Stesura Seveso Archivio Italiano di Urologia e Andrologia 2015; 87, 2144 SHORT COMMUNICATION Our percutaneous nephrolitotomy experience in patients with horseshoe kidney Tufan Suelozgen, Cemal Selcuk Isoglu, Hakan Turk, Mehmet Yoldas, Ozlem Yusuf Ilbey, Ferruh Zorlu Tepecik Training and Research Hospital, Urology Clinic, Izmir, Turkey. Objectives: Horseshoe kidney is the most common renal congenital fusion anom- aly. Kidney stone formation is more common in horseshoe kidneys and some of them requires surgical procedure. So we want to evaluate the results of PNL in patients with horseshoe kidney anomaly. Matherial and method: Between January 2009- January 2014 PNL operation was performed in 6 patients with horseshoe kidney anomaly in our clinic. Success of surgery and postoperative/peroperative complications were evalu- taed retrospectively. Results: No severe complications occured in any patient caused by surgery. Three patients became stonefree. One patient had less than 4 mm. residual stone, two patients had more than 4 mm. residual stone. Conclusion: PNL is safe surgical method and it can be per- formed successfully in patients with horseshoe kidney anomaly. KEY WORDS: Horseshoe kidney; Stone formation; Percutaneous nephrolithotomy. Submitted 2 September 2014; Accepted 3 November 2014 Summary No conflict of interest declared. patients had symptoms becasue of stone. Detailed anam- nesis was taken and physical diagnosis is performed for each patient. After that biochemical tests including com- plete blood count, urea, creatinine and urine culture are made. All the patients were evaluated with non-contrast abdomen tomography. Imaging methods requires con- trast drugs weren't used. All patients were informed about the operation and informed conset is taken . In opreation morning, second generation cephalosporin antibiotic prophlaxis was performed 1 hour before sur- gery. Under general anesthesia, 5 Fr. open end uretheral catheter was placed with 22 Fr. cystoscope in lithotomy position. And it was fixed to the urinary cathater with silk. Prone position was given to the patient. Contrast material was given from the uretheral catheter and col- lector system was visualised with fluoroscopy. After plan- ning the access place, biplanar percutanous access was placed with access needle. Tract was dilated with Amplatz dilator over guide wire. 30 Fr. Amplatz sheet was placed. Renal collecting system was entered with 22 Fr. rigid nephroscope. Ultrasonic lithotriptor was used to break the stones. Five of 6 patients were have one access. Two access including upper pole intercostal entry and subcostal middle pole entry were performed to one of the patients. Finally, after evaluation of the fluoroscopic images, 14 Fr. mallecot nephrostomy catheter was placed and the oper- ation was terminated. RESULTS All 6 patients were male. Average age was 44,82 (32-63). Four patients (66.6%) had left, 2 patients (33.3%) had right kidney stone. Three patients (50%) had pelvis and lower pole stone, 2 patients (33.3%) had pelvis stone, 1 patient had pelvis-lower pole and middle pole stone. None of the patients had neither operation nor ESWL history. Average stone size was 1007 mm2 (375-1480), average operation time was 117.1 min. (44-250 min.), average fluoroscopy time was 209 seconds (45-450). Intercostal upper pole access between 11th and 12th ribs was made in 5 patients. For the patient who had upper middle and lower pole stones; upper pole access was made between 11 and 12th ribs and subcostal access was made to the middle calix under the 12.th rib (Table 1). DOI: 10.4081/aiua.2015.2.144 INTRODUCTION Horseshoe kidney is the most common renal congenital fusion anomaly with a incidence of 1/400. In 95% of cases fusion is in the lower pole of kidney. It is 2 times more common in males (1, 2). Most of the patients are asymptomatic. Symptoms come out because of kidney stone formation, infection caused by kidney stone and obstruction. Kidney stone formation is more common in horseshoe kidneys and some of them requires surgical procedure (3-5). ESWL treatment can be used in stones up to 2 cm in horseshoe kidneys. In literature there are studies that shows success rates between 50%-75% (5-7). But percutanous nephrolitotomy (PNL) should be the first treatment choise for stones more than 2 cm. In this study, results of PNL in horseshoe kidney patients in our clinic are given. MATHERIALS AND METHOD Between January 2009- January 2014 PNL operation was performed in 6 horseshoe kidney patients. All of the Suelozgen_Stesura Seveso 02/07/15 12:19 Pagina 144 145Archivio Italiano di Urologia e Andrologia 2015; 87, 2 Our percutaneous nephrolitotomy experience in patients with horseshoe kidney In 4 patients (66.6%) there was decrease in hematocrit, Average decrese was 5% (4-7) .But there was no need for blood transfusion. None of the patients had fever and lung complications after surgery. Three patients (50%) were stonefree in the control non contrast abdominal tomography which performed 1 month after the surgery. One patient had less than 4 mm. (16.6%) residual stone, 2 patients had averagely 6.5 mm residual stone (6-7) (Table 1). Becasue of the stones were in the lower pole and didn't casue sypmtoms, additional operation wasn't considered for these 2 patients. They were being followed-up. Patients were followed with direct X-RAY at intervals of 6 months. Average fol- low-up time was 25.3 months (6-54). During the follow up period, there was no increase in the stone size of the patients. DISCUSSION Percutanous approach for horseshoe kidney stones was firstly reported by Fletcher et al. in 1973 (8). Yohannes and Smith pointed that ESWL treatment should be cho- sen for the stones less than 2 cm in horseshoe kidney, percutanous approach should be chosen when ESWL fails or for bigger stones (9). With the practicing of per- cutaneous surgery, complications of open surgery is decreased. The most common complications that can be seen dur- ing or after PCNL procedure are fever, bleeding, urine leakage, complications caused by residual stones (10). In our study there was no high fever postoperatively. As is known, because of the vessels of the horseshoe kidney enters the hilum from anteromedial and calyxes rotates to posterior, the vascular injury risk during access is not higher than normal kidney (11, 12). In our patient group decrease of hematocrit was seen in 4 patients (66.6%) but there was no need for blood transfusion. For the kidneys with normal anatomy upper pole access is generally perfomed from over the 12th rib so intrathoracical complications are more common. Horseshoe kidneys are placed more inferior and far from pleura so access for upper pole becomes more secure. Pneumothorax risk for upper pole access in horseshoe kidneys were found to be 6% in a study (3). Although all the accesses were made over the 12th rib there was no intrathoracic complication in our study. In various studies, the success rate after PCNL in hor- shoe kidneys were reported as 72%-85% and residual stones under 4 mm. were included to the group consid- ered as succesful (13-15). When we consider the resid- ual stones under 4 mm as successful, our success rate becomes 66,6% and this result is consistent with the lit- erature. Before the surgery the stone burden of 2 patients, who had residual stone more than 4 mm, was higher than the others. We think that this situation can be one of the rea- sons of the significant residual stone. CONCLUSION PNL is safe surgical method and it can be performed suc- cessfully in patients with horseshoe kidney anomaly. Studies with more patients are needed for to make cer- tain conclusions. REFERENCES 1. Salas M, Gelet A, Martin X, et al. Horseshoe kidney: the impact of percutaneous surgery. Eur Urol .1992; 21:134-7. 2. Jones DJ, Wickham JE, Kellett MJ. Percutaneous nephrolithotomy for calculi in horseshoe kidneys. J Urol. 1991; 145:481-3. 3. Raj GV, Auge BK, Weizer AZ, et al. Percutaneous management of calculi within horseshoe kidneys. J Urol. 2003; 170:48-51. 4. Evans WP, Resnick MI. Horseshoe kidney and urolithiasis. J Urol. 1981; 125:620-1. 5. Pitts WR Jr, Muecke EC. Horseshoe kidneys: a 40-year experi- ence. J Urol. 1975; 113:743-6. 6. Clayman RV. Effectiveness of extracorporeal shockwave lithotrip- sy in the management of stone-bearing horseshoe kidneys. J Urol. 1998; 160:1949. 7. Gallucci M, Vincenzoni A, Schettini M, et al. Extracorporeal shock wave lithotripsy in ureteral and kidney malformations. Urol Int. 2001; 66:61-5. Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Age 32 38 45 47 54 63 Gender M M M M M M Stone size (mm2) 975 375 1115 1480 900 1200 Stone location Left kidney pelvis Left kidney pelvis Right kidney pelvis Left kidney pelvis, Left kidney pelvis Right kidney pelvis and lower calyx and lower calyx lower and middle calyx and lower calyx Access place Intercostal Intercostal Intercostal Intercostal Intercostal Intercostal upper calyx upper calyx upper calyx upper calyx, subcostal, upper calyx middle calyx Operation time (min.) 60 48 90 250 80 175 Fluoroscopy time (sec.) 50 45 90 450 80 153 Residual stone size < 4 mm No No 6 mm No 7 mm Table 1. Parameters before and after surgery. Suelozgen_Stesura Seveso 02/07/15 12:19 Pagina 145 Archivio Italiano di Urologia e Andrologia 2015; 87, 2 T. Suelozgen, C. Selcuk Isoglu, H. Turk, M. Yoldas, O. Yusuf Ilbey, F. Zorlu 146 8. Fletcher EW, Kettlewell MG. Antegrade pyelography in a horse- shoe kidney. 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Correspondence Tufan Suelozgen, MD tsuelozgen@hotmail.com Cemal Selcuk Isoglu, MD Hakan Turk, MD Mehmet Yoldas, MD Ozlem Yusuf Ilbey, MD Ferruh Zorlu, MD Tepecik Training and Research Hospital, Urology Clinic Izmir, Turkey Suelozgen_Stesura Seveso 02/07/15 12:19 Pagina 146