CASE REPORT – OPEN ACCESS
InternationalJournalofSurgeryCaseReports77(2020)668–672
ContentslistsavailableatScienceDirect
International Journal of Surgery Case Reports
jo u r n al hom e p a g e :w w w . c a s e r e p o r t s . c o m
Endoscopic-guided percutaneous nephrolithotomy (EPSL) with prone split-leg position for complex kidney stone: A case report
Soefiannagoya Soedarman
a,b, Nur Rasyid
a,b, Ponco Birowo
a, Widi Atmoko
a,b,∗aDepartmentofUrology,CiptoMangunkusumoHospital,FacultyofMedicine,UniversitasIndonesia,Jakarta,Indonesia
bDepartmentofUrology,UniversitasIndonesiaHospital,Jakarta,Indonesia
a rt i c l e i nf o
Articlehistory:
Received26October2020
Receivedinrevisedform3November2020 Accepted16November2020
Availableonline26November2020
Keywords:
Endourology Stonesdisease Minimal-invasive Complexstones
a b s t ra c t
INTRODUCTION:Theoptimalpatientpositioningforpercutaneousnephrolithotomy(PCNL)basedonthe complexityofstoneburdenisnotyetdefinedintheliteratureThisreportelaboratedleftcomplexkidney stonescaseunderwentendoscopic-guidedPCNLwithapronesplit-legposition(ePSL).
PRESENTATIONOFCASE::Forty-threeyearsoldwomenwerereferredwithahistoryoffailedleftopen kidneysurgerybecauseoffrozenkidney.Arenalbiopsyexaminationconfirmedxanthogranulomatous tissue.StandardpronePCNLwasperformed.Thereweresomanydebrisinpelviocalycealsystem,so weusedultrasoundguidancetopunctureinsteadoffluoroscopy.Therewasresidualstoneinsuperior calyxthatnephroscopecouldn’treach.ePSLmethodwasusedinthesecondprocedure.Thestonewas fragmentedwithpneumaticlithotripter.EvaluationusingC-armandnephroscopeillustratednoresidual stones,infundibulumlaceration,andactivebleeding.
DISCUSSION:Thistechnique’smainobjectivesaretoremoveurinarytractstonesalongthewholetract withaone-stepandone-accessapproachwithoptimalutilizationoffullarrayendourologicequipment.
Thepronesplit-legpositionwaschosenformultiplereasonssuchasoperatorpreference,thefamiliarity ofaspecificposition,andinabilitytoperformdirectpunctureintheupperpole.Themainlimitationis nolong-termfollow-upforpatientstoseetheeffectivenessandsafetyofthistechnique.
CONCLUSION:Toconclude,ePSLwithapronesplit-legpositionisasafeprocedurewitharelativelylow rateofcomplicationsandcanbeusedforcomplexkidneystone.
©2020TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Theoptimalpatientpositioningforpercutaneousnephrolitho- tomy (PCNL) based on the complexity of stone burden is not yetdefinedintheliterature.Optimalguidingtechniquesalsonot explainedfullyintheliteratureforcomplexstone.StudybyBatag- ello etal.explainedthat endoscopic-guidedPCNL(ePSL) witha pronesplit-legpositionaresafe,withalowrateofcomplications.
[1] Endoscopic-guidedPCNL(ePSL) alsoproducedlow radiation exposureandrequireslessneedforbothmultipleaccessandsec- ondaryprocedureforcomplexstonemanagement.Thistechnique also minimizesthepossibility ofover-dilatation oftractdue to direct visualexaminationfromtheflexible URS.Moreover,kid- neytissuesinjurycausedbytoodeeppenetrationandbleedingcan alsobeavoidedinthisapproach[2].Althoughthisprocedureused manyequipmentandmayaffectthehighercost,wethinkthatthis procedureshouldbedoneincomplexkidneystone.Thisreport
∗ Correspondingauthorat:Jl.PangeranDiponegoroNo.71,Kec.Senen,Central Jakarta,DKIJakarta10430,Indonesia.
E-mailaddress:dr.widiatmoko@yahoo.com(W.Atmoko).
elaborated one case in our centre that underwent endoscopic- guidedPCNLwitha pronesplit-leg positiontoachieveoptimal stonefreerateintheleftcomplexkidneystones.
2. Casepresentation
Forty-threeyearsoldwomenwerereferredtoourhospitalwith ahistoryofleftopenkidneysurgeryoneyearbeforeadmission toanotherhospital(Fig.1).Intraoperativelyduringopensurgery, afrozenkidneywasfound,andthesurgerywasstopped.LeftDJ stentwasinserted,andthexanthogranulomatoustissueswascon- firmedwithabiopsyexamination.Inourhospital,thepatienthad achiefcomplaintofdull,intermittentpainintheleftflankarea withoutdysuria,hematuria,andhistoryofpassingstone.Thereis nohistoryofthesamediseasesinthefamilyandnocertainregular drugsintakeinthepatient.Thevitalsignsandgeneralexamina- tionwerewithinnormallimits.Foleycatheterswiththesizeof16Fr wereinstalledwithnormalurinaryoutput.Laboratoryexamination showedleukocytosis(11.66103/uL).
Furthermore,patientswereplannedtoundergostandardprone leftPCNLbytheendo-urologyconsultant.Retrogradepyelography (RPG)examinationillustratedcompletestaghornstoneontheleft
https://doi.org/10.1016/j.ijscr.2020.11.094
2210-2612/©2020TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Fig.1. TheCT-scanresultofthepatientbeforeopensurgicalprocedureintheleftkidney.
kidneywithalackofclarityinthedilatedcalyx.Theoperatorper- formedseveralfailedpunctures.Therefore,weassumedthatthere isanaccumulationofdebrisinsideallofthecalyx.Thesuccessful puncturewasachievedwiththeadditionofultrasoundguidance.
However,therewasaresidualstonewithasizeof30×20mm in uppercalyxthat couldnotreachwithnephroscopefromthe lowercalyxapproach.Uncontrolledintraoperativebleedingfrom thepatientalsostrengthenedthedecision tostopfurtherstone evacuationprocedures.
Endoscopic-guidedPCNLwithapronesplit-legpositionwith superiorcalyxpuncture(intercostalXI-XII)wasimplementedby theendo-urologisttwomonthsafterpreviousPCNLinthiscase.The purposeofusingthistechniqueistoobtainanoptimalstone-free rateincomplexkidneycircumstancesandalsotoachieveaccurate punctureanddilationduringtheprocedure.Intheinitialsteps,the flexibleURSsize9Frwithureteralaccesssheathwasinsertedinto theleftpelvicalycealsystem,andatargetedstonewasfound.After that,apunctureinthesuperiorrightcalyxwithbull’seyetech- niquewithflexibleURSwasdone.Despitetheexcessiveamountof debrisinsidethepelvicalycealsystem,thestonewasfragmented withpneumaticlithotripterandtheresidualstoneevacuatedwith stoneforceps.EvaluationusingC-armandnephroscopeillustrated
noresidualstones,infundibulumlaceration,andactivebleeding.
Aftertheinterventionpatientwasinstableconditionand there isnopersistedcomplaintthegenitourinarysystem.Therewasno majorcomplicationinthispatient.Incontrast,aminorcomplaint ofmildpain1–3daysaftersurgerywasinvestigatedandmanaged byoralanalgesics.Patientssaidthedull,intermittentpainfollow- ingtheintervention issignificantly improved. Followup inthe outpatientclinicwasperformedforseveralweeksaftertheePSL procedure(Fig.2).
3. Discussion
Inourreports,itwasconcludedthatePSLprovidedadequate andeffectivestoneremovalincomplexkidneystones.Accumu- lationofdebrisincreasedthechallengesinperformingstandard fluoroscopyPCNL.Afterundergoingthisprocedure,thereareno residualstones found postoperatively, and there is noremain- ingcomplaintduringregularfollowup.Endoscopic-guidedPCNL (ePSL)isoneofthenovelurologytechniquesthatcombinesamulti- stepsantero-retrogradeapproachtothepelvicalycealsystem.The mainobjectivesofthistechniquesaretoobtainremovalofurinary tractstonesalongthewholetractwithone-stepandone-access
CASE REPORT – OPEN ACCESS
S.Soedarmanetal. InternationalJournalofSurgeryCaseReports77(2020)668–672
Fig.2.(A)FluoroscopywithoutcontrastinthefirststandardpronePCNLindicatedcompletestaghornstoneintheleftkidney.(B)Retrogradepyelographycontrastshowed thecalyxrepresentationisnotclear,severalpunctureswereperformedbutfailed,operatorandteamassumedthereweresomanydebrisinsideallofthecalyx.(C)There wasresidualstonewiththesizeof30×20mminupperleftcalyxthattheoperatorcouldn’treachwithnephroscopefromlowercalyx,intraoperativebleedinginfluenced thedeceisiontostoptheoperation.(D)pre-operativeCT-scanbeforeePSLwithpronesplit-legpositionprocedure.
approachwithoptimalutilizationoffullarrayendourologicequip- ment.Also,thecombinationoftwotypesofendoscopesinthesame operationhasfunctionalcomplementarity.Forrenalpelvisstone, thecombinationofupperandlowerendoscopyincreasesthefield ofvisionoperationandincreasestheangleofoperation.Asaresult, abetterstone-freeratemightbeachieved.[3]
Thepronepositionwasusedinourcasebecause,theureteral tract anatomy tends to be straight with the pressure of grav- ity,whichprovidelessforcefortheureteroscopetogetintothe upperureterandpelvis.Underthemonitoroftheureteroscope, thedilation ofthepercutaneousnephroscopepuncture channel canavoidrenalinjury.Ingeneralcircumstances,theendoscopic guidedPCNLwasperformedinGaldakao-modifiedsupineValdivia position.[4]However,inourcase,thepronesplit-legpositionwas chosen formultiplereasonssuchastheprecariousdebrisaccu- mulation intherenal thatcomplicatesthecalyxpuncturewith standardfluoroscopyguidance.Theotherreasonistheincapability toperformdirectpunctureintheupperpoleduetomultiplepunc- turedneeded(Lezrektechnique),whichincreasedthepossibility ofrenalanatomydisruptionandbloodloss.Operatorpreference
andfamiliaritywithaparticularpositionalsomightinfluencethe positionapproach. Craccoet al.inhisstudyalsoexplainedsev- eralreason and/oradvantages ofprone-split legposition. First, thespaceprovidesforthepercutaneousnephroscopyiswiderand moreextensive,andtheprobabilityofvisceralinjuryissmaller comparetoGaldakao-modifiedsupineValdiviaposition.Second, theabsenceofobesityandcardiovascularproblemsinpatientchar- acteristics(whicharealsoapplicableinourcase).Third,preventing thecompressiontolowerlimbbloodvesselsduetoprolonglimbs elevation[3].Furthermore,thebull’seyetechniquewereessentials duetoitsabilitytotargetthetipoff-URSdirectly.Unlikethesupine position,theprone-legsplitpositionaccommodatedthebull’seye punctureapproach.Therefore,ePSLismorefavorablecompareto ECIRSinthiscase(Fig.3).
WenJetal.inhisstudycomparedtheefficacyandcomplica- tionbetweenminimalinvasivePCNLwithEndoscopicCombined Intra-RenalSurgery(ECIRS)inpartialstaghorncalculi.Itwasfound thatthereisnostatisticaldifferenceintermstheclinicalcomplica- tions(spleeninjury,fever,urinaryleakage,urosepsis,haemorrhage, transfusion, nephrectomy, and embolisation) between the two
Fig.3.(A)Prone-splitlegpositionforePSL.(B)C-armduringthebull’seyetechniqueshowedthetipofpunctureneedle.(C)Bullseyetechniqueforthepuncture.
groups.[5]Thattheoryalsoexaminedinthiscase,thereismini- malbleeding,andthepatientwasmaintainedinstablecondition postoperatively.
Inourstudy,thereisnolong-termfollow-upforpatientstosee theeffectivenessandsafetyofthistechnique.Thisprocedurein ourcentrestillconsideredasascarcetechniquesinceitusedmany endourologyequipments.Thereisnotmuchevidenceorinforma- tion that canbecollected frommultiplepatients. Therefore, to establishePSL’sadequacywithapronesplit-legposition,amulti- centerstudyisrecommendedtoobtainamoreextensivedatabase providingmorestatisticallyrelevantdatatoconcludetheefficacy ofthisparticularapproach.
4. Conclusion
Endoscopic-guidedPCNL(ePSL)withapronesplit-legposition isasafeprocedurewithrelativelylowrateofcomplications.Itis alsoprovidedurinarytractstonesremovalwithoptimalutilization offullarrayendourologyequipment.
Scarecriteria
Weconfirmedthatourworkhasbeenreportedinlinewiththe SCARE2018criteria[6].
Conflictsofinterest
Theauthorsdeclarenoconflictofinterest.
Funding
Private funds form the Department of Urology Ciptoman- gunkusumohospital,FacultyMedicineUniversityIndonesia.There arenostudysponsors.
Ethicalapproval
Theauthorsdeclarethatweobtainedpermissionfromethics committeeinourinstitution.
Consent
Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest
CASE REPORT – OPEN ACCESS
S.Soedarmanetal. InternationalJournalofSurgeryCaseReports77(2020)668–672
Authorcontribution
•Soefiannagoya Soedarman MD., MRes. : Conceptualization, Methodology,Writing-OriginalDraft,Writing-Review&Edit- ing,Visualization,Formalanalysis,Investigation
•NurRasyidMD.,PhD.:Datacuration,Writing-Review&Edit- ing, Project administration, Conceptualization, Methodology, Resources,Fundingacquisition,Supervision
•PoncoBirowoMD.,PhD.:Datacuration,Writing-Review&Edit- ing,Methodology,Resources,Supervision
•WidiAtmokoMD.:Datacuration,Writing-Review&Editing, Methodology,Resources,Supervision
Registrationofresearchstudies
Ourstudydesigniscasereport,thereforewedidnotsubmitour reportintoanyregistry
Guarantor
SoefiannagoyaSoedarmanMD.,MRes.
WidiAtmokoMD.
Provenanceandpeerreview
Notcommissioned,externallypeer-reviewed
Akcnowledgement
ThecontributorswouldliketothankCiptoMangunkusumoHos- pitalteamforsupportingthisreport
References
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[5]J.Wen,G.Xu,C.Du,WangB.MInimallyinvasivepercutaneous nephrolithotomyversusendoscopiccombinedintrarenalsurgerywitha flexibleureteroscopeforpartialstaghorncalculi:arandomisedcontrolledtrial, Int.J.Surg.28(2011)22–27.
[6]R.A.Agha,M.R.Borrelli,R.Farwana,K.Koshy,A.Fowler,D.P.Orgill,Forthe SCAREGroup,TheSCARE,Statement:updatingconsensussurgicalCAseREport (SCARE)guidelines,Int.J.Surg.2018(60)(2018)132–136.
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