Case Report: Mini-endoscopic combined intrarenal surgery in an en-bloc kidney transplant

Background Overall incidence of stones in kidney transplant recipients is 1%. En-bloc kidney transplant is a rare anatomical condition in which kidney stones treatment can be extremely difficult to treat. As far as we know, no cases of staghorn calculi in en-bloc kidney transplant have been published so far. Case presentation A 27-year-old woman presented to the Emergency Department because of asthenia, adynamia and weight loss associated with lower urinary tract symptoms and subfebrile temperature. Ten years before, she had undergone an en-bloc kidney transplant because of end-stage renal disease secondary to perinatal asphyxia syndrome. One kidney was implanted capo-volta in the right iliac fossa and the other one in the right flank. NCCT scan showed incomplete staghorn calculi in the iliac fossa transplanted kidney. Besides, severe dilation of the native and the right flank transplanted kidney, due to two ureteral stones of 6 and 7 mm impacted in the uretero-ureteral anastomosis, was found. After hospital admission and under ceftriaxone prophylaxis, an attempt to perform primary RIRS following our COVID protocol was carried out. Nevertheless, we ended up placing a JJ stent because once the guidewire passed through the ureteral stones, purulent material came out from the ureteral orifice. She stayed 9 days in-hospital for management of postobstructive polyuria and was discharged with oral antibiotics. Three weeks afterward, we removed the stent and performed flexible ureteroscopy and holmium laser lithotripsy of the ureteral stones. In the same procedure, we performed Mini-ECIRS (21 French) previous ultrasound-guided upper pole puncture. Postoperative NCCT scan showed neither residual fragments nor operative complications. Conclusion This is the first clinical case reporting Mini-ECIRS in a patient with an en-bloc kidney transplant. This endourological approach seems to be a feasible, safe and effective approach to treat stones in this anatomically challenging condition.

No staghorn calculi and none/mild hydronephrosis may be risk factors for severe bleeding complications after percutaneous nephrolithotomy

Background To explore the risk factors for severe bleeding complications after percutaneous nephrolithotomy (PCNL) according to the modified Clavien scoring system. Methods We retrospectively analysed 2981 patients who received percutaneous nephrolithotomies from January 2014 to December 2020. Study inclusion criteria were PCNL and postoperative mild or severe renal haemorrhage in accordance with the modified Clavien scoring system. Mild bleeding complications included Clavien 2, while severe bleeding complications were greater than Clavien 3a. It has a good prognosis and is more likely to be underestimated and ignored in retrospective studies in bleeding complications classified by Clavien 1, so no analysis about these was conducted in this study. Clinical features, medical comorbidities and perioperative characteristics were analysed. Chi-square, independent t tests, Pearson’s correlation, Fisher exact tests, Mann–Whitney and multivariate logistic regression were used as appropriate. Results Of the 2981 patients 70 (2.3%), met study inclusion criteria, consisting of 51 men and 19 women, 48 patients had severe bleeding complications. The remaining 22 patients had mild bleeding. Patients with postoperative severe bleeding complications were more likely to have no or slight degree of hydronephrosis and have no staghorn calculi on univariate analysis (p < 0.05). Staghorn calculi (OR, 95% CI, p value 0.218, 0.068–0.700, 0.010) and hydronephrosis (OR, 95% CI, p value 0.271, 0.083–0.887, 0.031) were independent predictors for severe bleeding via multivariate logistic regression analysis. Other factors, such as history of PCNL, multiple kidney stones, site of puncture calyx and mean corrected intraoperative haemoglobin drop were not related to postoperative severe bleedings. Conclusions The absence of staghorn calculi and a no or mild hydronephrosis were related to an increased risk of post-percutaneous nephrolithotomy severe bleeding complications.

Staghorn Calculus: A Stone out of Proportion to Pain

Case Presentation: A 25-year-old woman presented to the emergency department with two weeks of crampy right-flank pain, and urinary urgency and frequency. She was found to have a staghorn calculus filling her entire right renal pelvis on computed tomography imaging. Discussion: In contrast to ureteral calculi, staghorn calculi are more commonly observed in female patients and typically present with an indolent clinical course. A low threshold for imaging should be maintained, as prompt referral to urology for stone removal or treatment is necessary. Staghorn calculi have a high likelihood of leading to renal failure or urosepsis without treatment.

MO091BILATERAL EMPHYSEMATOUS PYELITIS: A CASE REPORT AND ULTRASONOGRAPHY FEATURES

Background and Aims Emphysematous pyelitis is a rare urinary infection with gas formation in the excretory system. Diabetes mellitus and urinary tract obstruction are the main risk factors. Most patients are women over 60 years old. The pathogenesis is unknown. Diabetes mellitus and the elevated glucose levels may create a favorable microenvironment for gas-forming microbes, but it does not exhaustively explain clinical and pathological symptoms. Escherichia Coli and Klebsiella Pneumoniae are the most involved bacteria. Clinical features are the same as other forms of pyelonephritis e.g. fever, chills, flank abdominal pain, nausea and vomiting. Ultrasonography, and especially computed tomography (CT) are important diagnostic tools for demonstration of gas within pelvicalyceal system, urethers or even in bladder. Use of parenteral antibiotic, relief of urinary tract obstruction if present, percutaneous catheter drainage of gas and purulent material and nephrectomy are the mainstays of therapy. This report introduces a case of bilateral emphysematous pyelitis with emphasis on its ultrasound presentation. This is one of the few cases of bilateral emphysematous pyelitis reported in literature. Method A 49-year-old female presented to the emergency with asthenia, epistaxis, orthostatic hypotension and nocturnal cramps. Two months before she was referred to Department of Nephrology for proteinuria. In that occasion, renal ultrasound showed normal kidneys and renal biopsy was performed. She started oral therapy with corticosteroid for ANCA-negative vasculitis and iatrogenic diabetes mellitus occurred. She was admitted again to our Department of Nephrology, blood test was performed and revealed: white cell count 20.500/ml; glucose 243 mg/dl; serum creatinine 2.3 mg/dl; C-reactive protein, 0.65 mg/dl ( &lt; 0.5), procalcitonin 2.05 µg/l (nv &lt; 0.5). Urine culture was positive for E. Coli. Results Renal ultrasound revealed the presence, in both kidney pelvises, of multiple and diffuse hyperechogenic images associated with some reverberation artefacts. The ultrasound findings were unusual and of doubtful interpretation: staghorn calculi, encrusted pyelitis, gas? (Fig. 1, 2). Reverberation artifacts give rise the suspicion of gas presence in kidney pelvises, usually absent in case of staghorn calculi and encrusted pyelitis. CT confirmed the diagnosis of bilateral emphysematous pyelitis due to the diffuse presence of gas within the renal calyces, also extending to the ureters and bladder lumen (Fig. 3). We promptly started parental antimicrobial therapy with cefalosporine. After one week we observed a clinical and laboratory improvement, and the renal ultrasound revealed the resolution of bilateral pelvises alteration (Fig. 4). Conclusion In emphysematous pyelitis, renal ultrasound is characteristic due to the presence of diffuse hyperechogenic images located in the renal pelvis associated with some reverberation artifacts, usually absent in case of renal stones. Therefore, the renal ultrasound in association with clinical and laboratory findings, especially in patient with positive urine culture, should arouse the suspicion of emphysematous pyelitis to start promptly antimicrobial therapy, even when CT examination is not immediately available.