Challenges in stone man - Comtecmed€¦ · Patient underwent combined open pyelolithotomy and ultrasonic lithotripsy Title Challenges in stone man Author User Created Date 7/18/2016

Challenges in stone management

Dr. David Lifshitz

Panelist:

Dr. James Borin, USA

Dr. Mordechai Duvdevani, Israel

Dr. Scott Hubosky, USA

Dr. Eli Tavdy, Israel

Dr. Itay Vardi, Israel

Case- 1

• 31 y/o woman presents with recurrent UTI

• Married and planning pregnancy

• PMH: UTI since the early twenties

• Recently hospitalized due to left pyelonephritis

• Renal US reports few stones up to 12 mm in the upper pole calices

Next step:

KUB?

NCCT?

CTU?

IVU?

In op. retrograde?

A 13 and 12 mm stone measuring 600 HU. SSD 5 cm. Delayed films fail to demonstrate the stone occupying space

Next step:

SWL?

Other imaging modalities?

In op. retrograde and RIRS/PCNL?

Laparoscopy?

Preop. Preparation?

IV antibiotics for how long?

Insist on sterile urine culture?

Patient underwent a prone PCNL

• Pass a wire through the diverticular neck? • Fulgurate the urothelium? • Diverticular neck dilation? • Post op. drainage?

• PCNL with diverticular neck dilation and urothelial fulguration

• Following nephrostomy removal she had a urinoma which was treated conservatively

• She is now stone free and her urine culture is sterile

Case- 2

• 29 y/o woman presents with left renal colic.

• 30 weeks pregnancy

• PMH: healthy

• Physical and OB examination is normal

• Creatinine 0.6 mg/Dl

• WBC 14.000

• Urinalysis – 5 WBC

• Predictors for infection?

• Stent?

• Nephrostomy?

• Ureteroscopy?

• Conservative treatment?

A nephrostomy tube was placed. Stone appears radiolucent

• Antegrade stent placement before ureteroscopy?

• Nephrostomy/stent exchange?

• 38 weeks normal delivery

• NCCT preformed after delivery due to left flank pain showed a 16 mm UPJ stone.

• She underwent an antegrade stent placement followed by ureteroscopy and is now stone free

Case- 3

• 62 y/o man, head of a yeshiva, presents with left flank pain

• PMH: Known Horseshoe kidney. Previously underwent left SWL, Failed RIRS and PCNL . The access was found to be transcolonic and he was treated conservatively. Some residual stones remained

• CIHD on Plavix

12mm left renal pelvic stone + 6mm lower pole. 1200HU

• SWL (prone position)?

• RIRS? Pre-stenting? One stage?

• PCNL- US/CT guided access? Lap assisted?

• Lap pyelolithotomy?

• What do you explain to the anxious patient?

CT guided access performed

• Immediate PCNL? Delayed?

• PCNL/mini-PCNL/ultra mini PCNL?

• Post op drainage- Totally tubeless? Ureteral stent? Nephrostomy?

• When to remove the urethral catheter?

• PCNL was performed and both stones removed. A D-J stent was placed + uretheral catheter

• Post op. day 1 patient has abdominal pain. The abdomen is mildly tender

• Creatinine is elevated relatively to base line

?

Case- 4

• 66 y/o man presents with mild flank pain

• PMH: Left renal stones known since 2010. Was recommended conservative therapy

• US shows a large lower-pole/parapelvic cyst and 3 renal stones up to 10mm

9+8+9 mm stones. 1400HU. SSD 9cm

• SWL? Any cyst influence on results?

• RIRS?

• PCNL? Cyst interference?

PCNL access is traversing the renal cyst what to do?

• PCNL was performed as planned. The three stones were removed intact

• A Nephrostomy tube was left in place for a week

• Following tube removal the patient has done well

• Follow up US is still pending

Case- 5

• 35 y/o man presents with mild abdominal pain

• PMH: Healthy

• US shows multiple stones in a dilated right pelvic kidney

• A DMSA renal scan shows a dominant pelvic kidney with 73% function

• Creatinine 1 mg/Dl, Uric acid 8.1 mg/Dl

• Urine pH- 5

Complete staghorn stone. HU- 450

• Dissolution trial?

• Lap assisted PCNL?

• Robotic laparoscopic anatrophic nephrolithotomy?

• Combined open and endoscopic lithotripsy?

Patient underwent combined open pyelolithotomy and ultrasonic lithotripsy