[SS-072]
Treatment of Multiple Kidney Stone in a Kidney-Transplanted Patient with the Combination of Retrograd Inrarenal Surgery and Mini-Percutaneous Nephrolithotomy
Mesut Tek, Erdem Akbay, Murat Bozlu, Hasan Erdal DorukINTRODUCTION: Kidney transplantation is the treatment choice for patients with end-stage renal disease, because it offers prolonged survival and better quality of life.Nephrolithiasis in a transplanted kidney is an uncommon complication, with an incidence reported less than 1%.
CASE: A 23-year-old girl received a kidney transplant from a living donor in December 2012 admitted to nephrology represented with groin pain and reduction of urine.Ultrasound revealed hydronephrosis (pelvic diameter 18 mm) and multiple stones in the pelvis and lower pole of the transplated kidney.Three stones; 11 mm in renal pelvis and two stones (8 mm) in the lower pole were seen in Pelvic CT scan(Figure 1).Serum creatinine was 1.1 mg/dL and ürine culture was negative. Retrograde intrarenal surgery was planned.
METHOD: Under general anesthesia hydrophilic guide wire was inserted into the pelvicalyceal system through the neouretheral orifice in the lithotomy position. Flexible ureteroscope(Wolf Cobra; Richard Wolf, Knittlingen, Germany) passed through the guide wire into the collecting system under fluoroscopic imaging. The stone was visualized and fragmented with dusting technique using 200 μm holmium:yttrium-aluminum-garnet laser fiber with the settings of 0.8-1.2 J and 5-10 Hz. We failed to access the lower pole stones due to the inadequate flexion angle of the ureteroscope. We decided to perform mini-PNL for the lower pole stones and placed a 5F uretheral catheter through the guide wire. In the supine position lower pole puncture was performed with the 18 gauge access needle and the hydrophilic guide wire with floppy tip was inserted into the pelvicalyceal system. Dilatation was performed by a single metal dilator using the one-step bougie technique.Via this dilator,15/16-Ch operating sheath(Karl Storz, Tuttlingen, Germany) was placed in the renal pelvicalyceal system.Dilation and advancement of the operating sheath was accomplished under floroscopy. Mini-nephroscope(instrument sheath diameter 12 Ch with 6.7 Ch working channel; Karl Storz) was introduced through the operating sheath.The stones were visualized and removed with graspers(Figure3). A single J was placed by antegrad technique under floroscopy control(Figure 4).
CONCLUSION: Our case shows that RIRC and the mini PNL technique can be safely used alone or in combination in transplanted kidney stones to obtain stone free graft.
Resim 1. Transplante böbrek pelvisinde yer alan taşın Bilgisayarlı Tomografideki görüntüsü
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Resim 2. Renal pelvisteki taşın fleksible üreteroskopideki görüntüsü
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Resim 3. Mini PNL yöntemi ile alt polden çıkarılan taşlar
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Resim 4. Olgunun preoperatif ve postoperatif direk grafi görüntüleri
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