Recurrent UPJ obstruction caused by stone formation on the suture material after open pyeloplasty, a case report
Yin-Chien Ou, Ho-Shiang Huang, Yung-Ming Lin
Department of Urology, National Cheng Kung University Hospital, Tainan, Taiwan
Objective: Non-absorbable sutures may act as a nidus for stone formation within the urinary system is a well-known condition. However, the non-absorbable material will still sometimes be applied into the urinary system and resulted in stone formation. We present a case that non-absorbable suture was used in a dismembered pyeloplasty 7 years earlier, and became a nidus for nephrolithiasis.
Case report: The case is a 55-year-old female with history of hypertension. She had left UPJ obstruction which underwent surgical management (no formal documentation was found) when she was 25 years old, and with recurrence which underwent laser endo-pyelotomy when she was 48 years old. The second procedure encountered perforation of the collecting system with active bleeding, and therefore emergent open conversion was carried out to ligate the bleeding vessels and to perform dismembered pyeloplasty. She experienced intermittent left flank pain after the second surgery. This time, she visited our hospital due to progressive left flank discomfort with fullness sensation for 2 months. Initial renal sonography revealed severe left hydronephrosis with renal stones. Intravenous urography showed left renal stones and severe left hydronephrosis with delayed left nephrogram. Tc-99m DTPA renal scan revealed partial obstruction in the left collecting system with impaired left renal function. We chose to assess this patient with diagnostic ureterorenoscopy (URS) to evaluate the UPJ condition, and with percutaneous nephrolithotomy (PCNL) to manage the renal stones. An 8Fr. percutaneous nephrostomy tube was inserted prior to the surgical procedure.
During the surgery, the ureterorenoscopy went upward to UPJ, where mild narrowing of the lumen and severe tortuosity were found. We passed the guidewire upward, and confirmed the position with antegrade pyelography (AP). The AP also showed that one of the renal stone was impacted over the UPJ, just above the tip of the URS. We placed one double-J stent, and changed the patient’s position for PCNL. After creating access tract to the kidney, we identified the double-J stent and also the stone over the UVJ. During performing lithotripsy for the UVJ stone, we identified one light blue suture material that protruded from the UVJ and was embedded by the stone. We inserted the scissor to cut and remove the visible material, and use Holmium laser cauterization for the surrounding mucosal tissue. The post-operative condition was stable, and the patient was discharged few days later.
Conclusion: This case emphasizes the potential for stone formation when non-absorbable sutures are used in the urinary tract. When we encounter a urolithiasis that locates over the place where a prior surgical procedure was done, we should keep in mind to find out any possible non-absorbable material remains.