Outpatient percutaneous nephrolithotomy in a renal transplant patient: World’s first case

Abstract

Percutaneous nephrolithotomy (PCNL) is an established safe and effective surgical treatment option for renal calculi in renal allografts. The advent of tubeless PCNL has led to reports of ambulatory or outpatient PCNL. This case report describes the successful outpatient management of a 49-year-old female with a symptomatic renal pelvic calculus in her transplanted kidney. Tubeless PCNL successfully removed the stone, free of complication, and the patient was discharged 2 hours and 17 minutes after the procedure in stable condition with minimal pain. This is, to the best of our knowledge, the first successful case of outpatient tubeless PCNL in a transplanted kidney. IntroductionPercutaneous nephrolithotomy (PCNL) is an accepted and widely used approach to extract large renal calculi. Since its description in the 1970s, 1 surgical and technological advances have obviated the need for routine nephrostomy tube placement.2-8 Tubeless PCNL, with ureteral stenting, has been shown to decrease patients' analgesic requirements and hospital length of stay.9,10 Although hospitalization is standard practice after PCNL, reports have described success with outpatient management. 11,12 This case report is the first to describe successful outpatient PCNL in a renal transplant patient. Case reportA 49-year-old female presented to her community hospital with hematuria and lower abdominal pain over the preceding 48 hours. She had received her second cadaveric kidney transplant 6 years previously for end-stage renal disease of unknown etiology. On presentation she was afebrile and hemodynamically stable. Urine was positive for blood, but negative for nitrites or pyuria. Creatinine was 164 μmol/L (estimated glomular filtration rate 29 mL/min/1.73m 2 ), slightly elevated from her baseline of 150 μmol/L. An ultrasound scan showed a large renal stone in the lower pole of the allograft kidney. Intravenous antibiotics were initiated and the patient was transferred to our tertiary care centre.At our institution, a computed tomography scan revealed a 14 × 12 × 11-mm stone located in the renal pelvis (Fig. 1a, Fig. 1b). There was mild hydronephrosis, yet the parenchyma of the graft was preserved. There was no evidence of a urinary tract infection (UTI)/sepsis and the patient's pain responded to oral analgesia. The surgical options were discussed and a decision was made to proceed with the PCNL. Informed consent was obtained and a 1-week course of levofloxacin was prescribed for UTI prophylaxis.On the morning of the procedure, a stress dose of 100 mg intravenous (IV) hydrocortisone was administered. Cefazolin 1 g IV was given prior to induction of general anesthesia. Flexible cystourethroscopy was performed and a 5Fr openended ureteral catheter was passed up the left transplanted ureteral orifice over a 0.035" guidewire. A Foley catheter was placed to straight drainage and the patient was repositioned supine for percutaneous access. Retrograde ureteropyelography outlined the allograft kidney's collecting system, demonstrating renal...

Tubeless percutaneous nephrolithotomy (pcnl) in renal allografts: a case report and mini-review

“…9 Transplant recipients are more predisposed to developing urolithiasis due to their conditions such as: hyperfiltration, excessively alkaline urine, renal tubular acidosis, obstructive uropathy, recurrent urinary tract infections, and increased serum calcium caused by persistent tertiary hyperparathyroidism. [10][11][12][13][14] Many series have reported the mean time of posttransplantation lithiasis between 1.6 to 3.6 years.…”

“…2 And also, the proximity to the bony pelvis causes that targeting the shock wave directly onto the stone becomes more difficult in ESWL. 1,4,9,10,22 But the anatomic position in the iliac fossa with the renal surface close to skin makes PCNL an attractive alternative and a feasible procedure in the treatment of urinary calculi. 10 Many cases have been reported in which allograft lithiass was treated successfully with PCNL.…”

“…10 Many cases have been reported in which allograft lithiass was treated successfully with PCNL. 2,9 PCNL has significant advantages in renal calculi extraction such as: need for minimal intra-operative bleeding, high stone-free rate, and renal access by one or maximum two attempts in tubeless approaches. 9,23,24 In our case, the patient had a large stone in the renal pelvis.…”

“…4 Percutaneous nephrolithotomy (PCNL) is an accepted procedure used for removing large kidney stone. 9 Herein, we report on the case of a renal-transplant recipient with urinary stone that was successfully treated with PCNL, as well as a mini review of the relevant literature, is also presented.…”

Safety and Efficacy of Day-case Percutaneous Nephrolithotomy: A Systematic Review from European Society of Uro-technology

“…With experience, its application can even be extended to patients with more complex stone disease and higher BMI. Its use has also been described for bilateral simultaneous PCNL cases and in a renal transplant patient [10,17]. Crook et al [18] previously reported the length of stay to be significantly reduced when patients undergo TT technique compared with those receiving PNT placement (2.3 vs 3.4 d, p < 0.05).…”