巨型輸尿管結石在不完全的雙套輸尿管中實行逆行性腎臟內碎石手術: 案例報告與文獻分析

黃品叡 1、莊蕙瑄 1、洪啟峰 1、周詠欽 1,2、沈正煌 1、林昌德 1、鄭明進 1

1 戴德森財團法人嘉義基督教醫院 外科部 泌尿科 2 亞洲大學 食品營養與保健生技學系

Retrograde intrarenal surgery for huge ureteral stones at Y junction of bifid ureter: A case report and literature review

Pin-Jui Huang1, Hui Husan Chuang1, Chi-Feng Hung1, Yeong-Chin Jou1,2, Cheng-Huang Shen1, Chang-Te Lin1, Ming-Chin Cheng1

1Divisions of Urology, Department of Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan

2Department of Food Nutrition and Health Biotechnology, Asia University

Introduction:

Duplex system can be described as the kidney with two pyelocaliceal systems, with either single ureter or bifid ureter (partial ureteral duplication) or double ureter draining separately into the urinary bladder (complete ureteral duplication). The incidence of duplex renal collecting system and ureter ranges from 0.5 to 3.0%. However, it is rarely to see huge ureteral stone which size was larger than 3.5 centimeters (cm) in incomplete duplicated ureteral system, which was so-call as bifid ureter. In this article, we sincerely report a case who was diagnosed as huge ureteral stone with size 3.8*3.6 cm initially stuck at the Y junction of unilateral incomplete duplicated ureteral system. Staged surgeries of rigid ureteroscopic lithotripsy (URSL) and flexible ureteroscopic retrograde intrarenal surgery (RIRS) were performed sequentially in two months. The literatures of urolithiasis in incomplete duplicated ureters are also reviewed in this article.

Case presentation:

This is a 53 years old man, who has history of left renal cyst found accidently by renal echo within a health check. According to his statement he had suffered from bilateral flank discomfort for 4-5 days, with left side more than right side. He visited Nephrology outpatient department for help initially. Where renal echo showed multiple renal simple cysts of left kidney, suspect a renal stone or angiomyolipoma (AML) of right kidney. Abdomen computed tomography (CT) scan revealed left duplication kidney with stone formation over the ureteral junction, with size up to 3.8*3.6 cm. The left ureteroscopic lithotripsy (URSL) with Homium-YAG laser and double J stent insertion was performed with a total operative time of 3 hour and 15 minutes. Follow KUB revealed residual stone at left lower ureter and ureteral junction. Unfortunately, symptom of intermittent left flank pain was still noticed after discharge. He came back for scheduled arrangement for the operation. The follow-up abdominal CT showed residual stone streets at left middle and lower third ureter with marked hydronephrosis and hydroureter. The size of residual stones was measured as 3.0*2.0 cm. Operation of left retrograde intrarenal surgery and double-J stent insertion was performed smoothly with a total operative time of 2 hours and 45 minutes.

However, Fever with urinary frequency and dysuria was noted on postoperative 6. Renal echo still showed hydronephrosis. KUB revealed left lower ureteral stone with 4.0 cm in size. Left percutaneous nephrostomy drainage (PCN) was inserted with pus urine came out. The urine culture yielded Candida albicans. Therapeutic antibiotics with Diflucan 400mg QD IVD was given. After one week antibiotics

course treatment, operation of left ureterosopic lithotripsy (URSL) was performed with a total operative time of 2 hours and 15 minutes. KUB revealed some residual stone at lower ureter. There was no major discomfort after operation, and the patient was discharged on postoperative day 2.

Discussion:

It is rarely reported that huge ureteral stone with size larger than 3.5 cm with obstruction at the Y junction of bifid ureter. In Küpeli et al, extracorporeal shockwave lithotripsy (ESWL) was demonstrated to play a role in urolithiasis in cases of duplicated ureter. However, it also mentioned about patients whose stone size was > or = 3 cm in horseshoe or malrotated kidneys and duplex systems seem to be better candidates for percutaneous nephrolithotomy or open surgery. In Chertack et al, In patients without a prior diagnosis of ureteral duplication, our data suggests that intraoperative detection via endoscopy and fluoroscopy are sufficient to safely and completely treat stone disease. In Cancian et al, open ureterolithotomy and percutaneous nephrolithotomy (PCNL) were both introduced in case with stone size larger than 2 cm in diameter. Percutaneous nephrolithotomy may be limited due to anomaly of ureter and kidney, and it does less effort in case with middle or distal ureteral stone. Ureterolithotomy can resolve all cases with huge stones located in any sites of ureter and kidney, but the damage of the open process does not seem to reach the cost-benefit balance.

In our case, we use rigid ureteroscopic intervention as first line treatment for the ureteral stone. However, the operative field was limited due to the tortious ureter. As the initial size of stone was 3.8 * 3.6 cm, the much residual stone with size 3.0 * 2.0 cm was recorded by follow-up abdominal CT and KUB. Rigid ureteroscopy did not seem to be an effective way to decompose ureteral stone in tortious bifid ureter. Flexible ureteroscopy was then taken into consideration due to better operating function which can allow multi-angle action without limitation. During the second time of operation, the flexible ureteroscope was used and demonstrated a promising outcome and smooth operating. The main core of stone was broken down into piece and retrieved by stone basket. The total operative time was 2 hours and 45 minutes. Follow-up KUB revealed some residual stone street at lower ureter, but there was no residual stone stuck at the Y junction of bifid ureter. However, fever was noticed on postoperative day

6. The patient was brought to emergent department for further survey. Renal sonography revealed left hydronephrosis, and percutaneous nephrostomy (PCN) drainage was performed. Much pus urine came out from PCN drainage catheter. Left acute pyelonephritis with urosepsis was diagnosed. This event still reminded us about that longer operative time of flexible utereoscopy may have higher rate of bacterial translocation at urinary system, which may lead to be acute pyelonephritis or urosepsis.

Conclusions: