Final-1497.pdf 856 | 1Hasheminejad Clinical Research Development Center (HCRDC), Iran Uni- versity of Medical Sciences, Tehran, Iran 2Departmentof Urology, Tabriz University of Medi- cal Sciences, Tabriz, Iran Masoud Etemadian,1 Robab Maghsoudi,1 Vafa Abdollahpour,1 Mohsen Amjadi2 Percutaneous Nephrolithotomy in Horse- shoe Kidney Our 5-Year Experience Corresponding Author: Robab Maghsoudi, MD Department of Endourol- ogy, Hasheminejad Clinical Research Development Center (HCRDC), Valiasr Ave, Vanak Sq, Valinejad St, Tehran, Iran Tel: +98 914 411 0966 Fax: +98 21 8864 4497 E-mail: rmaghsudy@ yahoo.com Received May 2012 Accepted October 2012 Purpose: To review our 5-year experience in percutaneous nephrolithotomy (PCNL) for horseshoe kidney with large stone burden or failed shockwave lithotripsy (SWL). Materials and Methods: During 5 years (2006 to 2011), PCNL was performed on 21 patients with horseshoe kidney stone. We evaluated patients (age, gender), stones characteristics (size, number, side, and site), surgical technique, and outcomes. Results: Sixteen (76.16%) subjects were man and 5 (23.80%) were women, with the mean age of 35 ± 12 years. Mean stone size was 37.2 ± 16.6 mm. Percutaneous nephrolithotomy was performed because of the stone size (over 20 mm) in 18 (85.68%) and failed SWL in 3 (14.28%). Stone num- bers were more than one in 18 (85.68%) subjects, and were in the pelvis and at least one calyx. The most common access site was superior posterior calyx (66.64%). Stone-free rate with single ses- sion and rigid nephroscope was 71.40%. No major complication occurred during the surgery or in post surgical period. Postoperative minor complications occurred in 3 (14.28%) patients, including transfusion in one (4.76%), fever in one (4.76%), and ileus in one (4.76%) subject. Conclusion: Percutaneous nephrolithotomy has acceptable results in horseshoe kidney stone and kidney in our study. Keywords: kidney calculi, percutaneous nephrolithotomy, treatment outcome ENDOUROLOGY AND STONE DISEASE Endourology and Stone Disease 857Vol. 10 | No. 2 | Spring 2013 |U R O LO G Y J O U R N A L INTRODUCTION One of the most common renal fusion anomalies Berengario da Carpi in 1522,(1) with the preva- lence of 0.25% in general population. Fusion of lower poles during embryogenesis prevents normal kidney ascent and consequently leads to anterior malrotation of the collecting system.(2) Anatomical position of the pelvis and calyces and high insertion of the ureter in comparison with normal kid- ney cause more prevalence of complications in horseshoe kidney. The incidence of nephrolithiasis has been reported to be approximately 20%.(2) Percutaneous nephrolithotomy (PCNL) is one of the recommended modalities for horse- shoe kidney stone disease treatment. Fletcher and Ket- in 1973.(3) Percutaneous nephrolithotomy has been advised for stones larger than 20 mm or failed shockwave lithotrip- sy (SWL). It has been reported that performing PCNL in success and complications rates were both in the acceptable range.(4,5) Our center is a referral endourological center in Iran and ap- proximately 130 PCNLs are being performed monthly since several years ago. Our center is a referral center for stone - fer to us. Horseshoe kidney stone is one of the challenging issues in endourology and multiple treatment modalities ex- ist for its management. In this case series, we reviewed our 5-year experience in PCNL of horseshoe kidney in our center. MATERIALS AND METHODS Twenty-one patients with horseshoe kidney stone, who have undergone PCNL from April 2006 until April 2011 in our center, were enrolled in this case series study. Digital record- ing system was the source of patients’ information in our center. Patients were visited in outpatient clinic and became candidate for PCNL if their stone size was greater than 20 mm or had history of failed SWL with smaller stone size. The recorded variables were patients’ age, gender, stone- related factors (side, size on kidney, ureter, and bladder x- ray or computed tomography, stone number and location, access site, and tract number), serum hemoglobin and cre- atinine level before and after procedure, duration of hospital stay, and complications during and after the operation. Pre- operative intravenous urography had been obtained from all the patients (Figure 1), but computed tomography scan had been performed in 10 patients without any retrorenal colon (Figure 2). Percutaneous nephrolithotomy was performed in prone position with a subcostal access to the collecting system. In all the patients, only one tract was created. Ac- cess site was based on stone burden, stone location, and col- PCNL in Horseshoe Kidney | Etemadian et al Figure 1. Intravenous urography in a horseshoe kidney with left renal stone. Figure 2. Computed tomography scan of horseshoe kidney with nephrolithiasis. 858 | used, and lithotripsy was performed by pneumatic lithotripter alone or in combination with ultrasonic Swiss lithoclast mas- ter lithotripter. Large stone fragments (up to 10 mm) were extracted with grasping forceps. At the end of the procedure, nephrostomy tube, double-J (DJ) stent, or both were used if Fluoroscopy was not used for stone-free rate (SFR) evalu- ation because of low density of stones in some patients and low resolution of images, especially in the presence of ex- travasated contrast media. Stone-free rate was evaluated by kidney, ureter, and bladder x-ray or ultrasonography (in cases with non-opaque stones) 48 hours postoperatively. Routinely, patients were discharged on the 2nd postoperative day if they had clear urine, returned bowel habit, and no fever or urine leakage. - corded complications, such as blood transfusion, visceral in- jury during or after surgery, fever, urinary leakage, etc, were noticed. Follow-up visits were done at 2 weeks, 2 months, and 4 months postoperatively. Patients were evaluated with serum creatinine level and ultrasonography in each visit. Data were analyzed using SPSS software (the Statistical Package for the Social Sciences, Version 19.0, SPSS Inc, Chicago, Il- linois, USA). RESULTS Stone >20 mm was seen in 18 (85.68%) patients and failed - jects. Microscopic hematuria was detected in urinalysis of 17 (80.92%) patients. Three (14.28%) patients had a history of previous open stone surgery on the same kidney. Table 1 shows characteristics of the patients. Mean stone size was 37.2 ± 16.67 mm in the largest dimen- sion. Eighteen (85.68%) patients had more than one stone, of which 10 (47.60%) were staghorn stone with involvement of the pelvis and at least 2 calyces simultaneously and 13 (61.88%) had stone in the pelvis and one calyx simultane- ously. In 7 (33.33%) subjects, stone was either in the calyx or in the pelvis alone. Access site was subcostal in all the patients. In 14 (66.64%) subjects, access site was posterior superior calyx. Posterior middle and inferior calyx were the entrance site in 2 and 4 patients, respectively. In a patient with diverticulum-in stone, direct puncture of the diverticulum has been done. After Endourology and Stone Disease Table 1. Characteristics of patients with stone in horseshoe kidney. Mean age (range), y 35 (15 to 63) Mean stone size (range), mm 37.2 (15 to 90) Location, n (%) Right side Left side 52.36 (11) 47.60 (10) Gender, n (%) Male Female 76.16 (16) 23.80 (5) Stone number, n (%) 1 >1 (multiple or staghorn) 14.28 (3) 85.68 (18) Indication of PCNL, n (%) Stone size Failure of SWL 85.68 (18) 14.28 (3) PCNL indicates percutaneous nephrolithotomy; and SWL, shockwave lithotripsy. Table 2. Percutaneous nephrolithotomy results in horseshoe kidney. Stone site, n (%) Lower calyx 14.28 (3) Pelvis 19.04 (4) Mixed 61.88 (13) Lower calyx diverticulum 4.76 (1) Access site, n (%) Superior calyx 66.64 (14) Middle calyx 9.52 (2) Lower calyx 19.04 (4) Calyceal diverticulum 4.76 (1) Double-J insertion, n (%) 4.76 (1) Nephrostomy, n (%) 14.28 (3) Complications, n (%) Urine leak 0 (0) Fever 4.76 (1) Transfusion 4.76 (1) Stone-free rate, n (%) 71.40 (15) 859Vol. 10 | No. 2 | Spring 2013 |U R O LO G Y J O U R N A L stone extraction, the diverticular ostium has been dilated and a nephrostomy tube was inserted through the dilated ostium into the pelvis. In other two patients, a nephrostomy tube was used. Double-J stent was used in only one (4.76%) subject with previous open surgery and ureteropelvic junction severe edema. Percutaneous nephrolithotomy was tubeless in 17 (80.92%) patients. In order to lower the costs, access was achieved only by an in all the subjects. Furthermore, no patient was scheduled for only for homeostasis or good drainage of pyelocalyceal sys- tem. There was neither operation cessation (due to severe intra- operative bleeding) nor urinary leakage in our subjects. Transfusion was required in one (4.76%) patient. Mean hemoglobin level was 14.14 ± 1.72 g/dL and 12.84 ± 1.83 g/ dL before and after the operation, respectively. Drop in post- P < .001). Mean serum creatinine level was 1.07 ± 0. 25 mg/dL before the operation and 1.21 ± 0.26 mg/dL after the opera- P < .007). No acute tubular necrosis occurred. Only one (4.76%) patient with a history of previous surgery on the same kidney and positive urine culture before the operation developed fever postoperatively, which was controlled by antibiotics. Mean hospital stay was 3.4 ± 0.7 days. Longer hospitalization in horseshoe kidney PCNL was due to delay in resolution of gross hematuria. No major intestinal complications occurred. Ileus was detected only in one (4.76%) patient postopera- tively, which was treated with conservative management. Because of subcostal access, no pulmonary complication oc- curred (Table 2). Stone-free rate, stone residual fragments less than 4 mm, was 71.40%, which seems to be acceptable due to multiple stone numbers in 18 (85.68%) patients. Since our center is pioneer - this study as well. DISCUSSION Stone management in horseshoe kidney is a challenge in en- dourology. Altered pyelocalyceal system anatomy and high ureteropelvic junction position lead to relatively poor results of SWL and retrograde intrarenal surgery. Percutaneous nephrolithotomy is the routine treatment of large renal stones in a kidney with normal anatomy. It has also been reported as a treatment modality for horseshoe kidney stone as well.(6-10) In our study, acceptable results were achieved with respect to patients’ number. With one session operation using one SFR seems to be ideal and comparable with other studies - leagues’ study on 21 renal units, 52% had one pelvic stone and only 14% had staghorn calculi.(11) Lower stone burden in their study explains higher SFR (85.70%). Stone-free rate in Darabi Mahboub and associates’ study on 9 patients with horseshoe kidney stone is lower than our study (66.70% ver- sus 71.40%).(12) Viola and colleagues reported 75% SFR.(13) stone size in their study was less than ours (25.4 mm versus 37.2 mm).(14) additional intervention or prolonged hospitalization was re- quired. Minor complications in our patients included postop- erative transfusion, fever that was controlled by antibiotics, and ileus, which was managed with conservative treatment. Colon perforation and pelvis rupture did not occur in our pa- tients, while they have been reported by others.(11,15) Major Table 3. Published comparative data on percutaneous management of calculi in horseshoe kidney. First author Number of patients Complications (minor/major), % Initial stone-free rate, % Al-Otaibi(4) 12 42 (42/0) 75 Jones(6) 15 26 (20/6) 72.3 Lampel(8) 4 25 (25/0) 75 El Ghoneimy(11) 17 19 (14/5) 87.5 Darabi Mahboub(12) 9 11 (11/0) 66.7 Viola(13) 44 20 (20/0) 75 Aghamir(14) 30 7 (7/0) 83.3 Present series 21 14 (14/0) 71.4 PCNL in Horseshoe Kidney | Etemadian et al 860 | Endourology and Stone Disease complications reported by Raj and coworkers were 12.5%.(2) In our study, computed tomography scan was only performed for patients with a history of previous surgery. We believe that it is not necessary to perform computed tomography routinely in all the patients with horseshoe kidney who are planned for PCNL unless they have a history of previous open renal stone surgery. We had 6 patients with stone re- managed conservatively. Three other patients became stone- free with SWL in 4 months after PCNL. In our study, mean stone size was larger than other studies. horseshoe kidney stone with rigid nephroscope alone. It is not necessary to refer these subjects to a referral center any- more. Any endourology center with experienced surgeon can manage stone in this group of patients. CONCLUSION Percutaneous nephrolithotomy is a safe and effective treat- ment modality in horseshoe kidney stones with acceptable results. In skilled hands, PCNL complications in horseshoe kidney are similar to normal anatomy kidney. However, fur- this. CONFLICT OF INTEREST None declared. REFERENCES 1. Benjamin JA, Schullian DM. Observations on fused kidneys with horseshoe configuration: the contribution of Leon- ardo Botallo (1564). J Hist Med Allied Sci. 1950;5:315-26. 2. Raj GV, Auge BK, Weizer AZ, et al. Percutaneous man- agement of calculi within horseshoe kidneys. J Urol. 2003;170:48-51. 3. Fletcher EW, Kettlewell MG. Antegrade pyelography in a horseshoe kidney. 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