Donor-Gifted Allograft Staghorn Calculus Managed via Percutaneous Nephrolithotomy

Abstract

Donor-gifted lithiasis presents in <1%. Presentation is asymptomatic given allograft denervation, but it can be associated with infections, hydronephrosis, or creatinine (Cr) elevations. Ultrasonography (US) offers the possibility to detect calculi that can be managed during transplantation. However, its use has remained controversial due to the infrequent occurrence of these events, making the benefits of imaging cadaveric kidneys unclear. Historically, the management can be achieved through medical expulsion therapy or any percutaneous procedures. For those stones <1.5 cm, extracorporeal shock wave lithotripsy is commonly used. Retrograde ureteroscopy is challenging since access to the reimplanted ureter is at the dome. For large stones, percutaneous nephrolithotomy (PCNL) is preferred to achieve high stone-free rates. In the past, open or percutaneous procedures were avoided due to high morbidity along with risks of immunosuppression, like poor wound healing.1 However, multiple series have demonstrated favorable long-term outcomes in patients undergoing PCNL.2,3 Late diagnosis can lead to graft rejection. The downfall of long-term observation in a denervated kidney is the potential for obstruction, silent hydronephrosis, and pyelonephritis/sepsis in an immunocompromised patient. There are concerns regarding PCNL's safety in immunosuppressed, as the surgery itself results in a grade 4 renal laceration, albeit controlled and targeted. Heterotopic allograft positioning in the iliac fossa creates challenges in obtaining a direct calyceal puncture, increasing risk for vascular injuries. Additionally, immunosuppressives generate an inflammatory capsule surrounding the allograft, which may limit pyelocaliceal dilation and nephroscope manipulation.4,5 This is a rare presentation of a 53-year-old with a donor-gifted allograft staghorn calculus managed with PCNL. History included polycystic kidney that resulted in renal failure, hemodialysis was for 6 years prior to transplant. Postoperatively, a staghorn and multiple calyceal stones were diagnosed. Computed tomography was essential during planning to avoid inadvertent bowel injury while obtaining abdominal access. Interventional radiology placed two guidewires into the midpole through a 6F × 25 cm Terumo sheath. Intraoperatively, a 0.038″ hydrophilic guidewire was advanced to obtain through and through access given the short skin-to-stone distance and the risk of losing access. A dual lumen was placed over a guidewire following the markers to estimate the skin-to-stone distance and achieve optimal tract dilation. The 30F × 35 cm access sheath was placed, and the 25F nephroscope with a lithotripter was used to fragment stones. The flexible nephroscope with extraction devices were used to achieve a stone-free outcome. One consideration during this procedure is the short skin-to-stone distance in the abdomen compared to the traditional distance when working in the retroperitoneum. It is important to maintain placement of the sheath with the surgeon's nondominant hand to avoid dislodgement. Ultimately, a 6F × 22 cm stent was deployed (due to short ureteral distance). A 22F nephrostomy tube (NPT) was then placed. A 5F re-entry catheter was also inserted with the purpose of facilitating collecting system access for sequential NPT downsizing from a 22F to 10.2F Dawson–Mueller to improve healing. Ultimately, a 3-0 chromic was left untied at the NPT site to improve wound closure by tying it at the time of NPT removal to decrease leakage and enhance comfort. A 16F Foley catheter was also left in place for maximal drainage. Patient was discharged on day 3 voiding freely with NPT clamped (Cr 1.6/glomerular filtration rate [GFR] 34). The stent was removed 3 weeks postoperation. At week 5, the NPT was discontinued with satisfactory urinary output (Cr 1.5/GFR 36). The PCNL is an effective endourological technique for donor-gifted staghorn calculus, the patient was stone-free with no postoperative complications. Music: The music used in the video is royalty-free from freemusicarchive.org. The title is “Endless story about sun and moon” by Kai Engel. Patient consent: Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. No competing financial interests exist. No funding was received for this article. Runtime of video: 4 mins 46 secs