Controversial case in endourology. Retainedforeignbodyafter PCNL: case report

Abstract

Introduction

The treatment of nephrolithiasis has undergone significant advantages with development endoscopic technology. The goal of all surgical stone procedures is to maximize stone removal while minimizing morbidity to the patient. So the urologists have a big armamentarium that it permitted them to work in a optimal condition.

PNL is generally a safe treatment option and associate with a low but specific complication rate(1,2), but potentially serious complications may occur, including hemorrhage, septicemia, collecting system injuries, injury to adjacent structures and adjacent organs. Retained foreign bodies can occur during any stage of the procedure. When forgotten or lost in vivo during an operation, recognition of the retained material and its subsequent retrieval present a dilemma for both patient and practitioner(3,4). When pieces of instruments, used in percutaneous procedure can break off in the parenchyma kidney, it’s very difficult to retrieve the lost material. Many groups have described their experience with the extraction of retained foreign bodies in the collecting system, because they think that patients with retained renal foreign bodies benefit from extraction by way of the retrograde and/or antegrade endoscopic techniques(5).

Case report

A 15 year-old female patient with a past medical history of nephrolithiasis. She had stones in the upper calix, lower calix and in the pelvis of the left kidney, obstructive. We performed PCNL.

The patient underwent the following diagnostic work-up:

  • KUB and ultrasound to definition of stone size
  • CT-scan to define anatomy of the collecting system
  • Urine analysis and culture, presenting Klebsiella spp.
  • Serum creatinine, clotting parameters
  • Isotope renogram

The procedure was performed in general anaesthesia. Prior to the procedure, a retrograde study was performed and a ureteral catheter placed at the ureteropelvic junction. The collecting system was moderately filled with contrast dye.

PNL was carried out with the patient placed in the prone position. For the puncture of the collecting system, we used a combination of ultrasound (fully guided system) and fluoroscopy. Based on imaging, we perfomed the puncture in the upper calix. The placement of the needle was mostly performed under fluoroscopic control. Afterwards, a 0,031 floppy tipped guidewire was passed through the needle into the collecting system, but we withdrew the guidewire from needle, because we were not satisfied ourselves of this puncture. During this maneuver the guidewire was broken into the parenchyma. So we made a new puncture in the upper calix and we established to create the working channel using the Alken telescope metal dilators system under X-ray control to 24 F. Then we placed 26 F nephrscope into the kidney over the created tract. We preferred using the ultrasound lithotripsy probe and pneumatic lithotripsy devices. At the end of the procedure, a 20 Foley catheter we used as a nephrostomy tube and we inserted a 6 F stent JJ.

The postoperative care were uneventful. An antegradenephrogram was taken 42 h after the procedure to remove the tube. The postoperative stay was 4 days. The patient was discharged home completely stone-free, but with the piece of the guidewire. We removed the stent after 15 days.

At the clinical follow-up, after 6 months, the patient was stone-free and without urinary infection.

Discussion:

Any instrument employed in endourology surgery could break and remain in the collecting system. This can occur during any stage of the procedure. Foreign bodies can present as a nidus for infection or stone formation or mimic a renal neoplasm(7,8,9,10,11). In our cases,we had experience with a patient with retained stent in the collecting system, which then we treated with nephrectomy for abscess and 10 cases of retained stents removed with ureterorenoscopy and or fluoroscopically-guided retrograde traction and one case of the guidewire broken in the collecting system, which we removed it during reno-ureteroscopy.

Conclusion:

Although extremely rare, fracture of the guidewire canoccure during endoscopic procedures. When pieces of instruments, used in percutaneous procedure, can break off in the parenchyma kidney, it’s very difficult to retrieve the lost material. The management of this case is very hard. The retained foreign bodies are a dilemma for patient and practitioner,because could present as a nidus for infection or stone formation or mimic a renal neoplasm. It’s necessary make a close follow-up when the bodies remain in the urinary tract.

References:

  1. Michel M., Trojan L, RassweilerJ. Complications in percutaneousNephrolithotomy. EuropeanUrology 51 (2007) 899–906.
  2. Rudnick DM, Stoller ML. Complications of percutaneousnephrostolithotomy. Can J Urol 1999;6:872–5.
  3. Ahn J, Trost DW, Topham SL, et al. Retained nephrostomy threadproviding a nidus for atypical renal calcification. Br J Radiol. 1997;70:309-310.
  4. McBroom S, Schenkman NS, Stoller ML. Retained laser fiberureteral calculus. Urology. 2001;58:277-27.
  5. Eisenberg M, Lee K.L, Stoller L.: Endoscopic management of retained renal foreign bodies. UROLOGY 73: 1189–1194, 2009. 2009 Elsevier Inc.
  6. Ahn J, Trost DW, Topham SL, et al. Retained nephrostomy threadproviding a nidus for atypical renal calcification. Br J Radiol. 1997;70:309-310.
  7. Johnson JE, Conlin M. Calculus formation on a retained Acucisewire. Urology. 2001;57:168.
  8. Singh V, Srinivastava A, Kapoor R, et al. Can the complicatedforgotten indwelling ureteric stents be lethal? IntUrolNephrol.2005;37:541-546.

10.Dogra PN, Tandon S, Ansari MS, et al. Suture foreign bodygranuloma masquerading as renal neoplasm. IntUrolNephrol. 2005; 37:27-29.

11.Borboroglu PG, Kane CJ. Current management of severely encrustedureteral stents with a large associated stone burden. J Urol.2000;164:648-650