黃品叡、洪啟峰、陳丕哲、沈正煌、林昌德、鄭明進
戴德森醫療財團法人嘉義基督教醫院 外科部 泌尿科
Pin-Jui Huang, Chi-Feng Hung, Pi-Che Chen, Cheng-Huang Shen, Chang-Te Lin,
Ming-Chin Cheng
Department of Urology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan
Renal stone was a common disease of urology. In this article, we sincerely report a case who was diagnosed as left renal stone in an atretic caliceal diverticulum, and underwent retrograde intrarenal surgery (RIRS) with the help of fluoroscopy. The literatures of renal stones in diverticulum are also reviewed.
This is a 29-year-old man patient denied history of systemic disease and congenital anomaly. He suffered from left lower abdominal and left flank pain one day initially, and left lower ureteral stone with hydronephrosis and left renal stone (size 1.6*1.4cm) were noted by abdominal CT study. The patient decided to try medical expulsive treatment (MET) firstly. After urology department follow-up, the left ureteral stone was self-exhausted and the hydronephrosis was improved. The patient asked further treatment of left renal stone. Extracorporeal shock wave lithotripsy (ESWL) was performed, but KUB revealed almost the same size of left renal stone. The patient then chose retrograde intrarenal surgery (RIRS). The operation of RIRS (LithoVue) was performed. However, during operation, there was no stone identified in three calyxes. We used fluoroscopy for localization intraoperatively, and the stones seemed to be embedded in a diverticulum in middle calyx. After searching, there was no entry to the diverticulum. We then use laser fiber to ablate the parenchyma tissue to get access to the diverticulum. As for result, many renal stones were found in the diverticulum behind the wall. The stones were fragmented and extracted by N-gage basket. 7Fr.26cm double-J stent was inserted into left ureter. Postoperative Kidney-Ureter-Bladder (KUB) revealed minimal residual stone at middle calyx. The postoperative course was smooth and the patient was discharged on postoperative day 1.
Discussion:
Symptomatic renal stone was an indication for surgical intervention. In EAU and AUA guideline, the treatment of symptomatic calyceal diverticular stone including ESWL, PCNL, RIRS and laparoscopic surgery, according to such factors as diverticulum location, stone burden and size. RIRS had become more popular due to high stone free rate and unnecessary to create a new wound. However, it could be difficult when it happens to diverticulum with small entry or atretic diverticulum. Zhang et al. reported a method when the diverticulum was still not found under Blue Spritz technique. Instillation of methylene blue into the diverticulum via the ultrasonography guidance puncture. Then diverticulum ostium would be identified. But it seemed to do less effort in our case. As for our case, we use mobile fluoroscopy to localize the renal stone, and use laser fiber to create access to the diverticulum. Many stones were identified in the diverticulum.
Retrograde intrarenal surgery (RIRS) with flexible ureteroscopy and the help of fluoroscopy demonstrated a satisfied and safety outcome for renal stones in atritic diverticulum.