11/22/2023 0 Comments Staghorn calculus memeWe felt performing RIRS in a kidney situated in thoracic cavity with anatomical variations will be safer and easier than performing PCNL. So, surgical correction of diaphragmatic eventration was not performed for this patient. This condition warrants treatment in symptomatic cases, but our patient had no respiratory or gastrointestinal complaints. But due to thinned out and weakened diaphragmatic musculature, the intraabdominal contents are not restrained in the abdominal cavity but displaced upwards into the thoracic cavity. In diaphragmatic eventration, there is no true defect. Ours was a case of TK associated with diaphragmatic eventration on the right side. TK can be classified into four categories depending on the cause: True ectopia (normal diaphragm), diaphragmatic hernia, diaphragmatic eventration and traumatic diaphragm injuries. He is stone free and he does not have any stone/surgery related symptoms. The patient is under follow-up for 3 years. Additionally, as stone clearance in right TK had already been confirmed by endoscopic visual assessment during second-stage surgery of RIRS, no additional imaging other than ultrasound was performed. The ureteral stent that was placed on the left renal unit was removed after 4 weeks by office flexible cystoscopy under local anesthesia.Īn ultrasound of the abdomen and pelvis performed at 6 weeks after left ureteral stent removal (10 weeks after second-stage surgery of RIRS) did not show any residual calculi in either of the kidneys. Ureteral stent was replaced in the left side. Afterward, we proceeded with RIRS and laser dusting of the partial staghorn calculus in the left renal unit. Ureteral stent was not replaced on right side. Initially, diagnostic RIRS was performed on thoracic right renal unit and complete stone clearance was confirmed. The second stage of RIRS was performed 4 weeks after the initial surgery. The histopathology examination of right orchiectomy specimen showed no evidence of testicular malignancy. After completion of right RIRS, we proceeded with laparoscopic removal of the right intraabdominal atrophic testis. The surgical technique and principles of RIRS have been explained in detail in the literature. After complete dusting, a ureteral stent was placed on the right TK as well (Fig. The operative time of RIRS in right TK (from the initiation of sequential ureteral dilatation to placement of ureteral stent) was 120 min. We routinely prefer stone dusting rather than fragmentation, and the partial staghorn calculus was dusted with a laser setting of 0.2–0.4 J energy and 30-40 Hz frequency. A 100W high-power holmium/YAG system (Lumenis, Israel) and a reusable 200-μm laser fiber were used. RIRS was then performed with flexible ureterorenoscope-Flex-X 2s (Karl Storz, Germany) and holmium laser lithotripsy. Afterward, in the thoracic right renal unit, the patient underwent sequential ureteral dilatation and ureteral access sheath placement. During the first stage, on the normally positioned left renal unit a ureteral stent was placed initially. The patient underwent staged bilateral RIRS under general anesthesia. The left kidney was positioned normally in the renal fossa. Elongated right ureter of TK showed unobstructed drainage in excretory phase of the CT urogram. The TK was malrotated, with the renal hilum facing anteromedially (Fig. Mild caliectasis of the upper pole calyces with normal sized pelvis in the right TK was noted (Fig. A well-defined soft tissue density structure measuring 23 × 18 mm was noted lateral to and abutting right psoas muscle at L4 level (suggestive of intraabdominal testis in the given case scenario) (Fig. The right kidney was displaced superiorly with simultaneous upward displacement of right lobe of liver and colon (Fig. CT also showed smooth elevation of diaphragm on right side and was suggestive of diaphragmatic eventration. 1a and b), and left partial staghorn calculus was measuring 24 × 18 mm (Hounsfield unit 1135) (Fig. Right partial staghorn calculus was measuring 36 × 20 mm (Hounsfield unit 1340) (Fig. The right testis was not palpable in the scrotum, whereas his left testis was palpable in the scrotum and was normal in volume.ĬT (Computed tomography) abdomen showed bilateral partial staghorn calculi. There was no history of any surgery or significant trauma in the past. There was no history of respiratory tract infections in the past. There were no complaints of vomiting, difficulty in breathing or chest pain. A 23-year-old male presented with the complaints of back pain of three months of duration.
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