RESUMO
Percutaneous nephrolithotomy [PCNL] for large calculi within malpositioned and malformed kidneys is a challenging problem for urologist because of the abnormal anatomy. The aim of this study was to evaluate and to review our experience with PCNL in malpositioned and malformed kidneys with large calculi. Between January 2000 and December 2009, we performed PCNL in 36 patients with large calculi in malpositioned and malformed kidneys, including 16 patients with horseshoe kidneys, 11 patients with rotational anomalous, three patients with transplanted kidney and six patients with ectopic pelvic kidneys. After appropriate preoperative evaluation, the procedure was performed by choosing anterior, posterior or laparoscopic assisted approaches under fluoroscopic and ultrasound guidance. PCNL access was made in the upper pole of the kidney in 21 [58.3%] patients, in the midpole in 14 [38.9%] patients, and in the lower pole in one patient [2.8%]. The mean age of the patients was 37.5 years [range 21-57] with male: female ratio 2.7: 1, the mean stone size was 2.9 cm [range 2.1-4.9]. Complete stone removal was achieved in 26 [72.2%] patients. A second-look procedure for residual stone removal was required in nine patients [25%], five of them via the same tract and three patients required another access, four of them became stone free, four patients required adjuvant ESWL sessions for the residual stones, and one patient converted to open surgery due to difficulty in creating an access. The mean operating time for PCNL was 95 minutes [range 45-120], and the mean hospital stay was 3.7 days [range 3-8 days]. Blood transfusion was required for three [8.3%] patients, transient postoperative pyrexia encountered in six [16.7%] patients and one patient had persistent urine leak [2.8%]. Serious complications were encountered, small bowel perforation was occurred in two [5.6%] patients, and both were treated by laparatomy with primary repair of injury with uneventful outcome. Patients with malposition and malformed kidneys and large calculi can be managed safely and effectively with PCNL when they are properly selected and appropriately assessed before operation. Stone management in malformed and malposition kidneys is challenging, and establishing percutaneous renal access is the most crucial step in the procedure