Transparenchimal nephrolithotomy in a patient with bilateral staghorn kidney stones, high number of comorbidities and recurrent urosepsis

Paolo Mondino1, Pietro Coppola1, Riccardo Rossi1, Diego Rosso1, Andrea Moiso1
  • 1 ASL CN1, SC Urologia (Savigliano)

Objective

A case report to evaluate the role of open transparenchimal nephrolithotomy access in order to reduce the risk of uroseptic events in a patient with high number of comorbidities and recurrent urosepsis.

Materials and Methods

We describe the case of a 67 year old women with chronic kidney disease, unilateral poorly functioning kidneys with functional exclusion of left kidney, bilateral staghorn kidney stones, percutaneous bilateral nephrostomy and right double J, recurrent urosepsis, alcoholism, lung resection for tumor, serious cachexia.
Uroculture was recurrent colonized with Klebsiella and Pseudomonas and The cultures guided us in antibiotic choice.
We used CT scans for classification of stone size, location and density (1) Additionally, in planning the operative approach.
Surgery in patients with this number of comorbidities has always been challenging and requires special care with a multidisciplinary approach (3-4). In this case report we described the management of a patient with bilateral staghorn kidney stones , elevated rates of comorbidities and recurrent urosespis.
We known that Sepsis secondary to urinary tract infection can significantly increase morbidity and mortality in patients who have undergone PCNL.
We examine CT scans and the elevated rates of comorbidities of the patient for the pre operative planning and the strategies to perform in operating room. Specially we considered the High risk of urosepsis.
In relation to that, we decided to perform a open transparenchimal nephrolithotomy access in order to reduce the risk of uroseptic events (2).
We describe renal access, patient position, tract dilatation, nephroscopes, litothripsy and post operative management.
The procedure was Performed in lateral recumbent position with a minimal lombotomy incision. We isolated the vascular peduncula, urether and so we are able to mobilize the kidney. We performe a Ultrasound guided puncture of the inferior calix and than, after a contrastography, we done a Access to the collecting system using successive Amplatz dilators for the tract dilatation. The access sheath finally was 24 fr and we used nephroscope 18 fr. To fragment the stone we used Pneumatic lithotripter and than we remove fragments with N-Perc device.

Results

The operative time was been of 130 minutes. The blood loss of 150 cc. The average rate used to irrigate was 20 litres of physiologic saline solution. The patient was afebrile during the recovery period.
Renal drainage upon termination PCNL leaving nephrostomy 8 fr and bladder drainage .
The recovery time was 6 days and the serum levels of creatinine decrease from 5,8 mg/dl to 1,8 mg/dl.

Discussions

After 20 days since the procedure , we decided to do a CT scan and the result was that into the right kidney there are only small fragments inferior to 5 millimeter. The patient is good, is asintomathic without nephrostomy and we decided to perform in the next mounth a nephrectomy at the other side for the unfunctional left kidney.

Conclusion

Although there are not enough data and evidence to make a clear conclusion, we suggest that transparenchimal nephrolithotomy can be performed safely in this kind of patients with high risk of urosepsis and elevated number of comorbidities.

Reference

1. Advances in percutaneous stone surgery
Christopher Hartman, Nikhil Gupta, David Leavitt, David Hoenig, Zeph Okeke, Arthur Smith
Hofstra North Shore-LIJ School of Medicine, The Arthur Smith Institute for Urology, New Hyde Park, NY, USA
Asian Journal of Urology 2015, Vol. 2 Issue (1): 26-32

2. Management of multiple/staghorn kidney stones: Open surgery versus PCNL (with or without ESWL).
Agrawal MS1, Singh SK, Singh H.
Indian J Urol. 2009 Apr;25(2):284-5.

3. Percutaneous Nephrolithotomy in Rare Bleeding Disorders: A Case Report and Review of the Literature.
Zumrutbas AE, Toktas C, Baser A, Tuncay OL.
J Endourol Case Rep. 2016 Nov 1;2(1):198-203. eCollection 2016.

4. Percutaneous nephrolithotomy success rate and complications in patients with previous open stone surgery.
Khorrami M1, Hadi M1, Sichani MM2, Nourimahdavi K1, Yazdani M1, Alizadeh F1, Izadpanahi MH1, Tadayyon F1.
Urol J. 2014 Jul 8;11(3):1557-62.

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