LAPAROSCOPIC TRANS-PERITONEAL PYELOLITHOTOMY FOR A LARGE ECTOPIC PELVIC RENAL CALCULUS

Manish Kumar Gupta, Associate Professor, Sarrah Idrees, Dr, Rathindra Sarangi, Dr. Sir Ganga Ram Hospital, New Delhi

Objective: Renal ectopia is a rare congenital anomaly which results in improper ascent of kidney during their embryonic development. Tortuous & high insertion of ureter leads to urinary stasis. Pelvic location of kidney, variation of pelvicaliceal system (PCS) anatomy, stone size and location make the management challenging. ESWL, PCNL and laparoscopic trans-peritoneal pyelolithotomy are the treatment modalities described in literature. We report a case of a huge symptomatic urolithiasis in right ectopic kidney which was managed successfully by laparoscopic trans-peritoneal approach.

Case Report: A 57 years male patient presented with history of episodic pain in lower abdomen for last 6 months which was not associated with dysuria, hematuria or any other abdominal symptoms. X ray abdomen, Ultrasonography & CT report revealed right ectopic kidney with large right extra renal pelvis having calculus of size 4.4 x 3.7 cm in renal pelvis. Delayed scan revealed evidence of adequate excretion of contrast & complete opacification of right ureter. CT angiography reported two renal arteries.

Laparoscopic trans-peritoneal pyelo-lithotomy was done successfully. A 4cm large speculated calculus was present almost occupying the whole of the pelvis and was densely adherent to the pelvic mucosa. The pelvis and ureter was flushed with the help of 6Fr catheter after removal of stone. The pyelotomy was closed with Vicryl 3-0 continuous suture & 24 Fr tube drain was placed in the pelvis. Patient was discharged and drain was removed on 3rd and 5th postoperative day respectively.

Discussion: ESWL is the treatment option for stone size < 2 cm in pelvic kidney with 54% success rate and causes more pain in post-operative period. Risk of injuring the bowel or vessels is always there in percutaneous access because of ectopic position of kidney. Laparoscopic management is better alternative for failed ESWL or stone of > 2cm size. Laparoscopic pyelotomy provide safe access to pelvis and also avoid any visceral and vascular injury. The ureteric catheter used for flushing and was taken out before closing the pyelotomy which ultimately prevent multiple sessions of interventions.

Conclusion: Laparoscopic trans-peritoneal approach should be a preferred approach for managing urolithiasis in ectopic pelvic kidney as it is a safer option which decreases the morbidity and makes patient stone free in single session.