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Common Urological Problems

Urinary Stone Disease - Special Situations

  • - General Urology - Common Urological Problems - Urinary Stone Disease
  • Jul 25, 2010
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Tags: | abdominal pain | asymptomatic hematuria | calcium | calcium nephrolithiasis |

I. CALICEAL DIVERTICULA
Pyelocaliceal diverticula are cystic urine-containing eventrations of the upper tract lying within the renal parenchyma; they communicate through a narrow channel into the main collecting system (Figure 16–12). These diverticula occur in approximately 0.2–0.5%  of the population and are congenital in origin; up to 40% are associated with calculi. Type I diverticula are the most common and are closely related to minor calyces. Type II have a direct communication with the renal pelvis and tend to be larger and symptomatic. 

image Figure 16–12.  Intravenous pyelogram demonstrating symptomatic right caliceal diverticula with numerous small calculi.

Caliceal diverticuli are usually asymptomatic, but patients may complain of flank pain or recurrent urinary tract infections.  Frequently many small calculi, rather than a solitary stone, are found in these obstructed cavities. When intervention was required in the past, treatment was with nephrectomy, heminephrectomy, or open surgical unroofing.  Less invasive means are used today.

Communications with the collecting system are commonly pinpoint and may be difficult to locate through a retrograde approach. Retrograde access into superior pole diverticula has been successful.  Surprisingly,  treatment may be successful with ESWL if stone fragments are small enough to pass uneventfully. More commonly, percutaneous access and, more recently, laparoscopic means are used with success. Dilation of the caliceal neck, direct cauterization or sclerosis of the caliceal epithelium, or direct cauterization and sclerosis of the caliceal epithelium can help reduce stone recurrence rates.

Urinary Stone Disease

Urinary Stone Disease

J. RENAL MALFORMATIONS
Anatomic renal variants such as ectopic kidneys, including the horseshoe kidney,  predispose to renal calculi due to impaired urinary drainage. Pain symptoms appear to be no different from those reported in patients with normally positioned kidneys.  Radiographic diagnosis may be difficult due to the unexpected location of the ureters and kidneys (Figure 16–13). If calculi can be targeted with ESWL, most stone fragments pass surprisingly uneventfully.


image Figure 16–13.  Scout abdominal radiograph demonstrating horseshoe kidney with lateral ureteral deviation and double-J ureteral stent. Extraosseous calcifications are left lower calyceal stones.

Large stone burdens should be approached percutaneously as in normally positioned kidneys.  Severe outlet obstruction should be corrected with open surgery, and concurrent calculi can be removed at the same setting. Aberrant vasculature should be appreciated before percutaneous and open procedures are undertaken.


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Marshall L. Stoller, MD

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REFERENCES

  1. Ackermann D et al: Influence of calcium content in mineral water on chemistry and crystallization conditions in urine of calcium stone formers. Eur Urol 1988;14:305.
  2. Allie-Hamdulay S et al: Prophylactic and therapeutic properties of a sodium citrate preparation in the management of calcium oxalate urolithiasis:  Randomized,  placebo-controlled trial.  Urol Res 2005;33:116.
  3. Bilezikian JP et al:  Primary hyperparathyroidism:  New concepts in clinical,  densitometric and biochemical features.  J Intern Med 2005;257:6.
  4. Fellstrom B et al: Dietary habits in renal stone patients compared with healthy subjects. Br J Urol 1989;63:575.
  5. Gentle DL et al: Geriatric nephrolithiasis. J Urol 1997;158:2221.
  6. Heller HJ et al: Effect of dietary calcium on stone forming propensity. J Urol 2003;169:470.
  7. Langley SE, Fry CH: The influence of pH on urinary ionized [Ca2+]:

Full References  »

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