雙側腎結石併腎盂腎炎及末期腎病接受腹腔鏡雙側腎切除手術:案例報告及相關文獻回顧

陳冠宇1,2、陳順郎1,2、陳文榮1,2、楊旻鑫1,2、宋文瑋1,2、何承儒1,2、王紹全1,2、謝佐宜1,2

1中山醫學大學附設醫院泌尿科;2中山醫學大學醫學院

Bilateral renal stones with pyelonephritis and end-stage renal disease underwent laparoscopic bilateral nephrectomies: a case report and literature review

Kuan Yu Chen1,2, Sung Lang Chen1,2, Wen Jung Chen1,2, Ming Hsin Yang1,2, Wen Wei Sung1,2, Cheng Ju Ho1,2, Shao Chuan Wang1,2, Tuzo Yi Hsieh1,2

1Department of Urology, Chung Shan Medical University Hospital, Taichung, Taiwan.  2School of Medicine, Chung Shan Medical University Hospital, Taichung,

Introduction:

End-stage renal disease (ESRD) is characterized by an irreversible decline in kidney function, often requiring hemodialysis or transplantation. Renal stone disease in these patients, though less common due to decreased urine output and altered renal function, can still persist or arise due to metabolic imbalances, chronic infections, and structural renal changes. Stones, particularly those with obstructive potential, can act as reservoirs for infection, making patients susceptible to chronic or recurrent pyelonephritis. The immunocompromised state of ESRD patients and urological anatomic changes increase the risk of infection. Pyelonephritis, or kidney infection, often poses a serious threat to these patients, leading to complications like sepsis, perinephric abscess formation, or emphysematous pyelonephritis. Recurrent pyelonephritis is particularly challenging due to the difficulty of achieving adequate renal concentration of antibiotics in ESRD patients. Here, we are going to present a case with a diagnosis of ESRD, bilateral renal stones, and pyelonephritis underwent laparoscopic bilateral nephrectomies.

Case presentation:

  This is a 54-year-old woman with a history of hypertension, ESRD with anemia under hemodialysis since April 2022, bilateral renal staghorn stones status post percutaneous nephrolithotomy in 2016 and 2018, left renal pseudoaneurysm status post micro coil embolization, and recurrent right pyelonephritis.

  The patient experienced persistent symptoms of dysuria and bilateral flank pain, especially on the right side. She maintained regular follow-ups and oral antibiotic treatment at the outpatient clinic. Sonography showed bilateral renal stones. [Figure 1&2.] Imaging studies, including KUB [Figure 3.] and a follow-up abdominal CT scan [Figure 4.] on July 20, 2024, demonstrated persistent bilateral staghorn calculi and evidence of active right-sided pyelonephritis. Cystoscopic examination revealed turbid urine and a diagnosis of cystitis cystica involving the trigone and anterior bladder wall.

Given the chronicity of her condition, recurrent infections, and presence of large calculi, surgical intervention was recommended and ultimately accepted by the patient following extensive counseling regarding risks and benefits. She was admitted for preoperative preparation and underwent laparoscopic bilateral radical nephroureterectomy on October 24, 2024.

On admission, the patient reported bilateral flank pain but denied other symptoms such as fever, nausea, dyspnea, chest pain, or gastrointestinal distress. Physical examination confirmed tenderness at the right costovertebral angle, without abdominal tenderness or rebounding pain. Laboratory investigations revealed leukocytosis, anemia, reduced eGFR, and urinalysis indicative of significant pyuria, hematuria, and bacteriuria. Bilateral severe adhesion of Gerota's fascia with surrounding tissues and ureter was found during the surgery, compatible with recurrent infectious inflammation. [Figure 5&6.] No complications were noticed during hospitalization. The patient recovered well and was discharged from the hospital on November 06, 2024.

 

Discussion:

  Renal stone disease and pyelonephritis, though uncommon in ESRD patients, are well-documented in patients with residual kidney function, anatomical abnormalities, or urinary stasis. Staghorn calculi—large, branching stones occupying a significant portion of the renal collecting system, pose unique risks in these individuals. The prevalence of stones can vary due to altered metabolism and diet, reduced urine output, and predisposing conditions like hyperparathyroidism, which may contribute to calcium-phosphate crystal formation.

  In ESRD patients, the pathogenesis of renal stones is influenced by metabolic derangements inherent to chronic kidney disease (CKD). These may include disturbances in calcium-phosphate balance, decreased citrate levels, and chronic metabolic acidosis. Staghorn stones may serve as a nidus for chronic bacterial infection, promoting recurrent pyelonephritis and creating a vicious cycle of infection and inflammation. Pyelonephritis in this patient population is particularly concerning given the impaired immune response and limited renal function, leading to increased risks of septicemia, abscess formation, and overall morbidity.

  Bilateral nephrectomy, or nephrectomy of one or both kidneys, may be indicated in ESRD patients when conservative measures for managing renal stones and infections fail. Indications include (1) Persistent or recurrent infections: Recurrent pyelonephritis is unresponsive to antibiotic therapy, especially when sepsis risk is present. (2) Obstructive stone disease: Large or complex stones causing chronic obstruction and significant symptoms. (3) Preparation for renal transplantation: Removal of diseased kidneys may reduce infection risks, facilitate transplant placement, or alleviate space constraints. (4) Pain management: Chronic flank pain refractory to other interventions.

Gambaro, Giovanni, et al. [1] reviewed the potential link between urolithiasis and the development of chronic kidney disease (CKD) and found out that the risk of nephrectomy is low but can be higher in patients with struvite stones, cystine stones, or a history of multiple surgical procedures.

  Nephrectomies in ESRD patients can be performed through open, laparoscopic, or robotic-assisted approaches. The choice of technique is guided by patient-specific factors such as stone burden, presence of infection, and anatomical considerations. The procedure is often complicated by dense perirenal adhesions due to chronic inflammation or infection, which increases surgical risk and complexity. Minimally invasive approaches may reduce perioperative morbidity, but careful case selection is essential. Dell'Atti L.[2] analyzed the feasibility and safety of laparoscopic radical nephrectomy (LRN) vs. open radical nephrectomy (ORN) in ESRD patients. Less blood loss (p<0.005) and shorter hospital stays (p<0.001) were noticed in the LRN group. Both groups were comparable with regard to mean operation time. Tepeler et al.[3] compared the effect of renal calculi as a reason for non-functioning on the progress and complication rates of the retroperitoneoscopic nephrectomy (RPN). RPN for nonfunctioning calculous kidneys is a more challenging procedure and is associated with prolonged operation time related to difficult dissection of dense adhesions (p=0.0001).

  The outcomes of nephrectomy in ESRD patients with renal stones and pyelonephritis are generally positive when infection control and symptom relief are achieved. However, postoperative care is crucial, particularly in terms of infection monitoring, dialysis management, and nutritional counseling to minimize stone recurrence in any remaining renal tissue or in the context of a future transplant.

  The patient's clinical course highlighted the intersection of chronic stone disease, infection, and renal failure in ESRD, necessitating a multidisciplinary approach to management, with surgical intervention providing definitive treatment aimed at infection control and symptom resolution.

Conclusion:

  Management of renal stones with pyelonephritis in ESRD patients remains a challenging aspect of urological care. Nephrectomy may be necessary for those with severe or recurrent infections and complex stone disease. Multidisciplinary care involving urologists, nephrologists, infectious disease specialists, and radiologists is essential to optimize outcomes and improve the quality of life for these patients.


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