Article Type : Case Report
Authors : Hussain A and Kuldeep
Keywords : EndoUrological; Anomalous Kidneys with Stone disease; Ectopic kidneys (EK)
Surgical treatment of stone disease has evolved through generations of research and usage of various engineering models. Now at present we have many technological advances in the field of EndoUrological Management of Stone disease at our disposal. Many of these advances has come as a boon to treat various cases of challenging stone situations.
Surgical
treatment of stone disease has evolved through generations of research and
usage of various engineering models. Now at present we have many technological
advances in the field of EndoUrological Management of Stone disease at our
disposal. Many of these advances has come as a boon to treat various cases of
challenging stone situations. We describe one such challenging condition where
surgical treatment of stone disease is always met with unexpected
complications, which is Anomalous Kidneys with Stone disease. commonest renal
anomaly is the horseshoe kidney (HSK) with an incidence of 1 in 400, ectopic
kidneys (EK) are reported with an incidence of 1 in 3000, with the incidence of
isolated malrotation (MR) less widely reported. Crossed unfused ectopia
constitutes a very rare variant of ectopic kidneys, with an approximate
incidence of 1:?75000. We hereby describe a rare case of an incidental finding
of crossed unfused ectopic kidneys, in a 33-year-old gentleman presenting with
lower abdominal pain.
Case
AA
33-year-old Bangladeshi gentleman presented to us with dull aching pain in the
lower abdomen and more on the right lower quadrant for the past 10 days. There
was history of dysuria and hematuria. Clinical examination showed soft and
non-distended abdomen with no tenderness, no palpable mass or organomegaly with
intact hernial orifices. External genitalia examination revealed normal
study. Investigations showed Haemoglobin
of 14.7 gm%, S. Creatine101mmol/L. WBC counts 9850 cell/cmm and Urine analysis
shows – 35 pus cells, RBC 45-60. USG
revealed absent left kidney and noted to be malpositioned and malrotated in the
right side of the pelvis with calculus of 23mm size.
Pre-Operative Images
Operation
performed: Cystoscopy
+ Left Double J stenting followed by Interval of 2 weeks later underwent Stent
removal + Flexible Ureteroscopy + laser Lithotripsy + Double j stenting
Procedure
highlights: Entire Left Ureter
coursing medially and onto the right of the midline posterior to bladder.
Dilated Pelvis with Large partial staghorn calculus with extension into the
upper pole.
Intra
Operative findings: Postoperative recovery was uneventful.
Patient improved well. Foleys catheter removal done on 1st day.
Discussion
Anomalous
kidneys arise from different abnormalities in the embryological development.
These may relate to abnormal ascent, fusion, rotation or a combination of
these. These anatomical anomalies not only lead to compromised renal drainage,
but also increase the risk of urolithiasis. Endourological management is
challenging due to these abnormalities leading to difficulties accessing the
stone. Treatment such as shockwave lithotripsy (SWL) and percutaneous
nephrolithotomy (PCNL) are well described in anomalous kidneys, but can be
technically challenging, with success rates often reported to be lower than
those in normal kidneys. Advances in technology and technique have allowed a
broadening of indications for flexible ureterorenoscopy (FURS). The development
of smaller calibre ureteroscopes with their increased deflection capability,
along with holmium laser fibres and other adjuncts, make FURS an attractive
treatment modality for challenging intrarenal anatomy. However, endoscopic
access can be challenging, with complications and stone-free rates (SFR) that
are variable across the reported studies. This article aims to review and
summarise the efficacy and safety of Flexible URS for urolithiasis in anomalous
kidneys (Figures 1-4) [1-5].
1.
Kumar S, Jaiswal
S, Kolla SB. Endourological management of stone disease in ectopic kidney: A
systematic review. Indian J Urol. 2018; 34: 267-275.
2.
Shaikh N, Somani
BK, Healy N. The role of flexible ureterorenoscopy and laser lithotripsy for
stone disease in ectopic kidneys. Urolithiasis. 2015; 43: 457-462.
3.
Tzelves L,
Mamoulakis C, Efthimiou I. Endoscopic management of stone disease in ectopic
kidneys. J Endourol. 2017; 31: 692-700.
4.
Reddy PK,
Prashanth P, Bharath R. Ureteroscopy for stone disease in ectopic kidneys:
Outcomes and comparisons. Indian J Urol. 2017; 33: 313-317.
5.
ElSheemy MS,
Aldaqadossi HA, Al-Kandari AM. Retrograde intrarenal surgery for the treatment
of renal stones in malrotated and ectopic kidneys. J Endourol. 2016; 30:
849-853.