J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 42/Sep 08, 2014 Page 10564

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1 MANAGING LARGE COMPLICATED BILATERAL STAGHORN, URETERIC AND VESICAL CALCULI: IMAGES AND DILEMMAS Ranjith Chaudhary 1, Kulwant Singh 2, Chirag Shanthi Dausage 3, Nidhi Jain 4 HOW TO CITE THIS ARTICLE: Ranjith Chaudhary, Kulwant Singh, Chirag Shanthi Dausage, Nidhi Jain. Managing Large Complicated Bilateral Staghorn, Ureteric and Vesical Calculi: Images and Dilemmas. Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 42, September 08; Page: , DOI: /jemds/2014/3378 DESCRIPTION: A 29 year old man presented in October 2008 with complaints of nausea, vomiting, dysuria and fever with chills. A skiagram of KUB (Kidney Ureter Bladder) region showed bilateral stag horn stones almost occupying the entire collecting systems along with a 3.5 cm right lower ureteric stone and 4.5 cm vesical stone (Fig. 1). Ultrasonogram showed right pyonephrosis. The renal functions were deranged (serum creatinine 2.8 mg %) though electrolytes were in normal range. The serum calcium, phosphorus, uric acid and parathormone values were within normal limits. Urine culture showed infection by Proteus. There was past history of open cystolithotomy and extensive burns on back, abdomen, left upper limb and head in (Fig. 2, 3) An ultra-sonography guided per cutaneous nephrostomy was inserted on right side on an emergency basis under local anaesthesia. (Fig. 4) After 10 days the patient was subjected to open surgery under general anaesthesia. A pfannensteil incision was made through which the vesical (Fig. 5) and right lower ureteric stones (Fig. 6) were removed. A DJ stent was kept on the right side. In the same sitting, a left flank 12th rib cutting incision was made and a left pyelo and nephrolithotomy was done resulting in partial clearance of left renal stones. (Fig. 7) A DJ stent was kept on the left side as well. (Fig. 8) 1 month after this surgery the patient was operated for right renal stones under general anaesthesia. A right flank 12th rib cutting incision was made and a right pyelo and nephrolithotomy was done under fluoroscopic guidance resulting in total clearance of right renal stones. (Fig. 9) A new DJ stent was kept on the right side (Fig. 10). Subsequently the patient was discharged after removal of left DJ stent and was advised to follow up for removal of right DJ stent and left renal stones. At the time of discharge serum creatinine was 2.2 mg%. Subsequently the patient was lost to follow up. He presented after 3 years in August 2011 with severe nausea, vomiting, breathlessness and fever with chills. USG was suggestive of left pyonephrosis and right hydronephrosis. Plain skiagram showed indwelling right DJ stent along with residual left renal stones (Fig. 11). The serum creatinine was 3.3 mg% and serum potassium was 6.6 mg%. On an emergency basis under local anaesthesia the right DJ stent was removed which was severely encrusted and per cutaneous nephrostomy was inserted on left side. (Fig. 12) 3 weeks after this a nephrostomogram was done (figure 13). It showed a grade III vesico ureteric reflux on right side. The patient was operated for left renal stones under general anaesthesia. A left flank incision was made and a left pyelo and nephrolithotomy was done under fluoroscopic guidance achieving total clearance. (Fig. 14) The patient was discharged after removal of left DJ stent (Fig. 15). The serum creatinine at discharge was 1.1 mg%. Remarkably the incisions healed well despite the presence of burn scar tissue. (Fig. 16, 17) The stones on physical analysis turned out to be struvite (ammonium magnesium phosphate) stones. J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 42/Sep 08, 2014 Page 10564

2 DISCUSSION: At the time of initial presentation, looking at the skiagram one provisional diagnosis was urolithiasis secondary to metabolic abnormality. Howsoever subsequent investigations revealed a normal metabolic profile and urine colonized by Proteus. In the hindsight taking into consideration the nature of stones (struvite), these were secondary to infection. Per cutaneous nephrostomy turned out to be a life saving measure twice in this patient (in October 2008 and August 2011). On both occasions he presented with pyonephrosis in one of the kidneys (right followed by left) with signs and symptoms of septicemia. Insertion of nephrostomy lead to a rapid recovery in this patient and made him stable enough to withstand the rigors of future surgeries. The advantages of an ultra-sonography guided per cutaneous nephrostomy include prompt insertion in an outpatient setting under local anaesthesia. It leads to drainage of infective urine/ pus and decompresses the collecting system leading to possible recovery of renal functions in obstructive uropathy as happened in this case. [1] Despite our proficiency in endoscopic surgery we opted for open surgery in this case and wish to highlight the same. Such a large stone load would have required multiple endoscopic procedures. The aim was to achieve maximum stone clearance with minimum number of procedures. [2] In the first surgery total clearance of vesical and right lower ureteric stone and partial clearance of left renal stones was achieved. Two incisions were made (pfannensteil and left flank). The left kidney was not operated under fluoro guidance which resulted in partial clearance of stones. This was a mistake which was rectified while operating on the right kidney. On the right side per operatively under fluoroscopic guidance all the stones were removed. In open surgery, the surgeon relies on palpation to ensure whether all stones have been cleared. Though it may work in a solitary stone, in a case with multiple stones, it will invariably result in stones being left behind as happened in this patient on his left side. The lesson learnt by us was that while performing open surgery in a kidney with multiple stones, one should always confirm on fluoroscopy whether complete clearance has been achieved. Subsequently the patient was lost to follow up and reported after 3 years only when he developed septicemia. He had an indwelling stent for 3 years which was removed under local anaesthesia despite being encrusted. Generally when a stent is left behind for such a long time, particularly in a patient with stone forming tendencies, one expects the stent to act as a nidus with large stone formation along the entire length, the management of which is very challenging. [3] One of the reasons that stone recurrence did not occur in the right kidney is that complete clearance was achieved which is of paramount importance. Partial clearance leads to recurrent infections and pyonephrosis, [4] as seen in the left kidney. When the left kidney was operated upon for the second time under fluoroscopic guidance, complete clearance was achieved. At the time of discharge there was an almost complete recovery of renal function (serum creatinine 1.1 mg %). The patient continues to be on regular follow up. The renal functions remain normal and no stone recurrence has been noted. CONCLUSION: In case of obstructive uropathy, infected hydronephrosis or pyonephrosisa per cutaneous nephrostomy should be inserted. It will lead to possible recovery of renal functions and will drain the septic foci. J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 42/Sep 08, 2014 Page 10565

3 Though endoscopic surgery is the gold standard, in selected cases with a very large stone load, open surgery may be considered to facilitate maximum stone clearance with minimum procedures. Total clearance of urinary stone should be the goal, partial clearance leads to infection and stone recurrence. While performing open surgery for multiple renal stones, one should employ fluoroscopy to ensure complete clearance. REFERENCES: 1. Sood G; Sood A; Jindal A; Verma DK; Dhiman DS. Ultrasound guided percutaneous nephrostomy for obstructive uropathy in benign and malignant diseases. IntBraz J Urol May-Jun; 32(3): Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS, Wolf JS Jr; AUA Nephrolithiasis Guideline Panel. Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol Jun; 173(6): Damiano R, Oliva A, Esposito C, et al. Early and late complications of double pigtail ureteral stent. UrolInt 2002; 69(2): Abdelhafez M F (2013) Residual Stones after Percutaneous Nephrolithotomy. Med SurgUrol 2:115. doi: / Fig. 1: Plain skiagram KUB showing bilateral stag horn stones, right lower ureteric calculus and vesical calculus Fig. 2: Scar of previous open cystolithotomy and burn scars on abdomen and left upper limb J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 42/Sep 08, 2014 Page 10566

4 Fig. 3: Burn scars on head, back and left upper limb Fig. 4: Plain skiagram KUB after PCN (per cutaneous nephrostomy) insertion in right kidney Fig. 5: Right ureteric stone (3.5 cm long) Fig. 6: Vesical calculus (4.5 cm long) Fig. 7: Stones extracted from left kidney Fig. 8: Plain skiagram KUB after open cystolithotomy, right ureterolithotomy and left pyelo/ nephrolithotomy (incomplete clearance) J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 42/Sep 08, 2014 Page 10567

5 Fig. 9: Stones extracted from right kidney Fig. 10: Plain skiagram KUB after open right pyelo/ nephrolithotomy (complete clearance). Bilateral DJ stents and residual stones in left kidney are also seen Fig. 11: Plain skiagram KUB showing residual stones in left kidney. Also seen is forgotten right DJ stent (indwelling for 3 years) Fig. 12: Plain skiagram KUB after PCN (per cutaneous nephrostomy) insertion in left kidney Fig. 13: Skiagram showing left nephrosto mogram (NSG), also seen is grade III vesicoureteral. reflux (VUR) on the right 14. side. Fig. 14: Plain skiagram KUB showing complete clearance of stones in left kidney. Left DJ stent, PCN (per cutaneous nephrostomy) tube and drain are also seen. J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 42/Sep 08, 2014 Page 10568

6 Fig. 15: Plain skiagram KUB after left DJ removal Fig. 16: Healed left flank incision Fig. 17: Healed right flank incision AUTHORS: 1. Ranjith Chaudhary 2. Kulwant Singh 3. Chirag Shanthi Dausage 4. Nidhi Jain PARTICULARS OF CONTRIBUTORS: 1. Assistant Professor, Department of Surgery, People s College of Medical Science and Research Centre. 2. Assistant Professor, Department of Surgery, People s College of Medical Science and Research Centre. 3. Post-Graduate student, Department of Surgery, People s College of Medical Science and Research Centre. 4. Resident, Department of Obstetrics & Gynaecology, People s College of Medical Science and Research Centre. NAME ADDRESS ID OF THE CORRESPONDING AUTHOR: Dr. Ranjith Chaudhary, Assistant Professor, Department of Surgery, Peoples College of Medical Science and Research Centre. drnidhiranjit@gmail.com Date of Submission: 20/08/2014. Date of Peer Review: 21/08/2014. Date of Acceptance: 03/09/2014. Date of Publishing: 08/09/2014. J of Evolution of Med and Dent Sci/ eissn , pissn / Vol. 3/ Issue 42/Sep 08, 2014 Page 10569