Marshall L. Stoller, Maxwell V. Meng-Urinary Stone Disease

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442 Eichel and Clayman

Fig. 4. (A) Anterior view of right kidney showing the branching of the renal arteries and their

official nomenclature according to kidney regions. RA, renal artery; sa, segmental artery; ia,

interlobar (infundibular) artery; aa, arcuate artery. (B) The two adjacent pyramids and minor

calices showing the renal vasculature from the level of the interlobar arteries to the glomerular

level. Ia, interlobar (infundibular) artery; aa, arcuate artery; il.a, interlobular artery; and af,

afferent arteriole of the glomerulus. From ref. 6 with permission.

Chapter 23 / Anatomical Considerations 443

When testing forniceal punctures, however, there were no arterial injuries and less than

an 8% rate of vascular injury. Thus, puncture of the collecting system should always be

performed through a fornix or directly into a posterior calyx.

IMPACT OF ANATOMY ON SELECTION OF STONE THERAPY

Obstruction

URETERO-PELVIC JUNCTION OBSTRUCTION

Patients with primary uretero-pelvic junction (UPJ) obstruction have a 16–30% chance

of concomitant renal stones (29). Stasis and to a lesser extent metabolic factors are

thought to play a role in stone formation in the setting of UPJ obstruction (30–32). Hence,

one must consider that even after successful treatment of a UPJ obstruction with

endopyelotomy or surgery, these patients may still be at risk for recurrent stone disease

and treatable metabolic risk factors should be evaluated and treated. SWL is contrain-

dicated in the setting of UPJ obstruction because distal drainage is required (33). Occa-

sionally, when the stone sits directly at the UPJ, it can be difficult to discern whether or

not the UPJ is obstructed primarily or secondarily, from an impacted stone with edema.

In this situation, it is best to first treat the stones percutaneously, leave a nephrostomy

tube in place albeit well away from the UPJ, wait 2 wk for resolution of edema, and then

assess the drainage of the renal collecting system. This can be done using a DTPA or

MAG-3 renal scan with furosemide washout or, if the nephrostomy tube has been left in

place, a Whitaker test (29).

Open pyelolithotomy and pyeloplasty has long been the gold standard of therapy for

UPJ obstruction with renal stones. With the advent of minimally invasive techniques,

however, several other effective options for treatment now exist. One well recognized

alternative treatment for simultaneous renal stones and UPJ obstruction is to perform

percutaneous lithotripsy followed by antegrade percutaneous endopyelotomy. Using

these combined techniques patients can be rendered stone free and success rates of up

to 94% can be achieved in terms of UPJ patency (34).

Another possible minimally invasive option that blends the benefits of open surgery

with the minimally invasive philosophy of percutaneous surgery is laparoscopic

pyeloplasty and pyelolithotomy. In one study, Ramakumar et al. performed 20 laparo-

scopic pyelolithotomies with pyeloplasty and reported an overall long term patency rate

of 90% and a stone free rate of 80% at 1 yr (35).

ALYCEAL DIVERTICULI

Caliceal diverticula are nonsecretory outpouchings of the renal collecting system that

communicate via a tight neck, usually along the fornix. Up to 50% of patients with

calyceal diverticula will have stones within them (29,36). The condition itself does not

require treatment. The criteria for treatment are pain and/or infection.

Treatment options include SWL, percutaneous nephrolithotomy and simultaneous

calyceal obliteration, retrograde ureteroscopic approach, laparoscopic approach, and

open surgery. In general, SWL can provide a reasonable short-term pain free rate (36–

75 %) but because it does not address the actual mechanical obstructive process, the

stone clearance rate is poor (4–25%) (37–41). In contrast, direct percutaneous stone

extraction followed by incision of the diverticular neck and fulguration of the diverticu-

lar wall with placement of a nephrostomy tube through the dilated neck provides for both

stone extraction and treatment of the primary problem. Using such techniques, stone

444 Eichel and Clayman

clearance rates of 93–100%, symptom free rates of 85–100%, and diverticular oblitera-

tion in 73–100% can be achieved (40,42–44).

With the constant improvement of flexible ureteroscopes and the widely available use

of the holmium laser, a retrograde ureteroscopic approach to calyceal diverticula is also

an attractive option. This entails cannulation of the diverticular neck with a guide wire

under direct vision. Either balloon dilation or incision of the neck can be performed in

the 3 or 9 o’clock positions. This is followed by intracorporeal lithotripsy. In earlier

reports, no attempt was made to obliterate the diverticulum. Using this technique Batter

and Dretler report an immediate treatment success rate of 84% for upper and mid pole

diverticula. The success rate for lower pole diverticula was poor owing to a high rate of

failure to cannulate the diverticulum. The symptom-free rate at a mean follow up of 39

mo was 100% in those treated successfully; however follow-up results regarding the

drainage or disappearance of the diverticulum was not reported (45).

Another minimally invasive treatment option for a large diverticulum (i.e.,  5 cm),

especially those in an anterior or perihilar position that have poorly accessible necks and

very little overlying parenchyma (i.e., are bulging off of the surface of the normal renal

contour) is laparoscopic stone extraction and marsupialization. This can be done via a

transperitoneal or retroperitoneal approach depending on the circumstances. Intraopera-

tive ultrasound may be necessary to localize a relatively endophytic diverticulum. Sev-

eral authors report small series of patients treated successfully in this manner with

minimal complications (46–49).

ENAL CYSTS

Peripelvic cysts are simple cysts that are located within the renal hilus. They comprise

6% of all renal cysts. They are intimately associated with the renal pelvis, calyces, and

major renal vessels and can be single or multiple in number (50). The renal hilum is a

relatively tight space and the cysts can cause obstruction of the renal collecting system

resulting in pain, infection, hypertension, and stone formation (51). Because of their

intimacy with the collecting system and hilar vessels, the historical management of

peripelvic cysts required open surgical decortication (52). There have been anecdotal

reports of treatment with percutaneous drainage and endoscopic marsupialization; how-

ever, percutaneous drainage with sclerotherapy is contraindicated for fear of vascular

injury or injury to the collecting system from errant sclerosant (53,54). A growing

number of urologists are now considering laparoscopic cyst ablation for these lesions.

In one series reported by Roberts et al., 11 patients underwent laparoscopic peripelvic

cyst ablation. All patients were treated successfully and the complication rate for his

entire series, which also included parenchymal renal cysts (n = 32), was 13%, much

lower than the rate reported for open cyst decortication (33%) (55). In another case series

by Hoenig et al. involving four patients, three cyst ablations were successful long term

and there were no complications (51). The authors also noted occasional difficulty with

the differentiation between the stretched wall of the renal vein and the blue domed wall

of the cysts. Intraoperative ultrasound was used to distinguish between the two. In both

series it was noted that fulguration of the cyst base is not recommended owing to the risk

of damage to the collecting system or vasculature. They also noted that if a cyst could

not be opened widely, it was prudent to suture a tongue of omentum or pararenal fat

inside the cyst to act as a wick.

Occasionally, cysts within the parenchyma of the kidney can compress the collecting

system and cause stasis and stone formation proximally. Reports of such cases are

Chapter 23 / Anatomical Considerations 445

sporadic but Cass (56) reported a series of 13 patients of which two had peripelvic cysts,

four had autosomal dominant polycystic kidney disease (ADPKD), and seven had simple

or multiple cysts. All patients were treated with a Medstone STS lithotriptor under

general anesthesia. The stone free rate, not surprisingly, at 3 mo was only 46%. The

author attributed the retained fragments to continued obstruction and indicated that

PCNL or percutaneous cyst drainage and sclerosis would be a more appropriate option

for treatment.

Urolithiasis occurs in 10–36% of patients with ADPKD (57,58). Many of these

patients have uric acid stones that can be treated with urinary alkalinization. In general,

it is best to avoid instrumentation of polycystic kidneys, if possible, because the cysts

once infected are very difficult to penetrate with antibiotics. If, however, this is not

possible, SWL, PCNL, or a combination of the two can be performed. Ng et al. reported

the Cleveland clinic experience with urolithiasis in patients with ADPKD (58). They

found that 6 out of 13 patients could be treated with urinary alkalinization, and 7 out of

13 required subsequent treatment. The average number of procedures per patient was 1.7

indicating that often a second procedure or sandwich therapy (SWL, PCNL, and SWL)

is necessary. Overall, the success rate in treated patients was 57% with the remaining

patients having “dust.” Interestingly, stone analysis revealed uric acid stones in five out

of seven treated patients. In another series of 48 consecutive ADPKD patients 15 were

found to have stones. The presence of hypertension was not a significant factor. Patients

did seem to have a greater number of cysts and larger cysts adding to the proof that

anatomic factors (obstructing cysts causing urinary stasis) may play an important role

in stone formation. Patients with stones had lower GFR, 24-h urine volume, urinary

magnesium, potassium, and phosphate. Stone composition was not noted; however, the

urinary uric acid level was similar in stone and non stone formers (59).

Anatomical Variants

HORSESHOE KIDNEY

Horseshoe kidney is a common renal fusion anomaly that occurs in up to 1 in 400

births. In most cases the lower poles of the kidneys are fused. Normal renal ascent is

blocked by the inferior mesenteric artery and the inferior longitudinal axis of the kidneys

is pulled medially. Rotation of the kidneys is also abnormal such that the pelves and

ureters lie anterior to the isthmus and the ureters often insert high on the pelvis. This

configuration predisposes to renal calculi, which occur in 21% and potential UPJ

obstruction, which has been reported to occur in 15% (60). The unusual location and

rotation of the kidney makes management more challenging; however, the options still

include SWL, PCNL, retrograde ureteroscopy, and laparoscopy. The biggest problem

with these patients is that access to the lower pole is difficult with the ureteroscope and

the dependency of the lower pole plus the anterior insertion of the ureter into the pelvis

means poor clearance after SWL; hence PCNL is usually the most definitive therapy.

SWL is a valid treatment option for stones in horseshoe kidneys, however patient

positioning can be more challenging. Stones in the upper and middle poles can usually

be pinpointed in the supine position but lower pole stones often require prone positioning

owing to the medial and anterior deviation of that location (61,62). Pearle and Traxler

recently reviewed the results of seven stone series treated with the HM 3 and 7 with

various electromagnetic lithotripters and noted a 61.9% and a 66.7 % stone free rate

among patients with horseshoe kidneys, respectively. They also noted that although the

446 Eichel and Clayman

stone free rates come close to those achieved on conventional kidneys, the retreatment

rates tend to be higher, most likely secondary to poor drainage (22.5% and 38.1% for the

HM 3 and electromagnetic series, respectively) (29).

PCNL is an effective treatment option for stones in horseshoe kidneys, but the tech-

nique for establishment of the percutaneous tract must be modified owing to the abnor-

mal anatomy. Janetschek and Kunzel studied the anatomic variations found in cadaver

horseshoe kidneys (63). Accessory renal arteries may originate from the aorta, the iliac

bifurcation, the common iliac arteries, as well as the middle sacral arteries and insert

directly into the isthmus or the poles of the kidneys. Except for vessels going to the

isthmus, however, no arteries were found along the dorsal aspect of the kidney. They also

noted that the posterior row of calices points more dorsomedially and the ventral row of

calices dorsolaterally. In addition to the pelvis lying anterior, they also noted that the

calices to the isthmus lie within the coronal plane and point medially.

With the anatomy in mind, puncture of the upper pole posterior calyx provides the

shortest and safest access to the rest of the kidney. The position of the puncture is more

medial than a typical percutaneous nephrostomy and should traverse the paraspinous

muscles. In addition, the nephrostomy tract must travel a longer distance to reach the

anteriorly displaced kidney and may be in excess of 20 cm (64). For this reason, longer

nephroscopes, or a short semirigid ureteroscope, as well as a flexible nephroscope should

be available (28). Among series reporting results of PCNL in horseshoe kidneys, the

stone free rates are 75–89% and second procedure rates are 10–70 % (63,65,66). It is also

important to remember that PCNL is also very appropriate for the simultaneous treat-

ment of UPJ obstruction and renal lithiasis because lithotripsy and antegrade endopye-

lotomy can be performed at the same time, even in these patients (65). Ureteroscopy has

been reported anecdotally as being successful for upper and middle pole stones but is less

effective for lower pole stones (29). In a recent review article, Yohannes and Smith

recommend SWL as the first line treatment for small stones in horseshoe kidneys. For

larger stones or SWL failures, the authors recommend PCNL (67).

RANSPLANTED AND PELVIC KIDNEYS

The incidence of renal stone formation in renal transplant recipients is roughly the

same as in the population at large estimated as approx 0.4–1% (68,69). Anatomically,

transplanted kidneys lie within the pelvis overlying the iliac vessels. They are shielded

posteriorly by the sacrum and iliac bones and may have overlying bowel anteriorly.

These factors complicate the use of SWL and PCNL as treatment modalities. The

ureteral path may be tortuous and most commonly the ureter inserts into the bladder at

the dome and, if there are renal calculi, a ureteral stricture may be present. Retrograde

instrumentation of the ureter can therefore be difficult. There may also be scar tissue

encasing the kidney, which can make percutaneous access and endoscopic manipula-

tion difficult. Because of these potential variations, each individual case must be evalu-

ated with regard to stone size, location, the presence of infection, and the individual

renal and ureteral anatomy based on operative report and a comprehensive radiologic

evaluation.

The anatomy of the pelvic kidney was well described by Dretler et al. (70). Pelvic

kidneys occur with a frequency of 1 in 1000 autopsies and have a 3:2 male to female

ratio. Right and left ectopias have an equal frequency; 15% of ectopic kidneys are

crossed. These kidneys tend to be smaller and malrotated such that the collecting system

faces anteriorly. The pyelocalyceal system may be entirely extrarenal and appear to be

Chapter 23 / Anatomical Considerations 447

dilated because in these kidneys the collecting system is more easily distended with

urine. There may be multiple vessels arising from the aorta and common or internal iliac

vessels.

Because of the relative rarity of this condition, series reported in the literature are few.

SWL has been used successfully for the treatment of small stones in transplanted kid-

neys. The pelvic location of the kidney necessitates modified positioning: patients, if

supine, must be positioned such that the shock waves pass just below the sacrosciatic

notch (40), or they can be turned into the prone position (62,71). Furthermore, it is

recommended that only stones  1 cm be treated with SWL because the risk of

steinstrasse has much more severe ramifications in this patient population. SWL has also

been used for various size stones in ectopic pelvic kidneys. In one series, 11 of 12 stones

were cleared at 3 mo (72).

Retrograde ureteroscopy in the transplanted kidney has been reported for stone treat-

ment, retrieval of migrated stents, and evaluation of funguria and abnormal cytology

(73). The same issues with potential difficulty accessing the lower pole or negotiating

a malrotated kidney apply (29). Only sporadic cases of successful ureteroscopic stone

treatment in ectopic pelvic kidneys exist in the literature (73,74).

PCNL is another viable modality of treatment for larger stones in transplant or pelvic

kidneys. The anterior position of the transplanted kidney allows excellent visualization

of the stone and localization for nephrostomy puncture; however in the congenital pelvic

kidney one must contend with overlying bowel. If there is concern over bowel injury, the

nephrostomy access has been reported in one case to have been successfully obtained

using laparoscopic guidance (75). Cases of PCNL for transplanted kidneys in the litera-

ture are sporadic but indicate successful results (76–78).

If SWL is not successful or inappropriate and percutaneous and ureteroscopic tech-

niques are not possible, laparoscopic pyelolithotomy is another potential minimally

invasive option in ectopic or pelvic kidneys. Two case reports exist in the literature in

which a transperitoneal approach is described (79,80).

EIMPLANTED URETERS

Catheterization of the ureter in patients who have had a cross trigonal reimplantation

or post transplantation ureteroneocystotomy can be difficult owing to the abnormal

position and configuration of the orifice as well as the abnormal tortuous path of the

ureter. If routine retrograde access is not possible, one can use a special deflecting

catheter passed retrograde (e.g., Cohen deflecting guide wire and catheter, or Kumpe

catheter) or via a suprapubic puncture to cannulate the ureter.

If a retrograde approach is not possible then a guide wire can be retrieved from the

bladder following antegrade percutaneous guide wire placement (81). Retrograde pas-

sage of a ureteroscope using standard techniques is then possible.

LEAL CONDUITS

The ileal urinary conduit, popularized by Bricker, has been the standard solution to

urinary diversion for the last 50 yr (82). Rates of upper tract stone formation in patients

with ileal conduit urinary diversion range from 4.8 to 20% (83–87). In the absence of

stricture, the standard Bricker anastomosis as well as the Wallace anastomosis (88) both

allow free reflux of urine into the upper urinary tracts. In Dretler’s extensive study of this

topic, several significant risk factors for stone formation were identified. Infection with

urea splitting organisms was found in 91% and previous pyelonephritis was found in

448 Eichel and Clayman

84% of stone formers. Reflux of infected urine likely leads to struvite stone formation;

indeed, the overwhelming majority of stones in patients with urinary diversion are struvite

stones (83,89–91). Stone formers had a mean residual conduit volume of 30 mL vs 8 mL

for nonstone formers. The majority of patients with a high urine residual had a hyper-

chloremic metabolic acidosis, severe HCO

–

loss and a high incidence of hypercalciuria.

Although it was not measured in this study, these patients often have citrate levels so low

they cannot be measured, which may potentiate the stone diathesis affected by a urease

splitting infection. It should also be noted that in addition to renal lithiasis, Dretler also

noted two freestanding stones within the conduits themselves. Other stones associated

with permanent suture material were not included in the analysis but foreign bodies

within the urinary tract have long been known to act as a nidus of stone formation within

an ileal conduit (e.g., staples).

SWL, ureteroscopy, and PCNL alone and in combination can be used to treat upper

tract calculi in patients with ileal loop diversions. When opacification of the collecting

system is required for SWL or PCNL, a loopogram can be performed on the treatment

table. However, because these are usually infection stones, it is essential that the patient

receives appropriate antibiotic coverage and has a sterile urine culture, before proceed-

ing with stone manipulation or even a loopogram. The choice of treatment depends on

stone size, location, and the specific anatomic situation that exists. It should be noted that

patients with urinary diversions might respond to expectant management of their stone

disease (84). In patients who do require treatment, experienced centers (90) have found

that renal stones less than 2 cm, in the absence of obstruction, can be treated with SWL

with an initial expected success rate of 76%. If a secondary SWL is used to clean up

residual stones the success rate rises to 92%. PCNL can be used for larger stones with

a success rate approaching 100%. For residual stone fragments post PCNL, SWL can be

effective. For ureteroscopic access to the upper tracts in patients with intestinal loop

diversions, flexible looposcopy can be performed to pass a guide wire up the ureter in

question. If this is not possible owing to poor visibility or ureteroenteric stricture, an

antegrade approach can be taken via a nephrostomy tract (16,91). In this case, the stone

and stricture are treated simultaneously. One caveat is appropriate, in paraplegic or

quadriplegic patients, ureteral peristalsis is significantly impaired and hence success

with SWL or even ureteroscopic renal procedures may be markedly reduced versus

percutaneous stone removal.

CTOPIC CONTINENT NEOBLADDERS

From the standpoint of stone formation, continent urinary reservoirs can be classified

as those that contain exposed foreign body material such as sutures, staples, or mesh

(e.g., Kock pouch) and those that do not (e.g., Indiana pouch). The Kock pouch is a

nonrefluxing continent catheterizeable urinary reservoir that is fashioned from a 72-cm

segment of ileum. The midportion is detubularized and the proximal and distal 20 cm are

intussuscepted to form a nonrefluxing afferent and efferent limb. The valve is stapled in

three areas that can lead to stone formation on the exposed staples. To re-enforce the

limbs, a collar of mesh is placed around the outside. The mesh can erode into the reservoir

and also act as a nidus for stone formation (93).

The Indiana pouch is formed from an isolated segment of bowel comprised of the

ascending colon, cecum, and 10 cm of terminal ileum. The colon is detubularized and

the ureters are reimplanted in a nonrefluxing fashion. The catheterizeable continent limb

is formed by reinforcing the ileocecal valve with various imbricating suture techniques.

Chapter 23 / Anatomical Considerations 449

The catheterizeable limb is tapered into a narrow “Mitrofanoff” like tube that can be

brought out to a stoma (93).

Thus, the two main differences between a Kock pouch and an Indiana pouch is the

presence or absence of foreign body material and the ability or inability to place a

sizeable endoscope through the efferent limb. Infection with urea splitting organisms,

urinary stasis, and mucus formation are all lithogenic risk factors common to both types

of diversion (94).

Stone formation in the Kock pouch vs Indiana pouch is estimated to occur in 16.7–

43% vs 0–12.9% of patients, respectively (94,95). Although these ranges overlap, it is

generally believed that the Kock pouch has a higher rate of stone formation because of

the presence of exposed staples and mesh. In one study the rate of stone formation was

noted to drop significantly after the mesh was changed from permanent to absorbable

(95). Furthermore, a significant percentage of the stones that form within the Indiana

pouch occur on retained absorbable sutures or debris (94).

With the Kock pouch, the configuration of the efferent limb usually allows the place-

ment of a nephroscope directly through it into the pouch. Lithotripsy and evacuation of

debris can be performed with a wide array of devices (94–97). Retrograde ureteroscopic

retrieval of stones and retained stents within the afferent limb of the pouch have been

described (96). SWL has also been described for treatment of stones both in the pouch

and within the afferent limb (97) but, in general, SWL for this group of patients is

discouraged owing to inability to clear out the fragmented stone debris (96,97). Con-

cerns regarding injury to the continence mechanism of the Kock pouch have been raised;

however, a high rate of incontinence after the procedure has not been reported. One

author suggests placing a 26-Fr working sheath through the stoma to avoid repeated

traumatization (103).

Treatment of stones within the Indiana pouch or within urinary reservoirs with a

Mitrofanoff like efferent limb can be more challenging because, at times, the

catheterizeable lumen can be narrow and may necessitate the use of a small bore fiber

optic scope. Again, SWL has been used to treat stones within these pouches, however

other authors advise against this because of difficulty with clearance and irrigation of

debris through the small channel and the high risk of recurrence (96,97). One solution

is percutaneous pouch lithotripsy. To move overlying bowel out of the path to the pouch,

the puncture can be performed under direct vision with a small flexible cystoscope (100)

or better yet, after retrograde filling with saline under ultrasound guidance (101). The

tract is then dilated using standard techniques and pouchoscopy, lithotripsy, and evacu-

ation of debris can be performed.

RTHOTOPIC NEOBLADDERS

Orthotopic neobladders may be fashioned in multiple configurations but all rely on

preservation of the external sphincter mechanism to maintain urinary continence.

Because a urethroenteric anastomosis is created, these pouches are accessible trans-

urethrally. Thus, standard methods for cystolitholapaxy are used (93). Neobladders

that have exposed staple lines such as the hemi Kock pouch are at a higher risk of stone

formation than neobladders without foreign bodies.

SUMMARY

The skilled endoscopist requires a thorough knowledge of both normal and congenital

or iatrogenically altered renal, ureteral and bladder anatomy. A clear understanding of

450 Eichel and Clayman

this topic enables the astute clinician to effectively select the most appropriate form of

therapy.

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