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Unusual iatrogenic cause for renal stone formation following percutaneous nephrolithotomy A 49-year-old man underwent an uneventful percutaneous nephrolithotomy (PCNL) for right renal pelvis stones at another hospital in July 2010. A Cope 14F nephrostomy was left in overnight and removed by the ward staff. The patient was discharged home on the first post-operative day but presented to our emergency department the same day with right flank pain. The operation site appeared inflamed but otherwise uneventful. Suspecting retained stones a computed tomography was performed which showed slight renal inflammation and a tiny renal pelvis stone but no other problems. The pain improved with conservative measures and the patient was discharged after 2 days. The patient was reviewed regularly and developed a further right renal stone with possible tract calcification (Fig. 1) within 2 years. As a result, the patient was booked for ureterorenoscopic stone removal. During this procedure, the stone was seen attached to a blue thread. The stone was successfully fragmented but it proved impossible to remove the thread as it appeared to come from within the renal cortex and the available instruments could not provide sufficient pulling force. The findings were explained to the patient and he was booked for a percutaneous procedure. With a modified supine approach, access was gained into the middle pole calyx and the thread found in two pieces (Fig. 2) and pulled out after wrapping around 12F graspers. A total of 20 cm of thread was removed. The patient made an uneventful recovery and will be monitored for any further problems. This is the second reported case in literature of a retained nephrostomy thread resulting in stone formation in the collecting system. Ahn et al. first reported it in 1997 where a PCNL was required to remove the stone and thread.1 There have been many reports where stone formation in the collecting system secondary to sutures placed after a pyeloplasty or pyelolithotomy.2 In these instances, measures such as ureteroscopy and PCNL were required for successful stone clearance. In our case, utilizing PCNL was the most appropriate procedure to completely remove the suture that was extending outside the kidney. The use of nephrostomy tubes in decompressing obstructed upper urinary tracts has been well established. It is a relatively safe and effective method to use in a medically unstable patient. Their use for upper tract drainage, haemostasis and access for additional procedures after PCNL has allowed for PCNL to be routinely performed with minimal morbidity. The use of a cross-limbed loop anchor nephrostomy was first described by Cope in 1980.3 The nephrostomy tube has a suture that originates from the tip and runs the length of the tube to exit out the end. After the nephrostomy tube has been correctly positioned, the suture is pulled resulting in the tip to loop and anchor © 2015 Royal Australasian College of Surgeons

Fig. 1. Axial CT image demonstrating calcification in the right kidney.

Fig. 2. Endoscopic image of collecting system with ends of nephrostomy string.

the nephrostomy in place. This allows for the nephrostomy tube to be held in securely and no retaining skin suture is required. To remove or exchange the nephrostomy, the tethering suture is cut and the nephrostomy is pulled out, usually over a guidewire. The use of this type of nephrostomy is usually placed when the upper tract drainage is required for some period of time. After ANZ J Surg •• (2015) ••–••

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performing PCNL, a nephrostomy tube is usually placed for a few days. Other forms of percutaneous drainage using Malecot, Foley catheters or chest drains have been used to accomplish the same result. The criticisms with these are that they depend on a stitch on the skin surface to hold them in position. This is associated with an increased risk of dislodgement. The use of a Foley catheter is much cheaper than a specifically designed nephrostomy. They have no anchoring thread and therefore negate the risk of a retained suture. Performing a PCNL without a nephrostomy is also gaining acceptance. Case selection is very important for performing a ‘tubeless’ PCNL. This technique results in shorter hospitalization, reduced analgesia requirement and faster return to normal activity.4,5 Urologists and radiologists very commonly use the cross-limbed loop anchor nephrostomy tube. We report a rare case where the tethering suture failed to be removed completely resulting in stone formation in the kidney. This case highlights the need for careful removal of these nephrostomies over a guidewire to prevent inadvertent retention of suture.

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References 1. Ahn J, Trost DW, Topham SL, Sos TA. Retained nephrostomy thread providing a nidus for atypical renal calcification. Br. J. Radiol. 1997; 70: 309–10. 2. Applewhite JC, Assimos DG. Recurrent suture urolithiasis 29 years after open pyelolithotomy. J. Endourol. 1999; 13: 437–9. 3. Cope C. Improved anchoring of nephrostomy catheters: loop technique. AJR Am. J. Roentgenol. 1980; 135: 402–3. 4. Agrawal MS, Agrawal M, Gupta A, Bansal S, Yadav A, Goyal J. A randomized comparison of tubeless and standard percutaneous nephrolithotomy. J. Endourol. 2008; 22: 439–42. 5. Shen P, Liu Y, Wang J. Nephrostomy tube-free versus nephrostomy tube for renal drainage after percutaneous nephrolithotomy: a systematic review and meta-analysis. Urol. Int. 2012; 88: 298–306.

Nieroshan Rajarubendra, MBBS, MD Philip McCahy, MBBS, FRCS (Urol), FRACS Department of Urology, Monash Health, Casey Hospital, Melbourne, Victoria, Australia doi: 10.1111/ans.13110

© 2015 Royal Australasian College of Surgeons

Unusual iatrogenic cause for renal stone formation following percutaneous nephrolithotomy.

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