Ding J et al, 2015: Tailored minimally invasive management of complex calculi in horseshoe kidney.
Ding J, Zhang Y, Cao Q, Huang T, Xu W, Huang K, Fang J, Bai Q, Qi J, Huang Y.
Urology Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
Urology Department, Anhui Provincial Hospital, Hefei, Anhui, China.
Radiology Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Anesthesiology Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Ultrasonograhy Department, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
OBJECTIVE: Complex calculi in horseshoe kidney (HK) present a significant management challenge. Here, we report the clinical efficacy of extracorporeal shock wave lithotripsy (ESWL), minimally invasive percutaneous nephrolithotomy (MPCNL) and flexible ureteroscopy (FURS), combined with holmium laser lithotripsy, in the treatment of calculi in HK.
METHODS AND RESULTS: From January 2005 to May 2014, 62 HK patients with renal calculi were reviewed in terms of medical history, treatment modality and therapeutic outcome in a single tertiary care hospital. Among the patients, 11 with a solitary stone ≤ 1.5 cm in diameter received ESWL, leading to overall stone-free rate of 72.7%; 18 with stone diameter ≤ 2-3 cm received retrograde flexible ureteroscopy, with a recorded mean digitized surface area (DSA) of 339.6 ± 103.9 mm2, mean operation time of 93.1 ± 11.5 minutes and overall stone-free rate of 88.9%; and 33 with staghorn or complex calculi (d ≥ 2 cm) had MPCNL or MPCNL-FURS, with a recorded mean DSA of 691.0 ± 329.9 vs. 802.9 ± 333.3 mm2, mean operation time of 106.4 ± 16.6 vs. 124.4 ± 15.1 min and overall stone-free rate of 89.5% vs. 92.9%. For complex calculi (d ≥ 2 cm), MPCNL combined with antegrade FURS was superior in terms of reducing number of tracts, controlling mean hemoglobin drop, but required longer operation time, comparing with MPCNL alone.
CONCLUSIONS: As minimally invasive treatments, a combination of MPCNL and antegrade FURS provides a safe and effective modality in the management of staghorn or complex calculi (d ≥ 2 cm) in HK with significantly reduced blood loss comparing to MPCNL alone, and retrograde FURS alone is favorable for stones with a diameter ≤ 2-3 cm. ESWL is effective for viable small solitary stones (d ≤ 1.5 cm). Treatment modality should be tailored based on individual condition.
J Xray Sci Technol. 2015;23(5):601-10. doi: 10.3233/XST-150512.
The tailored approach of the authors offered stone free rates between 73% and 93%. Only 11 of the 62 patients were treated with ESWL. The details of percutaneous and ureteroscopic procedures are extensively discussed. The data on mean operative time are probably given per session and not cumulative and as such a little bit misleading: 8 of 18 fURS patients had two sessions and of the 33 patients treated by MPCNL with/without antegrade FURS 7 received two sessions and 2 three sessions.
Patients with ureteropelvic junction obstruction were excluded in this study because they would need repair by pyeloplasty. I wonder how the authors could technically rule out this condition in those 20 patients with medium and 4 with severe preoperative hydronephrosis.