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.
Calyceal; diverticulum; renal calyx; IVU; intravenous urogram
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.
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.
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.
Caliceal diverticula; Caliceal diverticular stones; percutaneous nephrolithotomy
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.
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.
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.
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.
An 18 year old girl presented with acute abdominal pain and a calcified opacity in the pelvis. She proved to have a Meckel's diverticulum which had a secondary diverticulum at its apex, containing a stone. Meckel's stones are uncommon and diverticula of a Meckel's diverticulum exceedingly rare. This is only the second recorded case of such a diverticulum containing a stone, and the first to describe a calcified stone in this location.
The most appropriate management of patients with lower-pole calyceal (LC) stones remains controversial. In this review we discuss the role of percutaneous nephrolithotomy (PCNL) in the management of LC stones 1–2 cm in maximum dimension.
Materials and Methods:
A detailed literature review was performed to summarize the recent technical developments and controversies in PCNL. The results of PCNL for 1-2 cm LC calculi were reviewed.
PCNL is increasingly employed as a primary modality in the treatment of LC calculi. It has a high success rate and acceptably low percentage of major complications in experienced hands. Supine position is found to be as safe and effective as prone position. Urologist-acquired access is associated with fewer access-related complications and better stone-free rates. Ultrasound is increasingly employed as an imaging modality for obtaining access. There have been increasing reports of tubeless PCNL in the literature. Most patients undergoing tubeless PCNL do not need hemostatic agents as an adjuvant for hemostasis. Non-contrast computed tomography does not yield statistically valuable increase in the diagnosis of significant residual stones compared with that of plain X-ray and linear tomography. Comprehensive metabolic evaluation and aggressive medical management can control new stone recurrences and growth of residual fragments following PCNL.
PCNL is a highly effective procedure with consistently high stone-free rates when compared with extracorporeal shockwave lithotripsy or retrograde intrarenal surgery. The results also do not depend on anatomic factors and stone size. It is associated with low morbidity in experienced hands.
Complications; lower calyx; management; percutaneous nephrolithotomy; renal calculi; technique
Diverticular disease of the colon is a common benign condition. The majority of patients with diverticular disease are asymptomatic and are managed non-operatively, however complications such as perforation, bleeding, fistulation and stricture formation can necessitate surgical intervention. A giant colonic diverticulum is defined as a diverticulum larger than 4 cm in diameter. Despite the increasing incidence of colonic diverticular disease, giant colonic diverticula remain a rare clinical entity.
This is the first reported case of laparoscopic-assisted resection of a giant colonic diverticulum. We discuss the symptoms and signs of this rare complication of diverticular disease and suggest investigations and management. Reflecting on this case and those reported in the literature to date, we highlight potential diagnostic difficulties and consider the differential diagnosis of intra-abdominal gas-filled cysts.
The presence of a giant colonic diverticulum carries substantial risk of complications. Diagnosis is based on history and examination supported by abdominal X-ray and computed tomography findings. In view of the chronic course of symptoms and potential for complications, elective surgical removal is recommended. Colonic resection is the treatment of choice for this condition and, where possible, should be performed laparoscopically.
Currently, no standardized method is available to predict success rate after percutaneous nephrolithotomy. We devised and validated the Seoul National University Renal Stone Complexity (S-ReSC) scoring system for predicting the stone-free rate after single-tract percutaneous nephrolithotomy (sPCNL).
Patients and Methods
The data of 155 consecutive patients who underwent sPCNL were retrospectively analyzed. Preoperative computed tomography images were reviewed. The S-ReSC score was assigned from 1 to 9 based on the number of sites involved in the renal pelvis (#1), superior and inferior major calyceal groups (#2–3), and anterior and posterior minor calyceal groups of the superior (#4–5), middle (#6–7), and inferior calyx (#8–9). The inter- and intra-observer agreements were accessed using the weighted kappa (κ). The stone-free rate and complication rate were evaluated according to the S-ReSC score. The predictive accuracy of the S-ReSC score was assessed using the area under the receiver operating characteristic curve (AUC).
The overall SFR was 72.3%. The mean S-ReSC score was 3.15±2.1. The weighted kappas for the inter- and intra-observer agreements were 0.832 and 0.982, respectively. The SFRs in low (1 and 2), medium (3 and 4), and high (5 or higher) S-ReSC scores were 96.0%, 69.0%, and 28.9%, respectively (p<0.001). The predictive accuracy was very high (AUC 0.860). After adjusting for other variables, the S-ReSC score was still a significant predictor of the SFR by multiple logistic regression. The complication rates were increased to low (18.7%), medium (28.6%), and high (34.2%) (p = 0.166).
The S-ReSC scoring system is easy to use and reproducible. This score accurately predicts the stone-free rate after sPCNL. Furthermore, this score represents the complexity of surgery.
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.
Diverticulum; Hydrocalycosis; Percutaneous nephrostomy; Transitional cell carcinoma; Urinary 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.
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.
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.
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.
Biliary calculi; Holmium laser; Endoscopic; Lithotripsy
Periampullary duodenal diverticula are not uncommon and are usually asymptomatic although complications may occasionally occur. Here, we report the case of a 72-year-old woman who presented with painless obstructive jaundice. Laboratory tests showed abnormally elevated serum concentrations of total and direct bilirubin, of alkaline phosphatase, of γ-glutamyl transpeptidase, and of aspartate and alanine aminotransferases. Serum concentrations of the tumor markers carbohydrate antigen 19-9 and carcinoembryonic antigen were normal. Abdominal ultrasonography showed dilatation of the common bile duct (CBD), but no gallstones were found either in the gallbladder or in the CBD. The gallbladder wall was normal. Computed tomography failed to detect the cause of CBD obstruction. Magnetic resonance imaging and magnetic resonance cholangiopancreatography revealed a periampullary diverticulum measuring 2 cm in diameter and compressing the CBD. The pancreatic duct was normal. Hypotonic duodenography demonstrated a periampullary diverticulum with a filling defect corresponding to the papilla. CBD compression by the diverticulum was considered as the cause of jaundice. The patient was successfully treated by surgical excision of the diverticulum. In conclusion, the presence of a periampullary diverticulum should be considered in elderly patients presenting with obstructive jaundice in the absence of CBD gallstones or of a tumor mass. Non-interventional imaging studies should be preferred for diagnosis of this condition, and surgical or endoscopic interventions should be used judiciously for the effective and safe treatment of these patients.
Ampulla of Vater; Diverticulum; Duodenum; Complications; Jaundice; Periampullary
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.
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.
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.
Percutaneous management of caliceal diverticula using cavity ablation is a minimally invasive technique that offers long-term symptomatic relief with minimal complications.
Objective parameters in computed tomography (CT) scans that could predict calyceal access during percutaneous nephrolithotomy have not been evaluated. These parameters could improve access planning for percutaneous nephrolithotomy. We aimed to determine which parameters extracted from a preoperative multiplanar reconstructed CT could predict renal calyceal access during a percutaneous nephrolithotomy.
From January 2009 through April 2011, 230 patients underwent 284 percutaneous nephrolithotomies at our institution. Sixteen patients presented with complete staghorn calculi, and 11 patients (13 renal units) were analyzed. Five parameters were extracted from a preoperative reconstructed CT and compared with the surgical results of percutaneous nephrolithotomy.
Fifty-eight calyces were studied, with an average of 4.4 calyces per procedure. A rigid nephroscope was used to access a particular calyx, and a univariate analysis showed that the entrance calyx had a smaller length (2.7 vs. 3.98 cm, p = 0.018). The particular calyx to be accessed should have a smaller length (2.22 vs. 3.19 cm, p = 0.012), larger angles (117.6 vs. 67.96, p<0.001) and larger infundibula (0.86 vs. 0.61 cm, p = 0.002). In the multivariate analysis, the only independent predictive factor for accessing a particular calyx was the angle between the entrance calyx and the calyx to be reached (OR 1.15, 95% confidence interval [CI], 1.053–1.256, p = 0.002).
The angle between calyces obtained by multiplanar CT reconstruction is the only predictor of calyx access.
Computed Tomography; Kidney; Percutaneous Nephrolithotomy; Urinary Calculi
With advancement in technology, improvement in endoscope and ancillary equipment, more complex procedures can be performed using flexible ureterorenoscopy. In this review article we provide a summary of flexible ureterorenoscopic procedures with “tips and tricks” for success for each type of procedure. It looks at the disposables used with flexible ureterorenoscopic procedures, set up and patient positioning for gaining access, insertion and handling of scope and the use of urethral access sheath. We also provide techniques for various flexible ureterorenoscopic procedures including management of renal stones, calyceal diverticula and upper tract urothelial tumours.
Calculi; flexible ureterorenoscopy; holmium laser; lithotripsy; laser vaporization
Urothelial carcinoma may occur anywhere in the urinary tract including the pendulous urethra. To prevent urethral stricture after resection and monopolor fulguration we describe the use of the holmium laser to fulgurate recurrent pTa UC from the urethra. The surgical approach was staged and provided excellent long term results for management of superficial UC.
Holmium laser; urethra; urothelial cancer
Recently there has been an increasing interest in the application of retrograde intrarenal surgery (RIRS) for managing renal calculi. In this review we discuss its application for the management of lower calyceal (LC) stones less than 10 mm in maximum dimension.
Materials and Methods:
Literature was reviewed to summarize the technical development in flexible ureterorenoscopy and its accessories. Further, the indications, outcome and limitations of RIRS for LC calculi < 1 cm were reviewed.
Use of access sheath and displacement of LC stone to a more favorable location is increasingly employed during RIRS. Patients who are anticoagulated or obese; those with adverse stone composition and those with concomitant ureteral calculi are ideally suited for RIRS. It is used as a salvage therapy for shock wave lithotripsy (SWL) refractory calculi but with a lower success rate (46-62%). It is also increasingly being used as a primary modality for treating LC calculi, with a stone-free rate ranging from 50-90.9%. However, the criteria for defining stone-free status are not uniform in the literature. The impact of intrarenal anatomy on stone-free rates after RIRS is unclear; however, unfavorable lower calyceal anatomy may hamper the efficacy of the procedure. The durability of flexible ureteroscopes remains an important issue.
RIRS continues to undergo significant advancements and is emerging as a first-line procedure for challenging stone cases. The treatment of choice for LC calculi < 1 cm depends on patient's preference and the individual surgeon's preference and level of expertise.
Flexible ureteroscopy; holmium laser lithotripsy; lower calyx; management; renal calculi; retrograde intrarenal surgery
Recently, few studies were reported about the treatment of large, solitary, renal calculi between shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PNL). We assess the feasibility of SWL for managing solitary, lower calyceal stones over 1 cm by comparing the results of lower pole calculi treatment between patients that underwent SWL or PNL.
We retrospectively reviewed clinical data for patients who had undergone PNL or SWL due to lower calyceal stones over 1 cm. Group 1 consisted of patients who underwent SWL to treat lower pole renal calculi from 2010 to 2011. Group 2 included patients who underwent PNL to manage lower pole renal calculi from 2008 to 2009. We compared patient age, gender, stone size, comorbidities, postoperative complications, additional interventions and anatomical parameters between the two groups.
A total of 55 patients were enrolled in this study. The mean ages (±SD) of groups 1 (n = 33) and 2 (n = 22) were 55.1 (±13.0) and 50.0 (±10.6) years (p = 0.133) and mean stone sizes were 1.6 (±0.7) and 1.9 (±0.8) cm (p = 0.135), respectively. There were no significant differences in gender distribution, comorbidities or stone laterality between the two groups. No significant differences in various parameters were observed between patients with stones 1 to 2 cm and ones with stones 2 cm or larger.
Our results demonstrated that SWL is a safe, feasible treatment for solitary, lower calyceal stones over 1 cm.
A systematic review of the 2.1 mu holmium-YAG laser for gall stone lithotripsy was undertaken. This infrared laser, which can be used endoscopically and percutaneously, has safety advantages over other lasers and has potential as a general purpose vascular and surgical tool. Twenty nine gall stones (mean mass 1.3 g) were fragmented in vitro using pulse energies of 114 to 159 mJ/pulse at 5 Hz with a 0.6 mm fibre, while being held in an endoscopy basket. All stones were successfully fragmented, requiring an average of 566 pulses with a 5 Hz pulse repetition frequency. The number of pulses required increased with gall stone size and mass (p < 0.01), and decreased with both pulse energy (p < 0.01) and operator experience (p < 0.05). The biochemical content of the stone did not significantly affect the number of pulses needed. The potential hazard of the laser to the biliary endothelium was investigated. At the pulse energies used, five pulses at close contact penetrated into the serosa of fresh gall bladder wall. No damage was seen when two pulses were fired. This laser shows considerable promise in gall stone lithotripsy. Until further safety data are available, however, its use with endoscopic vision is advised.
To assess the feasibility of retrograde ureteroscopic intrarenal surgery (RIRS) as a viable alternate to percutaneous nephrostolithotripsy (PCNL) in treating patients with renal and upper ureteric calculus of 1.6 cm to 3.5 cm stone burden.
Materials and Methods:
From October 2007 to November 2008, a total of 30 cases of upper ureteric and renal stone of 1.6 cm to 3.5 cm (Average size 2.5 cm) stone burden, for which PCNL would be done otherwise, were treated by RIRS with combined flexible and semi rigid ureteroscope and stones fragmented with holmium laser. The patients were discharged after 24 hours of the procedure and allowed to resume normal work after two days. X ray KUB for radio opaque stones and ultrasound for all the cases were done after three weeks and if any residual fragments of any size were present the patient was taken up for re-look flexible ureteroscopy under anesthesia. Stent and residual fragments were removed. If there was no residue the stent was removed under local anesthesia.
Complete clearance was considered if there were no fragments on USG screening after three weeks. Twenty six (86.6%) patients out of 30 had complete clearance in the first sitting and 4 (13.3%) patients needed re-look flexible ureteroscopy. The stone free rate in RIRS is 86.6% in the first sitting and 100% at second sitting.
RIRS is superior in terms of less complication, less morbidity and good stone free rate and has an advantage of one day of hospital stay and resuming duties after two days. RIRS is the best option for managing extracorporeal shockwave lithotripsy failed and post PCNL residual calculus. RIRS is definitely a viable alternate for PCNL for upper tract stones up to 3.5 cm.
Kidney stone treatment; laser ureteroscopy; RIRS
Urolithiasis is a very common problem, especially in industrialized societies. Extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy, and transureteral lithotripsy are effective less invasive treatments of renal and ureteral stones. Open stone surgery is used less commonly due to its invasiveness and availability of above mentioned techniques. We introduce a case, that due to heavy and complex stone burden and increased chance of failure of percutaneous nephrolithotomy, Open stone surgery is performed for stone removal.
The patient is a 55-years-old Iranian patient that referred to urology department due to a large left Staghorn kidney. After full evaluation and due to extensive spread of stone horns to the even peripheral calyces, open stone surgery performed successfully, that postoperative dynamic renal studies revealed, near normal functional left kidney.
In spite of wonderful advances in endourologic stone surgery, open stone surgery still has its role, but it must be done in experienced centers with good surgical expertise to retain good and acceptable functional kidney, postoperatively.
Background and Purpose
The EMS Swiss LithoBreaker is a new, portable, electrokinetic lithotripter. We compared its tip velocity and displacement characteristics with a handheld, pneumatic lithotripter LMA StoneBreaker.™ We also evaluated fragmentation efficiency using in vitro models of percutaneous and ureteroscopic stone fragmentation.
Materials and Methods
Displacement and velocity profiles were measured for 1-mm and 2-mm probes using a laser beam aimed at a photo detector. For the percutaneous model, 2-mm probes fragmented 10-mm spherical BegoStone phantoms until the fragments passed through a 4-mm mesh sieve. The ureteroscopic model used 1-mm probes and compared the pneumatic and electrokinetic devices to a 200-μm holmium laser fiber. Cylindrical (4-mm diameter, 4-mm length) BegoStone phantoms were placed into silicone tubing to simulate the ureter; fragmented stones passed through a narrowing in the tubing.
For both 1-mm and 2-mm probes, the electrokinetic device had significantly higher tip displacement and slower tip velocity, P<0.01. In the percutaneous model, the electrokinetic device needed an average of 484 impulses over 430 seconds to fragment one BegoStone, while the pneumatic device needed 29 impulses over 122 seconds to fragment one stone. Both clearance times and number of impulses needed for percutaneous stone clearance were significantly different at P<0.01. Ureteroscopically, the mean clearance time was 97 seconds for the electrokinetic lithotripter, 145 seconds for the pneumatic lithotripter, and 304 seconds for the laser. Comparing the pneumatic device with the electrokinetic device ureteroscopically, there was no significant difference in clearance time, P=0.55. Both the pneumatic and electrokinetic lithotripters, however, demonstrated decreased clearance times compared with the laser, P=0.027.
The portable electrokinetic lithotripter may be better suited for ureteroscopy instead of percutaneous nephrolithotomy. It appears to be comparable to the portable pneumatic device in the ureter. Further clinical studies are needed to confirm these findings in vivo.
Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.
Duodenal diverticula; Perforation; Conservative management
Gastric diverticula are the least common diverticula of the gastrointestinal tract. The two main categories identified are congenital and acquired ones. Diverticula of the antrum, prepyloric or pyloric, are extremely rare and usually asymptomatic. We report a diverticulum of the prepyloric region in a patient with a background of peptic ulcer disease and antiplatelet treatment who became symptomatic and was treated successfully with proton pump inhibitors.
Gastric diverticulum; Prepyloric region; Proton pump inhibitors
Objectives. To describe our novel modified technique of ultra-mini-percutaneous nephrolithotomy (UMP) using of a novel 6 Fr mininephroscope through an 11–13 Fr metal sheath to perform holmium: YAG laser lithotripsy. Methods. The medical records of 36 patients with moderate-sized (<20 mm) kidney stones treated with UMP from April to July 2012 were retrospectively reviewed. Patients were assessed at the 1st day and 1st month postoperatively by KUB and US to assess stone-free status. Results. The mean stone size was 14.9 ± 4.1 mm (rang: 6–20). The average operative time was 59.8 ± 15.9 (30–90) min. The stone-free rate at postoperative 1st day and 1st month was 88.9% and 97.2%. The mean hospital stay was 3.0 ± 0.9 (2–5) days. Complications were noted in 6 (16.7%) cases according to the Clavien classification, including sepsis in 2 (5.6%) cases (grade II), urinary extravasations in 1 (2.8%) case (grade IIIa), and fever in 3 (8.3%) cases (grade II). No patients needed blood transfusion. Conclusions. UMP is technically feasible, safe, and efficacious for moderate-sized renal stones with an advantage of high stone-free rates and low complication rates. However, due to the limits of its current unexplored indications, UMP is therefore a supplement to, not a substitute for, the standard mini-PCNL technology.
Diverticular disease of the colon may be responsible for abdominal symptoms requiring colonoscopy, which may reveal the presence of concomitant polyps. A polyp found during colonoscopy in patients with colonic diverticular disease may be removed by endoscopic polypectomy with electrosurgical snare, a procedure associated with an incidence of perforation of less than 0.05%. The risk of such a complication may be higher in the event of an inverted colonic diverticulum, which may be misinterpreted as a polypoid lesion at colonoscopy. To date, fewer than 20 cases of inverted colonic diverticula, diagnosed at colonoscopy or following air contrast barium enema, have been reported in the literature. The present report describes a 68-year-old woman who underwent a screening colonoscopy, which revealed a voluminous pedunculated polyp that was recognized to be an inverted giant colonic diverticulum before endoscopic polypectomy.
Colonic diverticulum; Colonic polyp; Colonoscopy; Polypectomy