Large renal calculus and ipsilateral flank (incisional) hernia: Perhaps another indication for Mini PCNL?

Abstract

Introduction: The use of the Mini PCNL has been gaining momentum since its first description in 2001. The range of indications for this particular procedure may also be expanding. We describe a case of a large renal calculus in a renal collecting system, found in a patient who underwent an Anatrophic Nephro-Lithotomy [ANL] procedure a few years back. He subsequently developed a flank (incisional) hernia after the ANL. Some, twenty years later he presented with another large (22 mm) stone in the same system.

Observation: Attempt at stone clearance was performed using the Mini PCNL. To avoid iatrogenic injury to the surrounding bowel loops in the hernia sac, a combined ultrasound and fluoroscopic technique was performed, with limited respiration and suspended abdominal fat at the time of renal access. The dilation was performed to accommodate the Mini PCNL sheath, thus minimizing the possibility of iatrogenic bowel injury. A serial balloon dilator was not used, in the presence of such severe fibrosis from the previous open surgery (ANL).

Conclusion: The presence of a hernial sac within the ipsilateral flank may be amenable to Mini PCNL,provided the basic principles of puncture are maintained. This includes the use of adequate positioning, limited respiration and the use of ultra-sound identification of the bowel loops during access puncture and tract dilatation. A new indication for the use of Mini PCNL is thus reported.

Keywords: Mini PCNL; PCNL; Hernia; Staghorn; New indication; Minimally invasive surgery