You are on page 1of 7

Case Report

Journal of International Medical Research


2019, Vol. 47(9) 4544–4550
Minimally invasive treatment ! The Author(s) 2019
Article reuse guidelines:
of an ectopic kidney stone: sagepub.com/journals-permissions
DOI: 10.1177/0300060519865845
a case report and journals.sagepub.com/home/imr

literature review

Chenglu Wang*, Lu Jin*, Xinyang Zhao,


Guobin Li and Boxin Xue

Abstract
An ectopic pelvic kidney is a rare congenital anomaly with a high incidence of complications such
as reflux, hydronephrosis, nephrolithiasis, and even renal failure. We herein report a case
of transperitoneal laparoscopic pyelolithotomy for treatment of a left pelvic kidney stone and
discuss various surgical procedures based on the published literature. A 64-year-old woman
presented to our hospital with generalized weakness and occasional nonspecific waist pain in
October 2017. Computed tomography showed a 2.6-cm renal pelvis stone located in the left
ectopic pelvic kidney with severe hydronephrosis. The patient underwent transperitoneal lapa-
roscopic pyelolithotomy and was discharged 7 days after surgery. Various treatment procedures
are available for ectopic kidney stones. Proper preoperative assessment and selection of the most
suitable surgical procedure play critical roles in successful treatment.

Keywords
Pelvic kidney, surgery, anatomic variation, renal ectopy, kidney stone, pyelolithotomy
Date received: 22 March 2019; accepted: 4 July 2019

Introduction Department of Urology, The Second Affiliated Hospital of


Soochow University, Suzhou, Jiangsu, P.R. China
The metanephric kidney originates from the
sacral region and subsequently becomes *These authors contributed equally to this work.
positioned more cranially during develop- Corresponding author:
Boxin Xue, Department of Urology, The Second Affiliated
ment. A kidney that fails to ascend from Hospital of Soochow University, No. 1055 Sanxiang Road,
the pelvis to the renal fossa is considered Suzhou, Jiangsu 215000, P.R. China.
an ectopic pelvic kidney. The actual Email: xbxurol@163.com

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which
permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is
attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Wang et al. 4545

incidence of renal ectopia in an autopsy normal. Laboratory tests revealed bacteri-


series was estimated at 1 in 900 without dra- uria by urine culture. Computed tomogra-
matic sex-related differences.1 Furthermore, phy without contrast material showed an
the occurrence rate of a pelvic kidney was ectopic kidney located in the left iliac
reported at 1 in 2200 to 3000.2 Because of fossa accompanied by severe hydronephro-
the abnormal anatomy and aberrant rota- sis and a renal pelvic stone (Figure 1). The
tion of an ectopic pelvic kidney, affected neurologists accordingly referred the
patients often have concurrent structural patient to the urologic surgery clinic. A ret-
and architectural anomalies. Conditions rograde pyelogram demonstrated a mark-
such as reflux, hydronephrosis, nephroli- edly dilated renal pelvis, severe
thiasis, and even renal failure are more hydronephrosis, and massively tortuous
common in patients with than without a ureter accompanied by an ectopic pelvic
pelvic kidney. Nephrolithiasis is one of the kidney. The patient underwent transperito-
most common causes of obstruction of the neal laparoscopic pyelolithotomy after
ureteropelvic junction in patients with an treatment of her urinary tract infection.
ectopic pelvic kidney. Various treatment She was placed in the supine position with
methods for such stones include extracor- lateral elevation on the left side.
poreal shock wave lithotripsy (ESWL), flex- Pneumoperitoneum was established by a
ible ureteroscopy, laparoscopic-assisted Veress needle. A 10-mm visualizing laparo-
percutaneous nephrolithotomy (PNL), and scopic trocar was placed at the level of the
laparoscopic pyelolithotomy. The combina- umbilicus. Two 5-mm ports were inserted in
tion of laparoscopy and flexible uretero- the right and left midline, half a hand-
scopy in the performance of pyeloplasty as breadth below the umbilicus. One addition-
well as robot-assisted laparoscopic pyelo- al 12-mm port was placed in the right iliac
plasty were recently reported as novel treat- fossa. Pyelotomy was performed, and the
ment modalities for these patients.3,4 We stone was then extracted by laparoscopic
herein describe a patient with an ectopic forceps. It was placed in a piece of a surgi-
kidney stone and generalized weakness cal glove for removal from the peritoneal
who was initially misdiagnosed with a neu- cavity. We placed a double J stent in the
rological disease and discuss the case with left ureter via the renal pelvic incision and
reference to previously published literature. then closed the pyelotomy margins with 3-0
polyglactin. A 20-Fr silicone rubber cathe-
ter was placed in the operative region for
Case report
postoperative drainage. The drainage tube
This study was approved by the local Ethics was removed on postoperative day 3. The
Committee of The Second Affiliated patient stayed in the hospital for 1 week
Hospital of Soochow University, and without any complications. At her follow-
the patient provided informed consent. up visits, an intravenous pyelogram showed
A 64-year-old woman initially presented stone clearance without hydronephrosis
to our neurology clinic for evaluation of (Figure 2). The double J stent was removed
generalized weakness and occasional non- 4 weeks after discharge.
specific waist pain in October 2017. Her
medical history was unremarkable with
the exception of chronic hypertension.
Discussion
Physical examination showed no abdominal An ectopic kidney can be found in the
abnormalities. The patient’s baseline hema- pelvis, ilium, thorax, or abdomen; addition-
tologic and biochemical parameters were ally, it can be contralateral or crossed fused.
4546 Journal of International Medical Research 47(9)

Figure 1. Preoperative retrograde pyelograms. A markedly tortuous ureter and hydronephrosis of the
pelvic kidney are evident.

Maldevelopment of the ureteral bud and kidneys had a higher rate of clinically insig-
Wolffian duct in a developing fetus are nificant residual fragments than did normal
thought to be the embryologic causes of kidneys (37% vs. 18.5%, respectively).
an ectopic pelvic kidney.5 Consequently, ESWL was been viewed as
Because of the aberrant location, orien- the first-choice noninvasive treatment
tation, and shape of an ectopic pelvic modality with a relatively poor success
kidney, conditions such as hydronephrosis rate for pelvic kidney stones. Flexible ure-
and nephrolithiasis are more common in teroscopy has emerged as an alternative
these patients. Therefore, treatment of treatment method for small- to medium-
pelvic kidney stones remains challenging sized renal calculi because of its advantages
for the urologist because of the structural of flexion and deflection. Several studies
and architectural anomalies of such kid- have shown that the success rates of
neys. ESWL in the prone position was flexible ureteroscopy in patients with
first recognized as a noninvasive method pelvic kidneys range from 75.0% to
for treatment of patients with pelvic 84.7%.9–11 Nonetheless, anatomic altera-
kidney stones in 1988.6 Several studies tions including a tortuous ureter and
have indicated that ESWL can be recom- malrotated kidney have been suggested as
mended as a first-line treatment option for significant factors that increase the difficul-
anomalous kidney stones because of the ty of the procedure and influence the stone
high rates of stone clearance.7,8 However, clearance rate in treatment by flexible ure-
Demirkesen et al.9 reported that ESWL teroscopy. The first laparoscopic pyeloli-
for normal kidneys had a higher stone-free thotomy was reported by Chang and
rate than that for aberrant kidneys (78% vs. Dretler in 1996.12 They described peritoneal
56%, respectively) and that aberrant urine leakage after the catheter was
Wang et al. 4547

Figure 2. Postoperative intravenous pyelogram.

removed. Also in 1996, Harmon et al.13 per- The transperitoneal route has the advan-
formed laparoscopic pyelolithotomy in a tage of clear exposure of the related struc-
patient without closing the pyelotomy site. tures as well as abnormal vessels. The
Because the patient experienced prolonged retroperitoneal laparoscopic approach can
postoperative urine leakage, the indwelling be achieved without peritoneal contamina-
stent and urethral catheter were not tion by urine. The transmesenteric route
removed until postoperative day 6. In provides faster access to visibility of the
recent years, as experience has increased pelvic kidney surface. Yin et al.4 reported
and technology has improved in the field that the combination of laparoscopy and
of laparoscopic surgery, laparoscopic pye- flexible ureteroscopy in the performance of
lolithotomy has been found to be an effec- pyeloplasty can be an alternative treatment
tive procedure with low morbidity in procedure for patients with inaccessible cal-
the treatment of pelvic kidney stones.14 iceal stones. They treated 16 patients with a
Transperitoneal, retroperitoneal, and trans- 100% stone-free rate, and no stone recur-
mesenteric access are the three most feasible rence was found in follow-up visits.4 The
approaches for laparoscopic pyelolithot- overall results of laparoscopic pyelolithot-
omy, and each has its own advantages. omy for treatment of patients with pelvic
4548 Journal of International Medical Research 47(9)

kidney stones are satisfactory.15 Therefore, reportedly higher than that after laparo-
laparoscopic pyelolithotomy is considered a scopic pyelolithotomy, and although
good option for treatment of a single pelvic patients may need follow-up treatment
kidney stone, especially a renal pelvic after surgery, laparoscopic-assisted PNL is
stone.16 PNL is a first-line treatment still an irreplaceable treatment option for
option for removal of large kidney stones. patients with an ectopic pelvic kidney with
Although some authors have suggested the caliceal calculi.15 Robot-assisted techniques
use of ultrasound or computed tomography have gradually become a critical part of
guidance to achieve percutaneous access in minimally invasive surgery. The use of
patients with pelvic kidney stones, there is such techniques can help to overcome the
still a high risk of injuring the surrounding technical challenges associated with the lap-
viscera and major vessels.17 Laparoscopic- aroscopic technique. Patients who undergo
assisted PNL for a pelvic ectopic kidney robot-assisted surgery generally have better
was first introduced by Eshghi et al.18 outcomes than those who undergo an open
in 1985. In 1998, Holman and Toth19 approach or pure laparoscopic approach.
successfully performed transperitoneal The first robot-assisted laparoscopic pyelo-
laparoscopic-assisted PNL in 15 patients plasty for treatment of an ectopic pelvic
with pelvic kidney stones. They mobilized kidney was reported by Nayyar et al.3
the surrounding bowel loops and dissected In their study, the duration of surgery was
the bowel off to ensure that the kidney 56 minutes and the patient was discharged
was visible under laparoscopic vision from the hospital on the third day with no
in the Trendelenburg position. Zafar short-term postoperative complications.3
and Lingeman2 described two patients However, there is still a need for long-
with ectopic kidneys who underwent term follow-up to compare the clinical out-
laparoscopic-assisted PNL in 1996. They comes between robot-assisted laparoscopic
performed laparoscopic suturing on the pyeloplasty and the pure laparoscopic
nephrotomy site after the nephrolithotomy approach or laparoscopic-assisted PNL.
procedure to avoid placement of a transper-
itoneal nephrostomy tube. Troxel et al.20
reported an improved laparoscopic
Conclusion
technique including an extraperitoneal In the present case, severe hydronephrosis
approach to the pelvic kidney and extraper- and a markedly tortuous ureter accompa-
itoneal placement of a drainage tube to nied a renal pelvic stone in a patient
limit the minimal postoperative drainage. with clinically silent pelvic renal ectopia.
In 2007, El-Kappany et al.21 successfully Several treatment modalities are available
treated five patients using laparoscopic- for patients with ectopic kidney stones,
assisted PNL with no intraoperative including ESWL, flexible ureteroscopy,
or postoperative complications. Besides laparoscopic-assisted PNL, laparoscopic
laparoscopic-assisted PNL, several unusual pyelolithotomy, and robot-assisted laparo-
approaches including the suprailiac scopic pyeloplasty. Because of our patient’s
approach, trans-sciatic approach under large renal pelvic stone, we performed lap-
fluoroscopic guidance, and transhepatic aroscopic transperitoneal pyelolithotomy.
approach during PNL access have been ESWL is a better treatment method for an
described to reduce the risk of injuring the ectopic kidney with pelvic a stone smaller
overlying bowel and aberrant vascular than 1.5 cm or for a patient who declines
structures. Although the recurrence rate of invasive surgery. For patients with an
stones after laparoscopic-assisted PNL is ectopic pelvic kidney containing caliceal
Wang et al. 4549

calculi, laparoscopic-assisted PNL may be a 6. Jenkins AD and Gillenwater JY.


safe and effective treatment. Our case and Extracorporeal shock wave lithotripsy in
the published literature indicate that proper the prone position: treatment of stones in
preoperative assessment and selection of the the distal ureter or anomalous kidney.
J Urol 1988; 139: 911–915.
most suitable surgical procedure play criti-
7. Rigatti P, Montorsi F, Guazzoni G, et al.
cal roles in the treatment of patients with
Multimodal therapy for stones in pelvic kid-
ectopic pelvic kidney stones. neys. Urol Int 1991; 46: 29–34. DOI:
10.1159/000281769.
Declaration of conflicting interest 8. Talic RF. Extracorporeal shock-wave litho-
The authors declare that there is no conflict tripsy monotherapy in renal pelvic ectopia.
of interest. Urology 1996; 48: 857–861.
9. Demirkesen O, Yaycioglu O, Onal B, et al.
Extracorporeal shockwave lithotripsy for
Funding
stones in abnormal urinary tracts: analysis
This work was supported by the Soochow Key of results and comparison with normal uri-
Medical Subject: Urology (No. Szxk201505). nary tracts. J Endourol 2001; 15: 681–685.
DOI: 10.1089/08927790152596235.
ORCID iD 10. Weizer AZ, Springhart WP, Ekeruo WO,
Boxin Xue https://orcid.org/0000-0001- et al. Ureteroscopic management of renal
6197-6849 calculi in anomalous kidneys. Urology
2005; 65: 265–269. DOI: 10.1016/j.
urology.2004.09.055.
References 11. Fayad AS. Retrograde holmium:YAG laser
1. Stein RJ and Desai MM. Management of disintegration of stones in pelvic ectopic kid-
urolithiasis in the congenitally abnormal neys: would it minimize the risk of surgery?
kidney (horseshoe and ectopic). Curr Opin J Endourol 2008; 22: 919–922. DOI: 10.1089/
Urol 2007; 17: 125–131. DOI: 10.1097/ end.2007.0289.
MOU.0b013e328028fe20. 12. Chang TD and Dretler SP. Laparoscopic
2. Zafar FS and Lingeman JE. Value of lapa- pyelolithotomy in an ectopic kidney. J Urol
roscopy in the management of calculi com- 1996; 156: 1753.
plicating renal malformations. J Endourol 13. Harmon WJ, Kleer E and Segura JW.
1996; 10: 379–383. DOI: 10.1089/ Laparoscopic pyelolithotomy for calculus
end.1996.10.379. removal in a pelvic kidney. J Urol 1996;
3. Nayyar R, Singh P and Gupta NP. Robot- 155: 2019–2020.
assisted laparoscopic pyeloplasty with stone 14. Kamat N and Khandelwal P. Laparoscopic
removal in an ectopic pelvic kidney. JSLS pyelolithotomy–a technique for the manage-
2010; 14: 130–132. DOI: 10.4293/ ment of stones in the ectopic pelvic kidney.
108680810X12674612015102. Int J Urol 2004; 11: 581–584. DOI: 10.1111/
4. Yin Z, Wei YB, Liang BL, et al. Initial expe- j.1442-2042.2004.00827.x.
riences with laparoscopy and flexible ure- 15. Elbahnasy AM, Elbendary MA, Radwan
teroscopy combination pyeloplasty in MA, et al. Laparoscopic pyelolithotomy in
management of ectopic pelvic kidney with selected patients with ectopic pelvic kidney:
stone and ureter-pelvic junction obstruction. a feasible minimally invasive treatment
Urolithiasis 2015; 43: 255–260. DOI: option. J Endourol 2011; 25: 985–989. DOI:
10.1007/s00240-015-0753-9. 10.1089/end.2010.0521.
5. Malek RS, Kelalis PP and Burke EC. 16. Gupta N, Mandhani A, Sharma D, et al. Is
Ectopic kidney in children and frequency laparoscopic approach safe for ectopic
of association with other malformations. pelvic kidneys? Urol Int 2006; 77: 118–121.
Mayo Clin Proc 1971; 46: 461–467. DOI: 10.1159/000093903.
4550 Journal of International Medical Research 47(9)

17. Desai MR and Jasani A. Percutaneous Adv Surg Tech A 1998; 8: 431–435. DOI:
nephrolithotripsy in ectopic kidneys. 10.1089/lap.1998.8.431.
J Endourol 2000; 14: 289–292. DOI: 20. Troxel SA, Low RK and Das S.
10.1089/end.2000.14.289. Extraperitoneal laparoscopy-assisted percu-
18. Eshghi AM, Roth JS and Smith AD. taneous nephrolithotomy in a left pelvic
Percutaneous transperitoneal approach to a kidney. J Endourol 2002; 16: 655–657.
pelvic kidney for endourological removal of DOI: 10.1089/089277902761402998.
staghorn calculus. J Urol 1985; 134: 525–527. 21. El-Kappany HA, El-Nahas AR, Shoma
19. Holman E and Toth C. Laparoscopically AM, et al. Combination of laparoscopy
assisted percutaneous transperitoneal neph- and nephroscopy for treatment of stones in
rolithotomy in pelvic dystopic kidneys: expe- pelvic ectopic kidneys. J Endourol 2007; 21:
rience in 15 successful cases. J Laparoendosc 1131–1136. DOI: 10.1089/end.2007.9930.

You might also like