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Authors: Dr. Sanjay P Dhangar , Dr. Rishabh Mehta , Dr. Vasistha Martha.
Assistant Professor, Department of Urology, Bharati Hospital & Research Center, BVU, PUNE, MAHARASHTRA, INDIA.
Abstract:
Introduction :
The incidence of ectopic kidney in autopsy
series is around 1 in 900 otherwise it is 1 in 3000. There
are various treatment modalities that can be utilised
to treat these renal calculi e.g., extracorporeal shock
wave lithotripsy, laproscopy assisted per-cutaneous
nephrolithotomy, retrograde intra-renal surgery using the
flexible ureteroscope, laproscopic/robotic pyelolithotomy
and open surgery. We here describe a case of RIRS for stone
in the pelvis of ectopic left kidney located on the right side
just below the right kidney, it was crossed but not fused.
To the best of our knowledge, this is first such case to be
reported in crossed non-fused ectopic kidney.
Case Report : A 33 years young male came with complaints
of intermittent pain right loin for 2-3 months, mild initially
but severe for last 24 hours. Physical examination suggested
mild tenderness right iliac fossa. Ultrasonography and
intravenous pyelography suggested ectopic left kidney
located on right side below the right kidney in the right iliac
fossa and not fused or attached to the right kidney with a
large 21mm pelvic calculus with mild hydronephrosis. He
later underwent retrograde intra-renal surgery where stone
was completely lased and double J stent was kept at the end
of the procedure.
Results : Complete stone clearance was confirmed visually
and under c-arm. Post operative USG and x-ray KUB showed
no residual calculus. Patient was discharged on second postop day. There were no post-op complications. The double J
stent was removed after two weeks.
Conclusion : RIRS is a very good option to treat stones in
an ectopic kidney. It may require more than one session
sometimes, but considering the minimal invasive nature, the
bothersome is less. Disposable ureteroscopes have further
revolutionised the armamentarium of the urologist, who can
now offer a personalised treatment plan for each patient.
Keywords :: RIRS, ectopic kidney, crossed ectopic non-fused kidney, stone in ectopic kidney, minimal invasive laser surgery
INTRODUCTION
The metanephrons of the kidney start to originate from
the sacral area and ascend cranially to the final position in
the retroperitoneum. Whenever the ascent of the kidney
is hampered or is halted, it leads to ectopic kidney. The
incidence of ectopic kidney in autopsy series is around 1 in
900 otherwise it is 1 in 3000 [1]. The abnormal location leads
to abnormal anatomy and rotation of the kidney in addition
to structural and architectural abnormalities. All these lead
to renal concentration and filtration abnormality leading to
more stone formation. Stone formation is one of the common
diseases in these patients. There are various treatment
modalities that can be utilised to treat these renal calculi e.g.,
extracorporeal shock wave lithotripsy (ESWL), laproscopy
assisted per-cutaneous nephrolithotomy (PCNL), retrograde
intra-renal surgery (RIRS) using the flexible ureteroscope,
laproscopic/robotic pyelolithotomy and open surgery. We
here describe a case of RIRS for stone in the pelvis of ectopic
left kidney located on the right side just below the right kidney,
it was crossed but not fused. To the best of our knowledge,
this is first such case to be reported in crossed non-fused
ectopic kidney.
CASE REPORT :
A 33 years young male came to our outpatient department
with complaints of intermittent pain right loin for 2-3 months,
mild initially but severe for last 24 hours. His medical history
was unremarkable. Physical examination suggested mild
tenderness right iliac fossa. Ultrasonography and intravenous
pyelography (Fig. 1) suggested ectopic left kidney located on
right side below the right kidney in the right iliac fossa and not
fused or attached to the right kidney with a large 21mm pelvic
calculus with mild hydronephrosis. His urine culture came
positive and he was started on antibiotics as per the antibiotic
sensitivity. He later underwent retrograde intra-renal surgery where stone was completely lased and double J stent was
kept at the end of the procedure. Prior DJ stenting was done
to straighten the ureter. Patient was discharged on second
post-op day. There were no post-op complications. Repeat
sonography and x-ray of the kidney-ureter-bladder showed
no residual calculus (Fig. 2). The double J stent was removed
after two weeks.
DISCUSSION
Abnormal development of the ureteric bud and the Wolffian
duct during embryogenesis leads to an ectopic kidney, which
can be found anywhere from the pelvis upto the thorax or on
the contralateral side. The incidence of crossed fused renal
ectopia is around one in 7000 to one in 1000 live births while
the incidence of crossed ectopia non-fused kidney is further
rare. Crossed fused ectopia is the second most common
anomaly after horse-shoe kidney [2]. Among the crossed
fused ectopic kidneys, the inferior fusion anomaly is the most
common. In our case, the left kidney crossed to right side
inferior to the right kidney but not fused. This may be the
variation of the above-mentioned anomaly.
Treatment of stones in the ectopic kidney is challenging for
the urologists due to the abnormal location and architecture.
RIRS has shown good results in such cases (3,4). The crossing
of the kidney caused angulations and tortuosity of the ureter
and to do RIRS in such cases need straightening of the ureter.
Therefore, pre-stenting is recommended in such cases [5] to
allow the ureteral access sheath to pass easily without any
trauma to the ureter. We also did prior DJ stenting in our case.
We used disposable ureteroscope (from bioradmedisys, 7.5
Fr outer diameter, 670 mm length) for RIRS and 30-watt laser
(from Allenger, Blaze 30 watt Holmium:Yattrium-AluminiumGarnet laser) for dusting the stone. Disposable ureteroscopes
are technically better with 360-degree deflection, good flow,
and a very good vision (6).
The success rate of RIRS in ectopic kidney is variable. Bozkurt
et al [7] had 84.4% success rate while Bogdan Geavlete et al
[8] had 94.4% success after third session.
The complications like ureteral perforation, ureteral injury may
happen in an ectopic kidney due to the malformations in the
renal anatomy. Bas et al [9] had 17.2 % rate of complications
and Bogdan Geavlete et al [8] had 19.7% complication rate.
We did not have any complication in our case.
The point to note in our case is the that every crossed kidney
is not crossed fused renal ectopia. Do pre-stent the ectopic
kidneys before the final procedure considering the tortuosity
and angulations.
CONCLUSION
RIRS is a very good option to treat stones in an ectopic
kidney. It may require more than one session sometimes, but
considering the minimal invasive nature, the bothersome is
less. Disposable ureteroscopes have further revolutionised
the armamentarium of the urologist, who can now offer a
personalised treatment plan for each patient.
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Citation:
Sanjay P Dhangar. RIRS - A Boon for The Crossed Ectopic Non-fused Kidney Calculi Patients : First Case Report. Annals of Urology 2024.
Journal Info
- Journal Name: Annals Of Urology
- Impact Factor: 2.0**
- ISSN: 2767-2271
- DOI: 10.52338/aou
- Short Name: AOU
- Acceptance rate: 55%
- Volume: 6 (2024)
- Submission to acceptance: 25 days
- Acceptance to publication: 10 days
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