Abstract
Background: Nonabsorbable sutures used during renal surgery represent a known substratum for stone growth. We hereby describe two cases of nephrolithiasis secondary to permanent suture material, originally placed during conservative renal surgical procedures and afterward migrated into the caliceal system, managed with endoscopic combined intrarenal surgery (ECIRS) with subsequent complete renal clearance.
Case Presentation: Case 1. A 54-year-old male, with history of laparoscopic excision of a left parapelvic cyst, presenting with left inferior caliceal stone. Case 2. A 79-year-old female, who underwent open enucleation of a left renal pelvis tumor 15 years before. She presented with bilateral lithiasis, including a staghorn stone in the left renal pelvis. Both patients underwent left ECIRS by two surgeons, revealing the presence of suture devices, which were completely removed. Abdominal CT at 1 month after surgery did not show residual lithiasic fragments in both cases.
Conclusion: To prevent the risk of stone formation, it is mandatory to use nonabsorbable suture agents sparingly during conservative renal surgery and furthermore to remove all foreign material from the collecting system because they have the potential for calculi growth. In this sense, ECIRS technique may also avoid further open or minimally invasive surgery and the use of suture instruments.
Keywords: kidney stone, sutures, surgical clip, percutaneous ultrasonic lithotripsy, laser lithotripsy, ureteroscopy
Introduction and Background
Nonabsorbable suture material is commonly used for hemostasis and suture stabilization during open or minimally invasive renal surgical procedures. Some of such devices are permanent sutures and Hem-o-Lok clips (Weck; Teleflex Medical, Research Triangle Park, NC), used for vascular pedicle control or during reconstructive phases (e.g., partial nephrectomy, pyeloplasty, and radical prostatectomy). Although rare, the potential and spontaneous postoperative migration of these surgical materials in the caliceal system, ureter, bladder, and urethra is described in the literature.1,2 Moreover, it is reported that these permanent agents can lead to secondary nephrolithiasis,3 because they act as a foreign substratum that facilitates nucleation and aggregation of stone constituent crystals.
We hereby report two cases of nephrolithiasis secondary to prior laparoscopic and open renal surgeries. Both patients underwent endoscopic combined intrarenal surgery (ECIRS) with total removal of stones and sutures.
Presentation of Case
Clinical history
Case 1
The case is a 54-year-old Caucasian man, with left solitary functioning kidney, who underwent laparoscopic excision of a left parapelvic cyst in 2014. He presented to our hospital for left nephrolithiasis for which he underwent retrograde intrarenal surgery in May 2018 for a 3 cm pelvic stone, stopped because of intraoperative evidence of Hem-o-Lok clip into the pelvis. During the hospital stay, he had contrast-enhanced CT of the kidney, ureter, and bladder (KUB), showing the presence of multiple millimetric radiopaque stones in the upper and middle left renal calices and a staghorn stone in the lower calix (890 HU) (Fig. 1). Preoperative serum creatinine (SCr) was 1.12 mg/dL. He had no fever, but urine culture was positive for Staphylococcus aureus MRSA (>100,000 CFU/mL) for which he underwent antibiotic therapy with teicoplanin according to infectious disease evaluation. Urinary pH was 6.5.
FIG. 1.
Preoperative CT scan (coronal reconstruction) of case 1 showing multiple radiopaque stones in the upper and middle calices of the left kidney and a staghorn stone in the lower calix (arrow).
Case 2
This is case of a 79-year-old Caucasian woman, stone former. She underwent open enucleation of left renal pelvis tumor at a different hospital in 2004 (histopathologic examination: urothelial papillary carcinoma G1), and left extracorporeal shock wave lithotripsy during the following years, without total clearance. She referred to our unit because of left flank pain, nausea, and vomiting. Before hospitalization, she had ultrasonography (US), KUB radiograph, and contrast-enhanced CT scan of the KUB, which revealed bilateral radiopaque stones, including a staghorn stone (1540 HU) in the left renal pelvis with accompanying hydronephrosis (Fig. 2). Her dynamic renal scintigraphy showed left side 22% function and bilateral obstructive clearance. Preoperative SCr was 1.15 mg/dL. She did not present fever, leukocytosis, or positive urine culture. Urinary pH was 6.
FIG. 2.
Preoperative CT scan (axial reconstruction) of case 2 showing (A) a staghorn stone of the left renal pelvis (arrow) and (B) bilateral stones (dotted arrows).
Intervention
Both patients underwent left ECIRS, performed by two surgeons who worked simultaneously by using a rigid (12F–8F) and flexible (7.5F) ureterorenoscope retrogradely, and a rigid (24F) and flexible (16F) nephroscope through a subcostal percutaneous access through left inferior caliceal puncture. The single percutaneous access was carried out on the posterior axillary line, integrating US and two-dimensional fluoroscopy imaging, under endoscopic vision. This allowed us to better reach the access to the collecting system along the calix axis. A ureteral sheath was also employed (9.5F/11.5F). The Galdakao-modified supine Valdivia position was used to allow the synchronous acting in the pelvicaliceal system. Holmium-YAG laser energy (MOSES™ Technology; Lumenis® Ltd., Yokneam Industrial Park, Israel;365 μm fiber; laser settings of 0.3 J, 40 Hz) and combination pneumatic and ultrasonic lithotripsy were used to disintegrate the stones, revealing the presence of large-sized Hem-o-Lok clips and suture in cases 1 and 2, respectively. Endoscopic forceps and Nitinol baskets were used for the extraction of stone fragments. In case 1, one Hem-o-Lok clip was removed using forceps. Another clip was found strongly adherent to the middle calix mucosa. This was carefully removed by anchoring site resection and coagulation using a monopolar resectoscope (22F). In case 2, sudden bleeding occurred because of tension in the suture line, but finally, the foreign suture was transected using endoscopic scissors and retrieved with endoscopic forceps. Figure 3A and B shows removed stone fragments and suture material. At the end of procedures, complete clearance was documented fluoroscopically and endoscopically with nephroscopy. All exogenous suture devices were extracted from the collecting system. A silicone 7F Double-J ureteral stent, a 12F nephrostomy tube, and a 16F urethral catheter were routinely placed in both cases to provide efficient drainage.
FIG. 3.
(A) Case 1: Fragments of stone and Hem-o-Lok clips. (B) Case 2: Fragments of stone attached to the suture.
Results
Case 1
The operative time (OT) and the estimated blood loss (EBL) were 180 minutes and 100 mL, respectively. Postoperative day 1 SCr and hemoglobin (Hb) were 1.26 mg/dL and 14.5 g/dL, respectively. Catheter was removed on postoperative day 4, nephrostomy tube and ureteral stent on day 18 and at 3 months after surgery, respectively, because of his solitary functioning kidney. Postoperative urine culture resulted positive for Pseudomonas aeruginosa, for which the patient underwent specific antibiotic therapy. Length of hospital stay was 11 days.
Case 2
OT was 210 minutes, EBL was 500 mL. Postoperative day 1 SCr and Hb were 1.6 mg/dL and 8.8 g/dL, respectively. Postoperative day 7 SCr was 0.98 mg/dL. Nephrostomy tube, catheter, and ureteral stent were removed on postoperative days 7, 9, and 14, respectively. Postoperative urine culture was negative. The hospital stay was complicated by the occurrence of a sudden idiopathic heart attack. Finally, the patient was discharged on postoperative day 16, tubeless.
As already mentioned, both patients presented postoperative complications according to the Clavien–Dindo classification (grade II and IVa for cases 1 and 2, respectively). In both cases, stones composition was of calcium oxalate.
Outcomes
The planned noncontrast CT performed at 1 month after surgery was negative for residual left stone fragments in both cases. SCr at 1 month was 1.05 mg/dL for case 1 and 1.12 mg/dL for case 2.
Discussion
Suture urolithiasis in the upper urinary tract has been described. More recently, with the diffusion of minimally invasive surgery in urology, use of hemostatic alternatives to suture ligation, such as Hem-o-Lok clips, has spread. Consequently, although described as safe if appropriately applied, they can cause secondary urolithiasis,1 and misdiagnosed as a stone. The way this postoperative event occurs is speculative. A valid explanation is that the persistent tension in the suture line may promote the migration into the renal pelvis and calices. Another reason could be related to the likely erosion of the suture material in the collecting system.3 In this case, it may act as a nidus for stone formation, because of the prolonged contact with the urine, and obstruct the urinary flow. Therefore, the surgeon must be aware of the possibility of these complications and should pay attention when using suture agents to limit the pressure on the violated site, preventing in this way erosion in the pelvicaliceal system. For this, an accurate follow-up should be programmed, and if stone formation occurs, all foreign bodies should be removed from the urinary tract to prevent the risk of recurrent disease.
Several cases reporting urinary stones secondary to urologic surgery and treated endoscopically are described in the literature, but few reports exist on a combined technique. McAdams and colleagues reported double access to the renal collecting system, carried out with the patient placed in the split-leg prone position.4 We hereby described two complex cases managed with ECIRS. The Galdakao-modified supine Valdivia position was used to perform percutaneous lithotripsy and retrograde ureteroscopy simultaneously. The combined and synchronous dual approach to the pelvicaliceal system is useful to reach all renal calices and to provide continuous irrigation of the collecting system, facilitating in this way a better observation of the operative field and, therefore, stones removal. It is well known that this approach is effective, with a high stone-free rate, and safe, with urologic and anesthesiologic advantages. Besides, the percutaneous access allowed us the use of the resectoscope, essential for the treatment of case 1, in which a Hem-o-Lok clip was embedded in the calix mucosa, impossible to remove with laser energy alone because of bleeding. The resection and coagulation of the anchoring site were a peculiar and unique step during the management of the complication.
We recommend a sparing, suitable, and judicious use of sutures and clips with the aim of reducing these sequelae after renal surgery.
Conclusion
Nonabsorbable suture agents should be used carefully and in a tension-free manner during renal surgery because stones typically grow on a foreign body. When stone formation occurs, it is fundamental to remove all extraneous suture devices from the collecting system to reduce the risk of recurrent stone formation. In this sense, ECIRS performed in the Galdakao-modified supine Valdivia position is a safe, effective, and overall advantageous procedure. Moreover, this technique may avoid further positioning of suture material used during open or minimally invasive surgery (laparoscopic or robot-assisted surgery).
Acknowledgments
The authors are grateful to the Urologic Clinic staff for patients' care and the “Trancanelli” Surgical Unit staff for its fundamental contribution to surgical procedures.
Abbreviations Used
- CFU
colony forming units
- CT
computed tomography
- EBL
estimated blood loss
- ECIRS
endoscopic combined intrarenal surgery
- Hb
hemoglobin
- HU
Hounsfield units
- KUB
kidney, ureter, and bladder
- MRSA
methicillin-resistant Staphylococcus aureus
- OT
operative time
- SCr
serum creatinine
- US
ultrasonography
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
Cite this article as: Turco M, Guiggi P, Tiezzi A, Boni A, Paladini A, Mearini E, Cochetti G (2020) Endoscopic combined intrarenal surgery for stone formation after previous laparoscopic and open renal surgery, Journal of Endourology Case Reports 6:2, 60–63, DOI: 10.1089/cren.2019.0082.
References
- 1. Park KS, Sim YJ, Jung H. Migration of a Hem-o-Lok clip to the ureter following laparoscopic partial nephrectomy presenting with lower urinary tract symptoms. Int Neurourol J 2013;17:90–92 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Tugcu V, Polat H, Ozbay B, et al. Stone formation from intravesical Hem-o-Lok clip migration after laparoscopic radical prostatectomy. J Endourol 2009;23:1111–1113 [DOI] [PubMed] [Google Scholar]
- 3. Yadav S, Singh P, Nayak B, et al. Unusual cause of renal stone following robotic pyeloplasty. BMJ Case Rep 2017;2017 pii: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. McAdams S, Sweet RM, Anderson JK. Operating endoscopically with “two hands” to remove calcified permanent suture after pyeloplasty. J Endourol Case Rep 2016;2:1–2 [DOI] [PMC free article] [PubMed] [Google Scholar]