; percutaneous nephrolitotomy
12.  Comparative evaluation of upper versus lower calyceal approach in percutaneous nephrolithotomy for managing complex renal calculi 
Urology Annals  2015;7(1):31-35.
Introduction:
Percutaneous nephrolithotomy (PCNL) is the treatment of choice for staghorn and large renal stones. The success of PCNL is highly related to optimal renal access. Upper calyceal puncture being more difficult and more demanding have relatively few studies presented.
Aims and Objectives:
This prospective study was carried out to evaluate the effectiveness and safety of upper calyceal versus lower calyceal puncture for the removal of complex renal stones through PCNL.
Materials and Methods:
A total of 94 patients underwent PCNL for complex renal stone in our institute. Fifty-one of them underwent lower calyceal, while 43 underwent upper calyceal puncture. The two approaches are compared as per total duration of surgery, intraoperative blood loss, infundibular/pelvic tear, rate of complete clearance and rate of postoperative complications (pulmonary, bleeding, fever and sepsis, etc.).
Observation and Results:
In our study, the success rate was 76.47% for those in the lower, 90.70% for those in the upper calyceal access group. Thoracic complications (hydrothorax) occurred to 1 patient in upper calyceal supracostal access group. Bleeding requiring blood transfusion happened to 5 patients in lower calyceal access and 1 in upper calyceal group.
Conclusion:
In our study for the management of complex renal calculi, we conclude that in a previously unoperated kidney, upper calyceal puncture through subcostal or supra 12th rib is a feasible option minimizing lung/pleural rupture and gives a better clearance rate. We suggest that with due precautions, there should not be any hesitation for upper calyceal puncture in indicated patients.
doi:10.4103/0974-7796.148591
PMCID: PMC4310113  PMID: 25657540
Percutaneous nephrolithotomy; staghorn; supracostal puncture
13.  Ultramini nephrostomy tract combined with flexible ureterorenoscopy for the treatment of multiple renal calculi in paediatric patients 
Korean Journal of Urology  2015;56(7):519-524.
Purpose
To assess the safety and efficacy of an ultramini nephrostomy tract, which we were using for the first time, combined with flexible ureterorenoscopy (URS) in the treatment of pediatric patients with multiple renal calculi.
Materials and Methods
Twenty pediatric patients (age, ≤6 years) underwent ultramini percutaneous nephrolithotomy (PCNL) combined with flexible URS. The group had multiple renal calculi, which were bilateral in 3 cases and were located in a total of 23 sites. The calculi were located in 2 calyces in 10 cases, scattered in more than 2 calyces in 7 cases, and limited to 1 calyx in 3 cases. The average patient age was 37.35 months (range, 14-68 months). The average stone diameter was 2.0 cm (range, 1-3.0 cm). In all patients, an ultramini nephrostomy tract was established under ultrasound guidance (dilated to F10) with simultaneous sheath placement. The flexible URS was placed into the collecting system during holmium laser lithotripsy.
Results
When ultramini PCNL was combined with flexible ureterorenoscopic holmium laser lithotripsy, the complete stone-free rate was 87% (20/23). The average level of hemoglobin decreased to 1.0 g/dL after the operation. No blood transfusions were needed. Levels of blood urea nitrogen, creatinine, and C-reactive protein were not significantly different before and after the operation. The average duration of hospitalization was approximately 4.85 days, and all cases were followed up for 6 to 12 months. No complications were found.
Conclusions
Ultramini PCNL combined with flexible ureterorenoscopic holmium laser lithotripsy is a safe and effective treatment for children with multiple renal calculi.
doi:10.4111/kju.2015.56.7.519
PMCID: PMC4500809  PMID: 26175871
Kidney calculi; Lithotripsy; Pediatrics; Percutaneous nephrolithotomy; Ureteroscopy
14.  Fluoroscopy free flexible ureteroscopy with holmium: Yttrium-aluminium-garnet laser lithotripsy for removal of renal calculi 
Arab Journal of Urology  2016;14(2):123-130.
Objective
To evaluate the feasibility of access sheath insertion and ureteric stent placement without image guidance in flexible ureteroscopic lithotripsy with holmium:yttrium-aluminium-garnet laser for renal stones.
Patients and methods
Between March 2014 and October 2015, 80 patients with renal stones treated with flexible ureteroscopic laser lithotripsy were evaluated. Indications for surgery were renal obstruction, failed shockwave lithotripsy (SWL), stones in polycystic kidneys, and mal-rotated kidneys. A 6.5-F Cobra flexible ureteroscope was used in all cases with an access sheath of 12 F, 35/45 cm in length. Fluoroscopy was not intended for use in all cases and postoperative JJ stenting was optional. The perioperative complications were listed and the collected data were analysed.
Results
The study included 80 patients (66 male, 14 female), with a mean (SD; range) age of 48.2 (8; 28–54) years and a stone burden of 13 (3.5; range 6–23) mm. In all, 26 patients had a stone burden of >15 mm and 48 patients had lower calyceal stones. The mean (SD; range) operative time was 71.5 (20; 25–130) min. Overall, 76 (95%) access sheath insertions were performed successfully without the use of fluoroscopy. JJ stenting was used in 22 patients (27.5%). The mean (SD; range) hospital stay was 10 (8.5; 10–36) h. After one session, a stone-free rate (SFR) of 87.5% was achieved (93.3% for stones of <15 mm). A single session was successful in 87.9% of cases with lower calyceal stones, with a SFR of 91.7% for post-SWL failure cases. The perioperative complication rate was 15%.
Conclusion
Access sheath insertion without fluoroscopic guidance is feasible. This technique reduces radiation exposure in patients requiring flexible ureteroscopy.
doi:10.1016/j.aju.2016.04.004
PMCID: PMC4963160  PMID: 27489739
KUB, plain abdominal radiograph of the kidneys ureters and bladder; PCNL, percutaneous nephrolithotomy; PCS, Pelvicalyceal system; SFR, stone-free rate; SWL, shockwave lithotripsy; URS, ureteroscopy; URSL, ureteroscopic laser lithotripsy; US, ultrasonography/ultrasound; YAG, yttrium-aluminium-garnet; Renal calculi; Ureteroscopy; Ho:YAG laser; Lithotripsy
15.  Mini percutaneous nephrolithotomy for renal calculi in paediatric patients: A review of twenty cases 
Urology Annals  2016;8(1):16-19.
Objective:
The objective was to report our initial experience of mini percutaneous nephrolithotomy (mPCNL) performed on patients in the pediatric age group (<18 years) using a miniature nephroscope (12F).
Subjects and Methods:
A total of 20 children underwent mPCNL for renal stone extraction in the Department of Urology, Yenepoya Medical College, Mangalore, India, from February 2013 to January 2014. The patients were evaluated on the basis of parameters viz. age at the time of surgery, size and number of stones, duration of surgery, stone clearance, and postoperative complications.
Results:
A total of 20 mPCNLs were performed on children, with age ranging from 8 to 16 years. Three children had three stones each, six children had two stones each, eight children had one stone each, and three had multiple. The median stone burden was 1.36 cm. The procedure was via single puncture in 15 cases, and two punctures in five cases. Punctures were upper calyceal in seven cases, lower calyceal in seven cases, and combined upper and lower calyceal in six cases. The calculi were accessed by a 12F mini nephroscope, laser lithotripsy was used in 12 cases and pneumatic lithotripsy used for the rest. Total clearance was achieved in 18 out of 20 cases (90%). Postoperative complications developed in one child, in the form of sepsis.
Conclusion:
Our initial experience concludes that mPCNL is a safe and efficacious tool for the management of renal calculi in the pediatric population.
doi:10.4103/0974-7796.163794
PMCID: PMC4719505  PMID: 26834395
Mini; nephrolithotomy; pediatric; percutaneous; renal calculi
16.  Calyceal Diverticulum - a Mimic of Different Pathologies on Multiple Imaging Modalities 
Calyceal diverticula are outpouchings of a renal calyx. Often found incidentally on radiological imaging, they are generally benign and usually asymptomatic, although complications include infection and stone formation. More importantly, calyceal diverticula may mimic other potentially more serious pathology on imaging, such as renal tumour or abscess on ultrasound or computed tomography and even rib metastasis on bone scintigraphy. We present a case of a patient with a calyceal diverticulum found incidentally on imaging, in which the diverticulum is demonstrated on ultrasound, computed tomography, intravenous urogram and bone scintigraphy, and discuss the potential differential diagnoses that need to be excluded in this condition.
doi:10.3941/jrcr.v6i9.1123
PMCID: PMC3558255  PMID: 23378883
Calyceal; diverticulum; renal calyx; IVU; intravenous urogram
17.  Clinical Manifestation of a Calyceal Diverticular Abscess in a Pregnant Woman 
Calyceal diverticula are congenital, nonsecretory abnormalities in which the transitional cell-lined cavity communicates with the renal collecting system. Here we present the case of a calyceal diverticular abscess during pregnancy. A 40-year-old primiparous woman developed the abscess at 23 weeks of gestation, with right flank pain and a 37.8°C fever. A transabdominal ultrasound revealed a 12 × 10 cm cystic mass in the right kidney. She was initially diagnosed with a simple renal cyst infection, and intravenous antibiotics were initiated. Percutaneous drainage was started at 26 weeks of gestation. When urine excretion from the cyst was confirmed by dye test using indigotindisulfonate sodium, the patient was diagnosed with a calyceal diverticular abscess. She gave birth to a 2,870 g healthy male at 38 weeks of gestation. Percutaneous drainage with low-dose antimicrobial therapy could thus allow for the continued pregnancy of women with a calyceal diverticular abscess until full term.
doi:10.1155/2014/975071
PMCID: PMC4265685  PMID: 25525537
18.  Percutaneous Endoscopic Holmium Laser Lithotripsy for Management of Complicated Biliary Calculi 
Background and Objectives:
Advances in endoscopic techniques have transformed the management of urolithiasis. We sought to evaluate the role of such urological interventions for the treatment of complex biliary calculi.
Methods:
We conducted a retrospective review of all patients (n=9) undergoing percutaneous holmium laser lithotripsy for complicated biliary calculi over a 4-year period (12/2003 to 12/2007). All previously failed standard techniques include ERCP with sphincterotomy (n=6), PTHC (n=7), or both of these. Access to the biliary system was obtained via an existing percutaneous transhepatic catheter or T-tube tracts. Endoscopic holmium laser lithotripsy was performed via a flexible cystoscope or ureteroscope. Stone clearance was confirmed intra- and postoperatively. A percutaneous transhepatic drain was left indwelling for follow-up imaging.
Results:
Mean patient age was 65.6 years (range, 38 to 92). Total stone burden ranged from 1.7 cm to 5 cm. All 9 patients had stones located in the CBD, with 2 patients also having additional stones within the hepatic ducts. All 9 patients (100%) were visually stone-free after one endoscopic procedure. No major perioperative complications occurred. Mean length of stay was 2.4 days. At a mean radiological follow-up of 5.4 months (range, 0.5 to 21), no stone recurrence was noted.
Conclusions:
Percutaneous endoscopic holmium laser lithotripsy is a minimally invasive alternative to open salvage surgery for complex biliary calculi refractory to standard approaches. This treatment is both safe and efficacious. Success depends on a multidisciplinary approach.
PMCID: PMC3015947  PMID: 19660213
Biliary calculi; Holmium laser; Endoscopic; Lithotripsy
19.  Flexible ureterorenoscopy: prospective analysis of the Guy's experience. 
OBJECTIVE: To report our outcomes with small diameter, actively deflectable flexible ureterorenoscopy from a prospective database. PATIENTS and METHODS: 114 flexible ureterorenoscopies were performed in 105 patients (mean age, 49.5 years; range, 19-85 years; 71 males, 34 females) over a 9-month period. Of these, 101 were for refractory stones following failed ESWL and 13 for diagnostic reasons. An Olympus URF P3 flexible ureteroscope with pressure irrigation was used. Electrohydraulic lithotripsy was used to fragment stones and the fragments were retrieved with Graspit, triradiate graspers or tipless baskets. RESULTS: Stents had previously been placed in 53% and dilatation of the ureteric orifice was necessary in 15%. In the stone group, the median operating time was 55 min (range, 15-210 min) and the median screening time 2.2 min (range, 0.3-9.1 min). Success was defined as complete stone clearance or good fragmentation to 2 mm or less. Overall success in this group was 72.3%. There was no statistically significant difference between lower and other calyces (P=0.83 Chi-square test). Successful outcome was achieved in 72% for stone size 10 mm or less, 80% for 11-20 mm and 50% for greater than 20 mm. Two or more procedures were needed in 8 patients. In the diagnostic group, the median operating time was 45 min (range, 20-60 min) and the median screening time 2 min (range, 0.3-8.3 min). The majority were for upper tract filling defects. Access and successful diagnosis was achieved in all cases. The major complication rate was 2.6%. The ureteroscope needed repair once during this series. CONCLUSIONS: Flexible ureterorenoscopy is an effective diagnostic and therapeutic tool in a select group of patients. It should be considered for ESWL-resistant upper tract stones but the results are poor in stones larger than 20 mm and percutaneous nephrolithotomy may be a better option in these patients.
doi:10.1308/147870804768
PMCID: PMC1964230  PMID: 15333176
20.  Percutaneous Management of Caliceal Diverticuli 
Journal of Endourology  2009;23(10):1723-1729.
Abstract
Background and Purpose
Caliceal diverticula are rare congenital abnormalities that can become symptomatic if associated with a calculus or infection. We review percutaneous management of caliceal diverticula.
Methods
Pathogenesis, clinical evaluation, management options, and recommended follow-up for symptomatic caliceal diverticula are reviewed. We present our single-stage and prepercutaneous nephrolithotomy opacification techniques for the management of caliceal diverticula. This involves complete extraction of all stone particles and ablation of the diverticular cavity without infundibular identification or dilation. Comparison of outcomes between our current ablative technique and our previous dilation technique is evaluated.
Results
Percutaneous management of caliceal diverticula offers the highest symptomatic relief and stone-free rate of available management options. We identified 106 patients with caliceal diverticula who were treated with a percutaneous approach. Review of 85 of these patients demonstrated that most procedures can be performed with a small nephrostomy tube in place for 24 hours and an overnight hospital stay. Minimal complication and stone recurrence rates were observed. Patients treated with caliceal diverticular ablation experienced a shorter hospital stay, fewer complications, and a higher stone-free status than those patients who were treated with dilation of the diverticular infundibulum.
Conclusions
Percutaneous management of caliceal diverticula using cavity ablation is a minimally invasive technique that offers long-term symptomatic relief with minimal complications.
doi:10.1089/end.2009.1541
PMCID: PMC3744839  PMID: 19814580
21.  Laparoscopic Wedge Resection and Partial Nephrectomy - The Washington University Experience and Review of the Literature 
Open partial nephrectomy is an accepted form of treatment for a variety of benign conditions and for localized renal cell carcinoma. To date, there is limited experience with the clinical application of laparoscopic partial nephrectomy and wedge resection for benign and malignant disease of the kidney. Herein, we report our clinical experience with laparoscopic partial nephrectomy and a review of the current literature.
Twelve patients (27 - 81 years) have undergone laparoscopic wedge resection (3) or attempted polar partial nephrectomy (9) since 1993. In the group of 12 patients, 5 had a mass suspicious for a malignancy, 4 patients had symptomatic polar calyceal dilation with or without stone disease, and 3 patients had an atrophic or hydronephrotic upper pole moiety.
Among the patients in the polar nephrectomy group, a third were converted to an open procedure. The remaining 6 patients had a mean operative time of 6.5 hours (5.7 - 8.3 hours). These patients resumed their oral intake on average 0.8 days postoperatively. In the 2 patients with a mass, the final pathology was oncocytoma (1), and xanthogranulomatous reaction in a renal cyst (1). Postoperative complications included a nephrocutaneous fistula which was endoscopically fulgurated, a retroperitoneal urinoma which was percutaneously drained, and a two-day bout of ileus. The mean hospital stay was 5.3 days (2-9). Their full convalescence was completed in a mean of 4.2 weeks (2 - 8).
Three patients underwent a wedge resection for a superficial < 2 cm mass. The average operative time in this group was 3.5 hours (2 - 5.4). The mean time to resuming oral intake was 0.7 days (0.3 - 0.7). The final pathology was oncocytoma (1), oncocytic renal cell cancer (1), and old infarction (1); none of the patients had any complications. The mean hospital stay was 2.7 days (2- 4). Convalescence was completed in 4 weeks (range 1-8).
Laparoscopic wedge resection and polar partial nephrectomy are feasible, albeit currently tedious techniques. While wedge excision of a < 2 cm superficial lesion is relatively straightforward and efficient, laparoscopic polar partial nephrectomy remains a difficult technique and at present remains in evolution. Further development of instrumentation to provide for a reliable, expeditious, and hemostatic partial nephrectomy is needed.
PMCID: PMC3015259  PMID: 9876705
Partial nephrectomy; Laparoscopy; Kidney tumor
22.  The imaging appearances of calyceal diverticula complicated by uroliathasis 
The British Journal of Radiology  2010;83(994):888-894.
The presence of diverticula arising from the calyceal system is a relatively uncommon urological problem, occurring with an incidence of 2.1-4.5 per 1000 intravenous urogram (IVU) examinations. While the incidence of calyceal diverticula is low, the frequency of stone formation within them is high. We describe the aetiology and clinical presentation and describe the role of imaging with ultrasound, intravenous and retrograde pyelography and CT in diagnosis and planning treatment. We also describe the potential of fluid-sensitive magnetic resonance imaging techniques as a radiation-free alternative to the use of more conventional modalities, such as intravenous urography and retrograde pyelography, in delineating the anatomy of calyceal diverticula before surgical and radiological intervention especially in young patients and pregnant women.
doi:10.1259/bjr/22591022
PMCID: PMC3473751  PMID: 20846986
23.  Percutaneous nephrolithotomy in horseshoe Kidneys: is rigid nephroscopy sufficient tool for complete clearance? a case series study 
BMC Urology  2009;9:17.
Background
this study represents a case series to evaluate how successful is the rigid percutaneous nephroscopy as a tool for clearance of all stones in various locations in horseshoe kidneys.
Methods
Between 2005 and 2009, we carried out PCNL (percutaneous nephrolithotomy) for calculi in horseshoe kidneys in 21 renal units (17 patients) in our department. The indications were large stone burden in 18 units and failed SWL(shock wave lithotripsy) in 3 renal units. All procedures were done under general anesthesia; using fluoroscopic guidance for localization and standard alkan dilatation followed by rigid nephroscopy and stone extraction with or without stone disintegration. We analyzed our results regarding the site and number of the required access, the intra and postoperative complications, the presence of any residual stones, as well as their location.
Results
The procedure was completed, using a single access tract in 20 renal units, with the site of puncture being the upper calyx in nine units and the posterior middle calyx in eleven units. Only in one renal unit, two access tracts (an upper and a lower calyceal) were required for completion and a supracostal puncture was required in another case. There was no significant intraoperative bleeding and no blood transfusion was required in any patient. A pelvic perforation occurred in one case, requiring longer PCN (percutaneous nephrostomy) drainage. One patient with infection stones suffered urosepsis postoperatively which was successfully managed. Three cases had residual stones, all located in the renal isthmus, all residuals were un approachable with the rigid instrument; resulting in a overall stone-free rate of 85.7% at discharge.
Conclusion
Percutaneous nephrolithotomy is generally safe and successful in the management of stones in horseshoe kidneys. However, location of the stones in these patients is crucial to decide the proper tool for optimal stone clearance result.
doi:10.1186/1471-2490-9-17
PMCID: PMC2785831  PMID: 19917111
24.  Outcome of ureteroscopy for stone disease in patients with horseshoe kidney: Review of world literature 
Urology Annals  2015;7(4):470-474.
Introduction and Objectives:
The management of urolithiasis in patients with horseshoe kidney (HSK) is difficult. Stone formation occurred in 1:5 patients with HSK due to impaired urinary drainage and infections. Percutaneous nephrolithotomy and shock wave lithotripsy can be technically challenging due to altered anatomy.
Materials and Methods:
We conducted a systematic review of the literature to look at the role of ureteroscopy for stone management in these patients. We searched MEDLINE, PubMed and the Cochrane Library from January 1990 to April 2013 for results of ureteroscopy and stone treatment in HSK patients. Inclusion criteria were all English language articles reporting on ureteroscopy in patients with HSK. Data were extracted on the outcomes and complications.
Results:
A total of 3 studies was identified during this period. Forty-one patients with HSK underwent flexible ureteroscopy and stone treatment. The mean age was 42 with a male:female ratio nearly 3:1. The mean stone size was 16 mm (range: 3-35 mm). The mean operating time was 86 min with multiple stones seen in 15 patients. All 41 patients had a ureteral access sheath used and flexible ureteroscopy and holmium laser fragmentation done. Thirty-two (78%) patients were stone-free with a mean hospital stay of 1-day. Minor complications (Clavien I or II) were seen in 13 (32%) of which 6 had stent discomfort, 3 needed intravenous antibiotics for <24 h, 3 had hematuria of which 2 needed blood transfusion and one had pyelonephritis needing re-admission and antibiotics. There were no major complications found in the review.
Conclusions:
Retrograde stone treatment using ureteroscopy and lasertripsy in HSK patients can be performed with good stone clearance rate, but with a slightly higher complication rate. This procedure should, therefore, be done in high volume stone center with an experienced stone surgeon/team.
doi:10.4103/0974-7796.157969
PMCID: PMC4660698  PMID: 26692667
Laser fragmentation; outcomes; stones; horseshoe kidney; ureterorenoscopy
25.  Balloon dilator versus telescopic metal dilators for tract dilatation during percutaneous nephrolithotomy for staghorn stones and calyceal stones 
Arab Journal of Urology  2015;13(2):80-83.
Objective
To compare the results of balloon dilatation (BD) vs. telescopic metal dilators (TMDs) in establishing the tract for percutaneous nephrolithotomy (PCNL) in patients with calyceal stones or staghorn stones, but with no hydronephrosis.
Patients and methods
Data from selected patients over 4 years were recorded retrospectively. Patients with complex staghorn stones, an undilated targeted calyx, or the stone filling the targeted calyx, were included in the study. In all, 97 patients were included, of 235 undergoing PCNL between March 2010 and March 2014, and were divided into two groups according to the technique of primary tract dilatation. Group A included patients who had BD and group B those treated using TMDs.
Results
In group A (BD, 55 patients) dilatation was successful in 34 (62%). The dilatation failed or there was a need for re-dilatation using TMD in 21 patients (38%). In one of these 21 patients the dilatation failed due to extravasation. In group B (TMD, 42 patients) dilatation was successful in 38 (90%) patients, with incomplete dilatation and a need for re-dilatation in four (10%) patients, and no failed procedures. Group A had a significantly higher failure rate than group B (P < 0.001). Differences in operative duration, blood loss, stone-removal success rate and complication rate were statistically insignificant.
Conclusion
BD has a higher failure rate than TMD when establishing access for calyceal stones or staghorn stones that have little space around them.
doi:10.1016/j.aju.2014.12.004
PMCID: PMC4561923  PMID: 26413325
BD, balloon dilator (dilatation); TMD, telescopic metal dilator (dilatation); PCNL, percutaneous nephrolithotomy; Percutaneous; Nephrolithotomy; Stones; Dilators

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