0022-5347/95/1536-1878$03.

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THE JOURNAL OF UROliOcY Vol. 153,1878-1881,June 1995
Copyright 0 1995 by AMERICAN UROLOGICAL
ASSOCIATION, INC. Printed in U.S.A.

Urologists At Work

ENDOSCOPIC MANAGEMENT OF THE SYMPTOMATIC CALICEAL

DIVERTICULAR CALCULUS
MICHAEL G W S O , * GREGORY IANG, PETER LOISIDES, DEMETRIUS BAGLEY AND
FRANK TAYLOR
From the Departments of Urology and Radiology, Loma Linda University, Loma Linda, California and Department of Urology, Thomas
Jefferson University, Philadelphia, Pennsylvania

ABSTRACT

Caliceal diverticular calculi are most often asymptomatic and of little clinical significance. In
certain cases they may be associated with flank pain, pyuria and chronic urinary tract infections.
Treatment has evolved from open surgical techniques to a purely endoscopic approach. Percu-
taneous techniques are frequently used to address the diverticular stone burden and to dilate the
diverticular neck, improving drainage.
Small volume caliceal diverticular calculi and those in the anterior portion of the collecting
system represent a greater technical challenge to the endoscopist. We describe a purely retro-
grade endoscopic technique for treating small stone burdens trapped in caliceal diverticula.
Flexible ureteroscopy combined with 3F dilating balloons passed through the endoscopic working
channel facilitated treatment. This retrograde technique was combined with a simultaneous
primary percutaneous puncture into the diverticulum to treat larger stone burdens and calculi
within long-necked diverticula. This combination facilitated prompt, through and through access
of a percutaneously placed guide wire, increasing the overall efficiency of treatment.
In conclusion, a retrograde endoscopic technique using the actively deflectable, flexible uret-
eroscope can successfully treat certain caliceal diverticular calculi. By combining this technique
with a simultaneous percutaneous puncture, caliceal diverticular calculi throughout the collect-
ing system may be cleared expeditiously.
KEY WORDS:endoscopy, urinary calculi, kidney calculi, kidney calices
A caliceal diverticulum differs from a renal cyst in that it is collecting system. With a narrow diverticular neck it is diflicult,
lined by urothelium and drains into the collecting system, if not impossible, to gain adequate purchase percutaneously
frequently through a stenotic neck. The majority of caliceal into the diverticulum and also direct a guide wire through the
diverticula are asymptomatic and are noted incidentally dur- diverticular neck into the remainder of the collecting system.
ing renal imaging. Calculi entrapped within a caliceal diver- Caliceal diverticular calculi can be treated by combining stan-
ticulum may, however, be associated with flank pain, chronic dard endoscopic techniques, including percutaneous nephrosto-
pyuria and urinary tract infections.1-4 lithotomy and retrograde actively deflectable, flexible ureteros-
Treatment of symptomatic caliceal diverticular calculi has copy. Variables, including the stone burden, location of the
evolved from open surgical excision, and includes primary caliceal diverticulum and the length of the caliceal diverticular
percutaneous access and ablation of the affected renal seg- neck, may define treatment options. The techniques described
ment as well as retrograde endoscopic therapy.”s Primary were specifically developed to address anterior caliceal divertic-
extracorporeal shock wave lithotripsy has also been sug- ular calculi. When applied to complex caliceal stone burdens,
gested as a treatment.9. lo Conceptually, the latter technique these same techniques are often extremely useful in increasing
would seem to be the least successful because, despite stone the efficiency of endoscopic therapy.
fragmentation within the caliceal diverticulum, the neck will
remain stenotic and, thus, inhibit clearance. MATERIALS AND METHODS
Percutaneous management of the caliceal diverticular cal-
culi is attractive, since it allows the endourologist not only to We treated 4 patients with a total of 5 symptomatic caliceal
clear the stone burden but also to fulgurate the urothelial diverticular calculi. One patient had bilateral calicea! diver-
lining. Thus, hopefully, the diverticulum will be ablated and ticular calculi, chronic pyuria and type I11 stress urinary
recurrence prevented. Percutaneous access can be difficult in incontinence. The opinion of the referring urologist was that
patients with a small caliceal diverticulum full of stone. further treatment of the incontinence should be deferred
In patients with anterior caliceal diverticula it is also difficult to until the stone burden and chronic pyuria resolved. She
obtain percutaneous access through the diverticular neck into underwent endoscopic therapy before a fascia1 sling urethral
the collectingsystem.8 The nephrostomy needle must traverse a suspension.
significant portion of renal parenchyma and then a guide wire The most common presenting symptoms were back pain and
must be directed back through the diverticular neck into the pyuria. Diverticula were noted in the upper, middle and lower
Accepted for ublication October 28, 1994. pole moieties, respectively. In all patients the caliceal divertic-
* Current adjress, Division of Urology, New York University Hos- ulum was lateral on contrast imaging. Standard retrograde
pital, 550 First Ave., New York, New York 10016. ureteroscopic techniques were used to treat caliceal diverticula
1878
 ENDOSCOPIC MANAGEMENT O F CALICEAL DIVERTICULAR CALCULUS
with small stone burdens (less than 1cm.). In these patients the
calculi frequently filled the diverticulum. A 7.5F actively de-
flectable,flexible ureteroscope was passed in a monorail fashion
Over a nickel titanium guide wire. The caliceal diverticular neck
was accessed initially with a hollow core, injectable guide wire
and, using half-strength contrast medium, the diverticulum
was opacified (fig. 1).A small diameter dilating balloon was
passed through the working channel of the flexible ureteroscope
and was used to dilate the diverticular neck to gain access to the
calculus. This dilating balloon has a sheath of 3F, is 2 cm.long
and will dilate up to 12F at a maximum of 8 atmospheres
pressure (fig. 2). Once the endoscope could be passed into the
diverticulum, standard endoscopic lithotripsy techniques were
used and stone fragments were extracted with a 3-prong
grasper.
In patients with a larger stone burden (greater than 1cm.)
the caliceal diverticulum was treated with a combined ante-
grade and retrograde approach. Patients were placed in the
prone position with access maintained to the genitalia as
described previously.ll Flexible cystoscopy was performed
and a guide wire was advanced up the ureter. The small
FIG.1. A, injectable guide wire is passed through diverticular
neck under direct vision. Diverticulum is opacified with half-
strength contrast medium. B, angioplasty-like balloon is used to
dilate diverticular neck. This maneuver allowed flexible uretero-
scopic access to diverticular stone burden.
FIG.2. Actively deflectable, flexible 7.5F ureteroscope with in-
flated guide wire passed through 3.6F working channel. This partic-
d a r prototype angioplasty-like wire is 2 cm. long and will dilate up
to 12F with a maximum of 8 atmospheres pressure.
1879
diameter actively deflectable, flexible ureteroscope was then
used to gain access to the diverticulum. The caliceal diver-
ticular neck was first intubated with an injectable guide wire
and the diverticulum was opacified with contrast medium.
Using the angioplasty balloon, the diverticular neck was
dilated and a 1.9F helical basket or Amplatz snare was
advanced into the diverticulum. Simultaneously, a percuta-
neous puncture was performed. Under fluoroscopic and ure-
teroscopic direction the tip of the percutaneous guide wire
was grasped by the snare basket and withdrawn into the
ureter through the bladder and out the urethra. Once
through and through guide wire control was obtained, stan-
dard percutaneous techniques for tract dilation were used.
Nephroscopy was then performed and the stone burden was
cleared with a hollow core ultrasonic lithotriptor. The urothe-
lium lining the diverticulum was fulgurated and a nephros-
tomy tube was left in place through the diverticular neck for
2 weeks to promote fibrosis.
RESULTS
All 4 patients with symptomatic caliceal diverticula were
referred with a diagnosis of renal calculi, chronic pain, and/or
chronic pyuria and urinary tract infections localized to a
specific upper urinary tract. Retrograde ureteropyelograms
were performed although the caliceal diverticular neck was
frequently not defined by this imaging. In 1 patient with
bilateral caliceal diverticular calculi shock wave lithotripsy
was unsuccessful, which led to the referral. In patients with
a caliceal diverticular stone burden of less than 1cm. retro-
grade endoscopic treatment was initially attempted. If un-
successful, then a combined antegrade and retrograde ap-
proach was used.
Our initial patient presented with small volume, bilateral
middle pole caliceal diverticula that were completely full of
stone. The left caliceal diverticular neck dilated easily with
direct ureteroscopic manipulation using the balloon angio-
plasty guide wire (fig. 3). The stone burden was completely
cleared with the aid of the laser lithotriptor and endoscopic
FIG.3. Contrast imaging defined left caliceal diverticulum with
short diverticular neck. Diverticulum was endoscopidy addressed
and stone burden was completely cleared in retrograde fashion.
1880 ENDOSCOPIC MANAGEMENT OF CALICEAL DIVERTICULAR CALCULUS

grasper. On the contralateral kidney the diverticular neck
measured approximately 1 cm. long. The balloon did not
dilate the diverticular neck sufficiently to allow for endo-
scopic extraction or fragmentation of the stone burden. Ret-
rograde endoscopic incision was then performed but did not
improve access and led to postoperative bleeding, which re-
quired transfusion. At a later date, the diverticular neck was
dilated in a retrograde fashion. Using a combination of an-
tegrade and retrograde techniques a through and through
guide wire was obtained and the stone burden was com-
pletely cleared.
The next patient had caliceal diverticular calculi treated
solely in a retrograde fashion. The patient suffered from
persistent pain and chronic pyuria localized to the right
upper urinary tract. An upper pole caliceal diverticulum with
entrapped calculi was diagnosed ureteroscopically. Underly-
ing cardiac disease prohibited lengthy general anesthesia.
Retrograde flexible ureteroscopy was then performed and
demonstrated a pinhole diverticular neck. Following dilation
many stone fragments and purulent material emptied spon-
taneously from the diverticulum. Additional calculi remained
within the diverticulum. The diverticular wall was also cal-
cified in many areas. The nonadherent calculi were cleared
endoscopically and a stent was placed through the divertic-
ular neck to facilitate drainage during the immediate post-
operative period.
Percutaneous techniques were chosen in the final 2 pa-
tients with relatively large caliceal diverticular stone bur-
dens. Both patients had calculi within lower pole caliceal
diverticula. Initially, retrograde access was achieved with
the flexible ureteroscopic techniques previously described
(fig. 4). The diverticular neck was then dilated with the
balloon dilator and a standard helical basket or Amplatz
snare was positioned into the diverticulum. A percutaneous
guide wire was then passed through the flank, into the bas-
ket and withdrawn down the ureter. With through and
through access, the treatment was straightforward. The di-
verticular neck was dilated and the stone burden was cleared
with ultrasonic lithotripsy. The diverticular mucosa was then
llgurated and a large 24F Malecot nephrostomy tube was
positioned through the diverticular neck.
Total operative time averaged 2.5 hours for the solely ret-
rograde ureteroscopic and the combined antegrade and
retrograde endoscopic treatments, respectively. Symptoms
had resolved in all patients with a minimum of 5 months of
followup.
DISCUSSION
Caliceal diverticular calculi are uncommon variants of up-
per urinary tract drainage. Most frequently they are asymp-
tomatic and of no clinical significance. However, there is
occasion to treat patients who present with chronic pain
andor pyuria and infection localized to an upper urinary
tract harboring a caliceal diverticular calculus. Even though
extracorporeal shock wave lithotripsy has been suggested as
a treatment for caliceal diverticular stones, the tight stenotic
neck of the caliceal diverticulum should inhibit clearance of
all but the smallest frag1nents.9~~0 For this reason percuta-
neous techniques have been developed to treat these calcu-

FIG.4. Findings in 55-year-old woman with chronic left flank pain and caliceal diverticular calculus. A and B, plain radiograph and
retrograde contrast study define calculus within caliceal diverticulum. Note long narrow diverticular neck. After dilation, tip of endoscope
could be passed within caliceal diverticulum. C and D,ureteroscopically placed gold tipped endoscopic loop was positioned within divertic-
ulum. Simultaneously, percutaneous puncture was performed into diverticulum, and guide wire passed through loop and extracted down
ureter. Through and through access was obtained, and standard percutaneous techniques were then used to clear stone burden.
 ENDOSCOPIC MANAGEMENT OF CALICEAL DIVERTICULAR CALCULUS 1881
b.”8 Unfortunately, i n patients with either small or anterior with simultaneous percutaneous therapy. The modest overall
caliceal diverticula, percutaneous access may be difficult. operating time per sitting exemplifies the efficient nature of
In 1990 Fuchs et a1 described a retrograde endoscopic these techniques.
technique to treat caliceal diverticular calculi.12 They specif-
ically described difficulty i n directing a standard ureteral
dilating balloon into lower pole diverticula. Subsequent mod- REFERENCES
ifications in t h e mechanical workings of the actively deflect- 1. Devine, C. J., Jr., Guzman, J. A,, Devine, P. C. and Poutasse,
able, flexible ureteroscope have increased its therapeutic po- E. F.: Calyceal diverticulum. J. Urol., 101: 8,1969.
tential, especially when addressing lower pole caliceal 2. Wulfsohn, M. A,: Pyelocaliceal diverticula. J. Urol., 123 1,1980.
1esi0ns.l~As noted i n our series, the addition of 3F angio- 3. Middleton, A. W., Jr. and Ester, R. C.: Stone-containingpyelo-
plasty-like dilating balloons passed through t h e working caliceal diverticulum: embryogenic, anatomic, radiologic and
channel of t h e ureteroscope allowed for retrograde access to clinical characteristics. J. Urol., 111: 2, 1974.
4. Timmons, J . W., Jr., Malek, R. S., Hattery, R. R. and DeWeerd,
diverticular calculi throughout the collecting system. J . H.: Caliceal diverticulum. J. Urol., 114 6,1975.
Bellman e t a1 recently described their extensive experience 5. Hulbert, J. C., Reddy, P. K, Hunter, D. W., Castaneda-Zumiga,
with percutaneous treatment of caliceal diverticular calculi.8 W., Amplatz, K and Lange, P. H.: Percutaneous techniques for
Percutaneous access of a caliceal diverticulum w a s believed the management of caliceal diverticula containing calculi. J.
to be more challenging t h a n that required for a standard Urol., 136 225, 1986.
nephrostolithotomy, which is especially true when the diver- 6. Silverstein, J. I., Karlin, G. S. and Smith, A. D.: Endourologic
ticulum is full of stone or anteriorly located, both of which can management of caliceal diverticula. J. Endourol., 4: S139,
prevent adequate purchase of the percutaneous guide wire 1990.
required for tract dilation. A percutaneously placed guide 7. Lingeman, J. E., Jones, J. A. and Steidle, C. P.: ESWL vs.
oercutaneous manmement of calvceal diverticula. J. En-
wire passed through the diverticulum and down the ureter iourol., 4 S140, 199;.
will ultimately provide t h e most secure access. In this series 8. Bellman, G. C., Silverstein, J . I., Blickensderfer. S. and Smith,
we combined retrograde endoscopic access to the diverticu- A. D.: Technique and follow-up of percutaneous management
lum with a percutaneous puncture in 2 patients with large of caliceal diverticula. Urology, 42:21, 1993.
stone burdens and in 1 who failed primary retrograde endo- 9. Psihramis, K.E. and Dretler, S. P.: Extracorporeal shock wave
ecopic treatment. Initial retrograde ureteroscopic access to lithotripsy of caliceal diverticula calculi. J. Urol., 138: 707,
these diverticula ensured placement of a through and 1987.
through guide wire and significantly increased the efficiency 10. Streem, S. B. and Yost, A.: Treatment of caliceal diverticular
calculi with extracorporeal shock wave lithotripsy: patient
of our overall treatment. selection and extended followup. J . Urol., 148: 1043,1992.
11. Grasso, M., Nord, R. and Bagley, D. H.: Prone split leg and flank
CONCLUSIONS roll positioning: simultaneous antegrade and retrograde ac-
We discuss 4 patients with stone burdens in 5 caliceal cess to the upper urinary tract. J. Endourol., 4 307,1993.
diverticula who were treated with either a primary retro- 12. Fuchs, A. M., David, R. D. and Fuchs, G. J.: Treatment of stones
in calyceal diverticuli using retrograde endoscopic approach.J.
grade or a combination of retrograde and antegrade endo- Endourol., 4 109,1990.
scopic techniques. Small stone burdens were addressed pri- 13. Grasso, M. and Bagley, D. H.: A 7.518.2 F actively deflectable,
marily i n a retrograde fashion. Large caliceal diverticular flexible ureteroscope: a new device for both diagnostic and
calculi. or those traDDed within a long necked diverticulum therapeutic upper urinary tract endoscopy. Urology, 43:435,
were treated by combining retrograde ureteroscopic access 1994.