Presented by: Amy NAGLE MBBS
Royal London Hospital

Introduction

Percutaneous nephrolithotomy (PCNL) is an accepted and widely used approach to extract large renal calculi. Treatment for symptomatic calculi in the transplanted kidney can be problematic. Percutaneous nephrolithotomy has routinely been used but concerns exist about potential injury to adjacent organs using a percutaneous access technique. We describe a successful case of mini percutaneous nephrolithotomy in a paediatric enbloc transplant kidney.

Materials

We describe the case of a percutaneous nephrolithotomy  (PCNL) in a transplant kidney. Our patient was a 42-year-old female who received a cadaveric kidney transplant in March 2019 on a background of Ig A nephropathy and ESRF.  

In September 2019 she attended the accident and emergency department complaining of lower urinary tract symptoms, haematuria and right flank pain with fevers. She consequently had computed tomography scan of the kidneys, ureter and bladder (CT KUB) which confirmed evidence of renal calculi in the pelvis and lower pole of the left, medial transplant kidney. The calculus in the pelvis measures approximately 12 mm. The calculus in the lower pole measures approximately 5 mm. There was no hydronephrosis.

Results

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Transplant PCNL was performed and full stone clearance achieved endoscopically and radiologically. The estimated blood loss 150ml.

Urolithiasis is an uncommon, but potentially catastrophic complication of renal transplantation. The risk of ureteral obstruction and subsequent graft compromise contribute to the urgent manner in which management is required. Additionally, patients are chronically immunosuppressed following transplantation predisposing them to sepsis should infection complicate the stone.

The extra-anatomical location of a renal allograft becomes an important consideration when planning stone extraction.  Extracorporeal shock wave lithotripsy can be used; however, targeting the shock wave directly onto the stone can be difficult due to the proximity of the bony pelvis, and there is risk of bleeding and haematoma. Ureteroscopic approaches are also possible, but can be challenging as the neo-ureteric orifice is often superior in the bladder and difficult to access.

Conclusion

Percutaneous nephrolithotomy is safe and effective in the transplanted kidney. Minimal postoperative complications were noted and stone-free status was achieved in this patient. 4 years post-surgery, she remains stone free with no stone recurrences and with stable graft function after the procedure.

Funding

Nil

Lead Authors

Mohammed Zain Adhoni, MBBS
Royal London Hospital

Zubeir Ali, MBBS, FRCS
Royal London Hospital