微創雙鏡聯合手術治療馬蹄腎及迴腸保管造口鹿角結石患者-案例分析

劉順琳¹, 謝博帆², 曾浩翔²

中國醫藥大學附設醫院 泌尿部

Ultramini ECIRS for a 3.7cm staghorn stone in a patient with horseshoe kidney and ileal conduit: a case report

Shun-Lin Liu ¹, Po-Fan Hsieh ², Hao Xiang Chen ²

Department of Urology, China Medical University Hospital, Taichung, Taiwan

Introduction

  Urologists may encounter challenges while managing kidney stones in individuals with congenital kidney anomalies and irregular variations. Endoscopic Combined Intrarenal Surgery (ECIRS) combined the application of an antegrade nephroscopy and retrograde flexible ureteroscope is widely used to clear the staghorn stones. Besides, Mini-ultra ECIRS provides specific benefits in certain cases that involve anatomical anomalies or ureteral strictures. We will present a case of using Ultramini ECIRS for a 3.7cm staghorn stone in a patient with horseshoe kidney and ileal conduit.

Case

  A 74-year-old male had congenital horseshoe kidney and history of UBUC s/p radical cystoprostatectomy and ileal conduit 5 years ago. He suffered from lower abdominal pain accompanied with nausea for 1 day before he visited the emergency department. There was no high-grade fever or decreased urine output, physical examination showed left CV angle knocking tenderness. CT showed horseshoe kidney with left hydronephrosis, APN change and left staghorn renal stones about 3.7cm in size. Emergent left percutaneous nephrostomy (PCN) was performed for hydronephrosis; antibiotics with ciprofloxacin was given for 5 days and the whole course was smooth.

After infection was controlled, we performed left ultramini ECIRS for his stone. The PCN working tract was made with 12French sheath before the surgery. Under general anesthesia, the patient was put in Galdakao modified supine Valdivia (GMSV position) with left flank pain upward. The standard preoperative practice involving skin sterilization was done as usual. We inserted a hydrophilic guidewire via PCN tract, passed through the ureter into the ileal conduit. We then used 2 flexible URS antegradely from PCN tract and retrogradely from his ileal conduit via the hydrophilic guidewire simultaneously. The stone was identified and disintegrated with holmium laser. A 6 French 24 cm D-J stent was set antegradely and a 10 French PCN tube was set. The whole course went smoothly.

Figure

1. Abdominal and pelvic CT showed staghorn stone in the left renal moiety of a horseshoe kidney.

2. Galdakao modified supine Valdivia (GMSV)position with left flank pain upward.

3. A hydrophilic guidewire was inserted via left PCN tract to the ileal conduit

4. Ultramini ECIRS: 2 flexible URS antegradely from PCN tract and retrogradely from ileal conduit

Conclusion

  After the operation, left PCN was removed on the postoperative day2. The postoperative course was uneventful; no fever or further sepsis was noted. Follow-up image showed no residual stone.

In conclusion, this case highlights the difficulty to manage large urinary tract stone in patient with anatomical anomalies. In such cases, ultramini ECIRS may play an important role.