Urolithiasis DOI 10.1007/s00240-015-0753-9

ORIGINAL PAPER

Initial experiences with laparoscopy and flexible ureteroscopy combination pyeloplasty in management of ectopic pelvic kidney with stone and ureter–pelvic junction obstruction Zhuo Yin · Y. B. Wei · B. L. Liang · K. Q. Zhou · Y. L. Gao · B. Yan · Z. Wang · J. R. Yang 

Received: 8 October 2014 / Accepted: 7 January 2015 © Springer-Verlag Berlin Heidelberg 2015

Abstract  To demonstrate the safety and efficacy of combine laparoscopy and flexible ureteroscopy to treat ectopic pelvic kidneys with ureteropelvic junction obstruction (UPJO) and stones. 16 patients of ectopic pelvic kidneys with ureteropelvic junction obstruction and stones were treated with laparoscopy and flexible ureteroscopy (FURS). The operative time, required dose of tramadol, visual analog pain scale (VAPS), postoperative day, stonefree rates (SFRs), perioperative complications, and serum creatinine were evaluated. The SFRs were evaluated with noncontrasted renal computed tomography (CT). Intravenous pyelography (IVP) and CT scan were used to evaluate the UPJO. Stone-free status was defined as absence of stone fragments in kidney or the size of that is less than 3 mm. Operation time from 118 to 225 min, average time

Z. Yin · Y. B. Wei · B. L. Liang · K. Q. Zhou · Y. L. Gao · B. Yan · Z. Wang · J. R. Yang (*)  Department of Urology, Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan, China e-mail: [email protected] Z. Yin e-mail: [email protected] Y. B. Wei e-mail: [email protected] B. L. Liang e-mail: [email protected] K. Q. Zhou e-mail: [email protected] Y. L. Gao e-mail: [email protected] B. Yan e-mail: [email protected] Z. Wang e-mail: [email protected]

(171 ± 28) min; lithotomy time from 16 to 45 min, average time (32 ± 6) min. Average tramadol required at the first day postoperation was (118 ± 49.6) mg; at the second day was (78 ± 24.8) mg. VAPS score at 24 h (5.0 ± 0.7), VAPS score at 48 h (2.5 ± 0.8). Postoperative day (3.9 ± 0.6) days. Stone-free rate was 100 %. Average serum creatinine was (88.7 ± 24.3) mol/L before surgery and (92.8 ± 21.6) mol/L after surgery. No major complication. No stone and obstruction recurrence in the follow-up of average 29.3 months. Combined FUR and LC is a good option for patient of ectopic pelvic kidney with renal stone and UPJO. From our initial experience, the SFRs and the effect of pyeloplasty are satisfactory and without major complication, the operative time is acceptable. Keywords  Ectopic pelvic kidney · Ureter pelvic junction obstruction · Renal stone · Laparoscopy · Flexible ureteroscopy

Introduction The incidence of pelvic kidney is estimated at between 1 in 2,200 and 1 in 3,000 [1]. Because of the structural and architectural anomalies that can accompany a pelvic kidney, conditions such as chronic obstruction and nephrolithiasis are common [1]. The variation in anatomy of a pelvic kidney creates anomalous vascular patterns and altered spatial relations with adjacent pelvic organs. Therefore, the treatment of patients with pelvic kidney stones represents a great challenge to urologists. Various treatment options have been reported which include extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), Laparoscope (LC), and flexible ureteroscope (FURS) [2–5]. While ESWL is

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Urolithiasis

the least invasive approach, it has significantly lower efficacy (57.2 %) in pelvic kidney calculi when compared with normal kidney calculi [6]. In patients with lower calyceal calculi and with a stone diameter (dm) >30 mm, stone-free rate decreased to 50 and 34 % respectively [6]. PCNL offers higher efficacy but has higher risk of bowl injury [4, 7]. Reported by Weizer et al. [5], good results were achieved with FURS when stone burden is less than 1.5 cm, but large and complex stone is a relative contraindication for FURS. Laparoscope is a good option for patients with large stone and can correct ureter–pelvic junction obstruction simultaneously. However, laparoscope cannot treat calyceal stone. This article is to report our initial experiences on LC and FURS combination pyeloplasty in treating patients with ectopic pelvic kidney with renal calyceal stone and ureter– pelvic junction obstruction.

Fig. 1  CT with noncontrast before surgery

Table 1  Demographic of patients

Materials and methods The study received approval from the Institutional Review Board, and we obtained informed consent from all patients who participated in this study. We retrospectively analyzed 16 patients (7 women and 9 men, 22–41 years old, cumulative stone diameter 12–46 mm, body mass index 21.5–32.8, stone volume 784–2,648 mm3) of ectopic pelvic kidney with renal calculi and ureter–pelvic junction obstruction (UPJO) who underwent LC and FURS combination pyeloplasty from January 2010 to June 2013 (Table 1). All surgeries were performed by the same surgeon. Computed tomography (CT) without contrast and plain X-ray of kidney, ureter, and bladder (KUB) were used to identify the stone size, number, and location (Fig. 1). Intravenous pyelography (IVP) and urinary system (KUB) CT scan were used to identify the ureter–pelvic junction obstruction and to evaluate kidney function. Stones were sent for composition analysis. The perioperative data were collected for medical record. It included operative time, required dose of tramadol, visual analog pain scale (VAPS), postoperative day, stone-free rate (SFR), perioperative complications, and serum creatinine. VAPS was evaluated at 24 and 48 h after surgery. Preoperative imaging was reviewed for stone size, location, and evidence of obstruction. The postoperative images were reviewed and compared with the preoperative images. SFR was evaluated with noncontrasted renal CT obtained 4 weeks after the first procedure. SFR was defined as absence of stone fragments in kidney or the size of that is less than 3 mm—the layer thickness of CT scan was 3 mm. Ultrasound was used to evaluate the UPJO 1 and 3 months after the double-J stent was removed, patients are more likely to choose ultrasound because it is noninvasive (IVP and CT with contrast need inject contrast). However,

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Gender (F/M)  Female  Male Age BMI (kg/m2) Mean ± SD (mm) Cumulative stone diameter  Mean ± SD (mm3) stone volume

7 9 31.6 ± 5.4 (22–41) 26.4 ± 3.5 (21.5–32.8) 30.5 ± 2.6 (12–46) 1,179 ± 206 (784–2,648)

The stone volume was obtained from measurements on analog 3 D images of the stone, using 5-mm axial and 3.5-mm reconstructed coronal noncontrast computed tomography (NCCT). We used the following formula to calculate the stone volume: length × width × heig ht × π × 1/6 BMI body mass index

to compare with preoprative IVP and CT findings, IVP and CT scan were used to evaluate the UPJO 6 and 12 months after the double-J stent was removed (Fig. 2). Surgical technique The patient was placed in a Trendelenberg position. After pneumoperitoneum, a 10-mm laparoscopic trocar was placed at the umbilicus, a 12-mm trocar was placed at the lateral border of the rectus muscle, 2 cm below umbilicus, and a 5-mm trocar was placed at the lateral border of the rectus muscle opposite the 12-mm trocar. An additional 5-mm trocar was used if necessary. The free loops of the small bowel were moved out of the pelvis, and the site of the pelvic kidney was then localized and evaluated for any adhesions. For right side cases, the right colon was dissected off the anterior surface of the kidney. For left side cases, a transmesenteric incision was performed to expose the posterior peritoneal cover of the anterior surface of the

Urolithiasis Table 2  Introperative and postoperative characteristics

Fig. 2  CT with noncontrast after surgery

kidney. The pelvis with obstruction was visualized by LC. The pelvis was incised with endoscissors according the plan of ureter–pelvic reconstruction. The pelvis stones were collected by a bag and then taken out through a 12-mm trocar. The patients with inaccessible caliceal stones were treated with FURS (Olympus P5, Tokyo, Japan). The stones were passed through a 12-mm trocar and then entered into a collecting system through the pyelotomy incision. Nitinol stone basket (Cook Medical) was used to remove the stone, and laser lithotomy with a holmium laser machine at 0.5–1.0 J energy level and 5–15 Hz frequency was performed for those who needed. The last procedure of the lithotripsy was the examination of residual stones, which was performed by an ultrasound specialist, the gas in abdomen was released and fluid around kidney was sucked off before the examination. Then the patients were treated with classic dismembered Hynes–Anderson pyeloplasty using 4-0 absorbable interrupted suture for posterior anastomosis and running suture for anterior anastomosis. The double-J stents of all patients remained in place (Fig. 3).

Results All operations were successful, no patient need blood transfusion or had damage of surrounding organs. Duration of operations was 118–225 min (average 171 ± 28 min); duration of lithotomy was 16–45 min (average 32 ± 6 min). Average dosage of tramadol administered at the first day postoperation was 118 ± 49.6 and 78 ± 24.8 mg at the second day. Average VAPS score at 24 h was 5.0 ± 0.7 and 2.5 ± 0.8 at 48 h. On postoperative day (3.9 ± 0.6 days), SFR was 100 %. Average serum creatinine was 88.7 ± 24.3 μmol/L before surgery. Average serum creatinine was 92.8  ± 21.6 μmol/L after surgery. No major complication except for two cases with subcutaneous emphysema

Serum creatinine before surgery, mean ± SD (μmol/L) Serum creatinine after surgery, mean ± SD (μmol/L) Total operative time, mean ± SD (min) (range) Lithotomy time, mean ± SD (min) (range) Tramadol day1, mean ± SD (mg) (range) Tramadol day2, mean ± SD (mg) (range) VAPS score at 24 h (range) VAPS score at 48 h (range) Postoperative day (days) (range) Complication  Blood transfusion  Subcutaneous emphsema  SFR

88.7 ± 24.3 (40–142) 92.8 ± 21.6 (46–155) 171 ± 28 (118–225) 32 ± 6 (16–45) 118 ± 49.6 (50–200) 78 ± 24.8 (50–100) 5.0 ± 0.7 (4–6) 2.5 ± 0.8 (1–4) 3.9 ± 0.6 (3–5) 0 2 100 %

SFR stone-free rate, VAPS visual analog pain scale

Fig. 3  Laparoscopy pyeloplasty for pelvic kidney with UPJO

(Table  2). So, all of the complications were limited to Grade I of the modified Clavien system. The mean time of postoperative follow-up visit was 29.3 (12–41) months. No stone recurrence was reported from the follow-up visits. Intravenous pyelography (IVP) and CT scan demonstrated improvement in pelvicalyceal dilation compared to those performed before surgery. Stone composition Ten patients (62.5 %) had calcium oxalate monohydrate and dehydrate stones. Five patients (31.2 %) had mixed stones comprising calcium oxalate monohydrate and dehydrate and calcium phosphate. One patient (6.3 %) had magnesium ammonium phosphate stones.

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Urolithiasis Table 3  Comparison between the different procedures for pelvic kidney stone with the data published in the literature References

Patient number

Treatment

Stone burden

Hospitalization (days)

Stone-free rate

Follow-up (months)

Complication

Talic et al. [23] Tunc et al. [6]

11 14

ESWL ESWL

Not report 2.35 ± 0.95 cm2

Not report

81.8 % (9/11)

3

Not report

Not report

57.1 % (8/14)

3

Renal colic, acute pyelonephritis, stone-street formation

Küpeli et al. [9]

13

ESWL

2.09 ± 0.71 cm2

Matlaga et al. [7]

8

PCNL

Not report

Not report 2.6 (1–4)

Not report Not report

Not report No complicaton

Alomar et al. [2]

1

PCNL 2 cm (CT guided)

2

53.8 % (7/13) 75.0 % for single PCNL, 100.0 % for secondary PCNL 100.0 % (1/1)

Not report

No complication

Weizer [5]

4

FURS

Not report

75.0 % (3/4)

3

No complication

1.4 (0.3–2) cm

ESWL extracorporeal shock-wave lithotripsy, PCNL percutaneous nephrolithotomy, FURS flexible ureteroscope

Discussion The aim of this study was to assess the efficacy of combination therapy of laparoscope and flexible ureteroscope in treatment of ectopic pelvic kidney with stone and ureter–pelvic junction obstruction. It showed that this method has following advantages: (1) It removes renal calyces and pelvis stones directly through the pelvis incisions, which reduces lithotomy time. (2) It mitigates the risk of ureteral stenosis caused by damage during the removal of stone fragments through ureter. (3) It corrects anatomical deformities simultaneously, reduces the incident of stone recurrence. (4) Due to the application of FURS, it is easier to treat kidney calyceal stone. (5) As we know, when the hydronephrosis is severe or the angle between ureter and lower calyx is very small, flexible ureteroscope cannot access low calyces. When a flexible ureteroscope enter renal calyces through renal pelvis incision, there are no blind spots. Although with advantages mentioned above, the LC and FURS combination therapy should be controlled strictly with necessary indications. FURS monotherapy should be a better choice for patients with small stone burden, moderate hydronephrosis, or the angle between ureter and lower calyx is not too small, for a less invasive operation. Because the special anatomy of pelvic kidney, it has always been a great challenge for urologist in the treatment of pelvic kidney stone. Certainly, ESWL is a first-line and established option for the treatment of