ENDOUROLOGY
PERCUTANEOUS NEPHROLITHOTOMY IN TRANSPLANTED KIDNEY ANDRES ALDA, M.D. JUAN PLAZA, M.D. CARLOS ALFEREZ, M.D.
JOSE MINON CIFUENTES, M.D. EDUARDO GARCIA TAPIA, M.D. ENRIQUE GARCIA DE LA PEI~IA, M.D. REMIGIO VELA NAVARRETE, M.D.
From the Department of Urology, Jimenez-Diaz Foundation, Universidad Autdnoma, Madrid, Spain
ABSTRACT--Renal transplant patients with urologic complications can be managed sa]ely with percutaneous techniques. The development o] renal calculi in transplanted kidneys is uncommon, but in these cases complications such as injection and urinary tract obstruction with impairment o] graft function can occur. We report 2 cases managed success]ully with percutaneous nephrolithotomy.
Calculus formation is a rare complication postrenal transplantation, but when present it remains an important cause of deterioration of renal function. We present 2 patients in whom calculus developed after a renal transplant. These are the sixth and seventh case reports in the literature, concerning calculus formation after renal transplantation. Percutaneous nephrolithotomy is an efficient and safe technique in the management of such patients. Case Reports
Case 1 A thirty-year-old man had undergone cadaveric renal transplantation in December 1984 because of chronic renal failure due to an A1port-Perkoff syndrome. Six months later an excretory urogram (IVP) of the transplanted kidney showed marked dilatation of the collecting system as a result of ureteral stenosis. Intraoperatively the ureter was encased in scar tissue, and a crossed pyelopyelostomy was performed. Renal function returned to normal after this procedure, but recurrent urinary tract infection developed. In April 1986, a film of the kidney demonstrated three calculi in the pelvic area without hydronephrosis (Fig. 1A, B). 232
Because of the recurrei tion, a percutanous neph formed. Stone location in ing system was outlined contrast material retrogr viously placed ureteral , fluoroscopic assistance puncture was made in tl~ wall; the tract was dilate, and a 26F sheath was ins ing system. The calculus ultrasonic lithotripsy and ments was made with ap On analysis, the calculi monohydrate and calciul later, the patient underwl remove gravel remaining die calix. The nephrostoI five days later. Two mc creatinine was 1.5 mg/d clearance 61 mL/min, mained free of lithiasis (t
UROLOGY
Case 2 A twenty-five-year-old nal transplant in vivo in chronic renal failure as a pillar glomerulonephritis /
S E P T E M B E R 1991
/
VO]
. shows three calculi; (B) retrograde nephrostogram demonstrates calculus , after percutaneous nephrolithotomy.
~: ii~ a urinary fistula developed because of necrosis 'of the distal ureter and an ipsilateral pyeloipyelostomy was successfully accomplished. I n November 1986 she was hospitalized because of pain and oligoanuria. A film of the kidhe) showed three calcifications: two in the !plel~c area and one in the upper ureter (Fig. 2~)i An IVP showed hydronephrosis suggesting th~ point of obstruction to be at the site of the istone located in the upper ureter. A percutaneous nephrostomy was performed to allow id)ainage of the transplanted kidney. !',Four days later a percutaneous nephrolithowas performed by dilation of the nephros-
.'Percutaneous.
tomy tract to 26F and the insertion of a 26F sheath (Fig. 2B). Two calculi were disintegrated by ultrasonic lithotripsy, and the fragments were removed with small grasping forceps. One calculus was located in the middle calix and was removed successfully with the aid of the flexible nephroscope. A nephrostogram was performed four days later showing no extravasation and the tube was removed. The patient has remained free from lithiasis (Fig. 2C). One month later the serum creatinine was 1.1 mg/dL and the creatinine clearance 78 mL/ min. On analysis, the calculi were carbonateapatite with small amounts of struvite.
Case 2. (A) Arrows indicate two calcific densities overlying allograft and one in upper ureter; (B) nephrolithotomy; (C) plain .film four days later showing no residual stone.
~ROLOGy:!: / SEPTEMBER1991 / VOLUMEXXXVIII,NUMBER3
233
Comment Calculi formation in the kidney transplant patient is a rare complication occurring two months to seven years after transplantation. 1-4 Factors such as hyperparathyroidism, renal tubular acidosis, obstruction, and recurrent urinary tract infections, have been implicated2* Brient e t al. v found that urinary tract obstruction predisposed to stone formation in the transplant patient. Motayne e t al. s found that in 6.3 percent of patients with renal transplant in which a stapled ureteroureterostomy was performed calculi developed, and in all eases evidence of urinary tract obstruction was established radiographieally. Sehweizer et al. in 1977 ~ apparently reported the first ease in which a calculus was removed from a transplanted kidney by performing a pyelolithotomy. The first ease of stone extraction from ~a renal transplant patient by pereutaneous nephrostomy was reported by Fisher et al. in 1982. o In this ease the stone was rescued without dilation of the tract. Subsequently, Jarowenko et al.X° reported 1 case and Hulbert e t al. n 2 eases of renal calculi complicating transplanted kidneys that were managed sueeessfully by pereutaneous nephrolithotomy. The latter also described certain technical considerations that must be observed in these patients. Locke e t al. ~ reported a case in which a combination extracorporeal shock-wave lithotripsy (ESWL) and percutaneous extraction were used to remove multiple calculi from a renal allograft. In our cases, the renal calculi were diagnosed between two and four years postrenal transplant. In both cases, a pyelopyelostomy was performed because of ureteral stricture and urinary fistula. We believe that the urologic complications in the renal transplant patient should be evaluated appropriately prior to open surgery, because open techniques prove to be a risk in the development of calculi. The urologic complications in renal transplant patients, such as urinary fistula, ureteral obstruction, perirenal hematoma, and renal
234
UROLOGY
abscess, can be managed successfully by pereutaneous techniques, l°aaa4 Stone removal from a renal transplant may be necessary if there is ealieeal or ureteral obStruction and recurrent urinary tract infections, However, open surgical techniques can be very: complicated in these cases, since the identifiea){ tion of the vessels and renal pelvis in the retro,i peritoneal space may become difficult leading:i to obliterative scarring. There is also increased risk of infection and the impairment of wound healing in the immunosuppressed patient. 8 For these reasons, the pereutaneous nephrc lithotomy is for the present the best alternativ surgery for renal calculi developed from tram. planted kidneys, and in selected eases shod/ wave lithotripsy can be used as effective ad} junetive therapy. 28040 Madrid, Spaii (DR. MIlqON CIFUENTE
1. Rattazzi LC, et ah Calculi complicating renal transp]~ into ileal conduits, Urology 5:29 (1975). ~'~!~ 2. LueasBSC, and Castro JE: Caleuliin renal transplants, B~ Urol 50:302 (1978). ?'%: 3. Normann E, Fryjordet A, and Halvorsen S: Stones in reii~ transplants, Seand J Urol 14:73 (1980). :'::~ig!~ 4. Pearson RC, et ah The use of pereutaneous nephros~V',/~ techniques in renal allografts, Transplantation 45:506 (1988I~ 5. 8ehweizer RT, Bartus SA, Graydon RJ, and B e r l m ~ Pyelolithotomy of a renal transplant, J Urol 117:665 (19771{i![i~!~! ~ 6. Rosenberg JC, et al: Calculi complicating a renal '~:!!~.}'i plant, Am J Surg 129:326 (1975)• 7. Brient G, et ah Urolithiasis after kidney transplantafi~ clinical and mineralogical aspects, Urol Res 8:211 (1980)i ( ! i ~ 8. Motayne GG, Jindal SL, Irvine AH, and Abele liP: C ~ formation in renal transplant patients, J Urol 132:448 (i98~1f}:~{ 9. Fisher MF, et al: Renal stone extraction through a per{~t{{~ neons nephrostomy in a renal transplant patient ' R a d i o l 0;t,,~i?~4{; 95 (1982). z~
PERCUTANEOUS NEPHROLITHOTOMY IN TRANSPLANTED KIDNEY ANDRES ALDA, M.D. JUAN PLAZA, M.D. CARLOS ALFEREZ, M.D.
JOSE MINON CIFUENTES, M.D. EDUARDO GARCIA TAPIA, M.D. ENRIQUE GARCIA DE LA PEI~IA, M.D. REMIGIO VELA NAVARRETE, M.D.
From the Department of Urology, Jimenez-Diaz Foundation, Universidad Autdnoma, Madrid, Spain
ABSTRACT--Renal transplant patients with urologic complications can be managed sa]ely with percutaneous techniques. The development o] renal calculi in transplanted kidneys is uncommon, but in these cases complications such as injection and urinary tract obstruction with impairment o] graft function can occur. We report 2 cases managed success]ully with percutaneous nephrolithotomy.
Calculus formation is a rare complication postrenal transplantation, but when present it remains an important cause of deterioration of renal function. We present 2 patients in whom calculus developed after a renal transplant. These are the sixth and seventh case reports in the literature, concerning calculus formation after renal transplantation. Percutaneous nephrolithotomy is an efficient and safe technique in the management of such patients. Case Reports
Case 1 A thirty-year-old man had undergone cadaveric renal transplantation in December 1984 because of chronic renal failure due to an A1port-Perkoff syndrome. Six months later an excretory urogram (IVP) of the transplanted kidney showed marked dilatation of the collecting system as a result of ureteral stenosis. Intraoperatively the ureter was encased in scar tissue, and a crossed pyelopyelostomy was performed. Renal function returned to normal after this procedure, but recurrent urinary tract infection developed. In April 1986, a film of the kidney demonstrated three calculi in the pelvic area without hydronephrosis (Fig. 1A, B). 232
Because of the recurrei tion, a percutanous neph formed. Stone location in ing system was outlined contrast material retrogr viously placed ureteral , fluoroscopic assistance puncture was made in tl~ wall; the tract was dilate, and a 26F sheath was ins ing system. The calculus ultrasonic lithotripsy and ments was made with ap On analysis, the calculi monohydrate and calciul later, the patient underwl remove gravel remaining die calix. The nephrostoI five days later. Two mc creatinine was 1.5 mg/d clearance 61 mL/min, mained free of lithiasis (t
UROLOGY
Case 2 A twenty-five-year-old nal transplant in vivo in chronic renal failure as a pillar glomerulonephritis /
S E P T E M B E R 1991
/
VO]
. shows three calculi; (B) retrograde nephrostogram demonstrates calculus , after percutaneous nephrolithotomy.
~: ii~ a urinary fistula developed because of necrosis 'of the distal ureter and an ipsilateral pyeloipyelostomy was successfully accomplished. I n November 1986 she was hospitalized because of pain and oligoanuria. A film of the kidhe) showed three calcifications: two in the !plel~c area and one in the upper ureter (Fig. 2~)i An IVP showed hydronephrosis suggesting th~ point of obstruction to be at the site of the istone located in the upper ureter. A percutaneous nephrostomy was performed to allow id)ainage of the transplanted kidney. !',Four days later a percutaneous nephrolithowas performed by dilation of the nephros-
.'Percutaneous.
tomy tract to 26F and the insertion of a 26F sheath (Fig. 2B). Two calculi were disintegrated by ultrasonic lithotripsy, and the fragments were removed with small grasping forceps. One calculus was located in the middle calix and was removed successfully with the aid of the flexible nephroscope. A nephrostogram was performed four days later showing no extravasation and the tube was removed. The patient has remained free from lithiasis (Fig. 2C). One month later the serum creatinine was 1.1 mg/dL and the creatinine clearance 78 mL/ min. On analysis, the calculi were carbonateapatite with small amounts of struvite.
Case 2. (A) Arrows indicate two calcific densities overlying allograft and one in upper ureter; (B) nephrolithotomy; (C) plain .film four days later showing no residual stone.
~ROLOGy:!: / SEPTEMBER1991 / VOLUMEXXXVIII,NUMBER3
233
Comment Calculi formation in the kidney transplant patient is a rare complication occurring two months to seven years after transplantation. 1-4 Factors such as hyperparathyroidism, renal tubular acidosis, obstruction, and recurrent urinary tract infections, have been implicated2* Brient e t al. v found that urinary tract obstruction predisposed to stone formation in the transplant patient. Motayne e t al. s found that in 6.3 percent of patients with renal transplant in which a stapled ureteroureterostomy was performed calculi developed, and in all eases evidence of urinary tract obstruction was established radiographieally. Sehweizer et al. in 1977 ~ apparently reported the first ease in which a calculus was removed from a transplanted kidney by performing a pyelolithotomy. The first ease of stone extraction from ~a renal transplant patient by pereutaneous nephrostomy was reported by Fisher et al. in 1982. o In this ease the stone was rescued without dilation of the tract. Subsequently, Jarowenko et al.X° reported 1 case and Hulbert e t al. n 2 eases of renal calculi complicating transplanted kidneys that were managed sueeessfully by pereutaneous nephrolithotomy. The latter also described certain technical considerations that must be observed in these patients. Locke e t al. ~ reported a case in which a combination extracorporeal shock-wave lithotripsy (ESWL) and percutaneous extraction were used to remove multiple calculi from a renal allograft. In our cases, the renal calculi were diagnosed between two and four years postrenal transplant. In both cases, a pyelopyelostomy was performed because of ureteral stricture and urinary fistula. We believe that the urologic complications in the renal transplant patient should be evaluated appropriately prior to open surgery, because open techniques prove to be a risk in the development of calculi. The urologic complications in renal transplant patients, such as urinary fistula, ureteral obstruction, perirenal hematoma, and renal
234
UROLOGY
abscess, can be managed successfully by pereutaneous techniques, l°aaa4 Stone removal from a renal transplant may be necessary if there is ealieeal or ureteral obStruction and recurrent urinary tract infections, However, open surgical techniques can be very: complicated in these cases, since the identifiea){ tion of the vessels and renal pelvis in the retro,i peritoneal space may become difficult leading:i to obliterative scarring. There is also increased risk of infection and the impairment of wound healing in the immunosuppressed patient. 8 For these reasons, the pereutaneous nephrc lithotomy is for the present the best alternativ surgery for renal calculi developed from tram. planted kidneys, and in selected eases shod/ wave lithotripsy can be used as effective ad} junetive therapy. 28040 Madrid, Spaii (DR. MIlqON CIFUENTE
1. Rattazzi LC, et ah Calculi complicating renal transp]~ into ileal conduits, Urology 5:29 (1975). ~'~!~ 2. LueasBSC, and Castro JE: Caleuliin renal transplants, B~ Urol 50:302 (1978). ?'%: 3. Normann E, Fryjordet A, and Halvorsen S: Stones in reii~ transplants, Seand J Urol 14:73 (1980). :'::~ig!~ 4. Pearson RC, et ah The use of pereutaneous nephros~V',/~ techniques in renal allografts, Transplantation 45:506 (1988I~ 5. 8ehweizer RT, Bartus SA, Graydon RJ, and B e r l m ~ Pyelolithotomy of a renal transplant, J Urol 117:665 (19771{i
