Document Type : Case Report
1 Ebnesina Hospital, Iran University of Medical Sciences, Tehran, Iran
2 School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
The Calyceal diverticulum is a nonsecretory urothelium-lined outpouching that communicates with the pyelocalyceal system with a narrow infundibular neck and represents less than 0.5 % of the general population (1). The incidence of calculi in calyceal diverticula is between 10 to 50 Most patients are asymptomatic despite stone formation. The available therapeutic modalities are shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and laparoscopy (2). Recent studies have introduced retrograde intrarenal surgeries (RIRS) as a new treatment (3, 4). We present a case of lower pole stone in a calyceal diverticulum that was refractory to SWL and underwent flexible ureterorenoscopy (f-URS) with holmium laser lithotripsy.
A 48-year-old female with a previous history of renal stones presented to our clinic with vague left flank pain. The laboratory findings were in the normal range. The spiral computed scan (CT) revealed a 14mm left lower pole renal stone and calyceal diverticulum. She had a history of SWL failure and a history of right nephrectomy in childhood due to a non-functional kidney. We recommended the PCNL and RIRS to the patient, but the patient chose to undergo RIRS due to the potential risk of bleeding during the PCNL procedure in a single kidney.
The patient underwent spinal anesthesia and then was placed in the lithotomy position. 9.8 Fr semirigid ureteroscope was used for the initial assessment of the left ureter. An 11/13 Fr, ureteral access sheath was inserted in the ureter. An 8.7 Fr flexible ureteroscope with 270-degree tip deflection was applied for the patient. After detecting the diverticulum location in the lower pole, we used the holmium laser and 200 µm fiber laser for incising the diverticular neck. The stone lithotripsy was performed with the combined fragmentation and dusting technique to pulverize the stone fragments less than 2 mm. The double-j stent was inserted at the end of the surgery. The operative time was 65 minutes. The patient was discharged postoperative day two without any complications. In the follow-up, the patient was asymptomatic, and imaging at three months revealed stone-free status.
Conclusion: Flexible ureteroscopy with holmium laser lithotripsy is a viable option for managing stones in calyceal diverticula, especially in single kidney and high-risk patients for bleeding during PCNL.
All authors contributed equally.
Special thanks to the Urology Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
Conflict of interests
All authors declare that there is no conflict of interest.
Informed consent was signed by the patient. This case report is presented based on CARE guidelines.
Data will be provided by the corresponding author upon request.
CT Computed scan
F-URS Flexible ureterorenoscopy
RIRS Retrograde intrarenal surgeries
SWL Shock wave lithotripsy