INTRODUCTION: The dissolution of urinarystones could be performed in the patients withurinary obstruction caused by phosphate, or uricacid stones, through the percutaneous nephros-tomy (PCN).CASE REPORT: A 27-year-old woman with com-plete obstruction of the solitary left kidney due to

uric acid stones is presented. The woman was admit-ted in emergency unit due to anuria. Five days afterPCN, irrigation with 1.6% sodium bicarbonate solu-tion was initiated. Due to complete ureteral obstruc-tion, the "Y" extension with the valve was connectedto PCN and to the urinary bag, which enabled the pa-tient to perform intermittent self- irrigation. After 12days of irrigation, all the stones dissolute and ceased.CONCLUSION: In the era of ESWL, PCNL andureterorenoscopy, PCN- dissolution of urinary stonesis rare procedure. However, this minimally invasiveprocedure could be successfully performed in selectedcases.

Key words: uric acid stones, PCN, PCN- dissolution,urine alkalization.

INTRODUCTION

The dissolution of urinary stones is relatively oldmethod. In 1932 Keyser treated urinary stones withthe retrograde infusion o hemolytic substance. Similar

procedure was performed in 1943, by Suby and Al-bright. Suby’s solution is manufactured today, in the

commercial form1. These first attempts of stone dissolu-tion were followed by common complications: ureteralstents were commonly occluded with debris and urinaryinfection was usual. Antegrade approach, via percutane-ous nephrostomy (PCN), was far more successful and fol-lowed by lower complication rate.

At least few percent of most common stones, like phos-phate and struvite stones, can be managed with the combi-nation of PCN - dissolution, extracorporeal shock - wavelithotripsy (ESWL) and percutaneous nephrolitholapaxy(PCNL). Available solutions for PCN - dissolution areHemiacidrin and Suby-G solution (citric acid in combina-tion with magnesium salts)2-4.

Uric acid stones constitute 10% of all urinary stones.These stones are the products of uric acid crystallization,in the acid urine, (pH < 5.75) in the presence of normal orincreased serum acid uric levels. Uric acid is the endproduct of the purine metabolism; increased serum con-centrations of uric acid can be the result of increasedpurine intake, or massive cellular destruction (during che-motherapy). The treatment options for uric acid stones in-clude urine alkalization, ESWL, PCNL, or, rarely, sur-gery5,6. Urine alkalization can be achieved with alkalinesolutions that maintain urinary pH in the range 6.2- 6.8.The most commonly used solutions are citric acid solu-tions (potassium-sodium citrate) which require constantmonitoring of urine pH. In cases with hyperuricemia, xan-thine oxidase inhibitors (allopurinol) are indicated7.

Stone dissolution is slow process; a 1 cm large uric acidstone requires approximately one month of peroral treat-ment for complete dissolution. The more rapid treatmentcan be achieved with direct irrigation of alkaline solu-tions, like 1.6% sodium bicarbonate solution, throughPCN, with the rate of 120 mL of solution per hour. Withthis technique, the majority of uric acid stones require 5-6days for complete dissolution8.

CASE REPORT

A 27-year-old woman with complete obstruction of thesolitary left kidney due to uric acid stones is presented.The woman was admitted in emergency unit, due to ex-treme fatigue, anuria and uremic syndrome, with highlyelevated serum creatinine (1200 µmol/L) and serum po-

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The dissolution of multiple renal uric acid stones viapercutaneous nephrostomy in the patient with asolitary kidney

Pej~i} Tomislav1, Markovi} Biljana2.3, Djura{i} Ljubomir4, Maksimovi} Helena2,Topuzovi} ^edomir1, D‘ami} Zoran1,3, Had‘i-Djoki} Jovan5.1Clinical Center of Serbia, Urological Clinic, Belgrade, Serbia2Clinical Center of Serbia, Institute for Radiology and MR, Belgrade, Serbia3University of Belgrade, Medical faculti, Belgrade, Serbia4Clinical Center of Serbia, Clinic for Physical Medicine and Rehabilitation, Belgrade,Serbia5Serbian Academy of Sciences and Arts, Belgrade, Serbia

/PRIKAZ SLU^AJAUDK 616.61-003.7-089

DOI: 10.2298/ACI1203093P

rezi

me

tassium level (7.2 mEq/L). Six years ago, the patient un-derwent nephrectomy on the right side, due to calculouspyonephrosis.

Abdominal ultrasonography (US) revealed marked dila-tion of the pyelocalyceal system and the ureter. In addi-tion, several stones were seen during abdominal US,while plain kidney-ureter-bladder (KUB) radiograph re-vealed no visible stones. Urgent PCN was done at the ad-mission, what was followed by rapid restoration of diure-sis. After three days, serum creatinine was within normalrange; serum level of uric acid was elevated. The first an-tegrade urography revealed dilated pyelocalyceal systemand five stones in the lower calyx (Figure 1).

The next antegrade urography revealed dilated ureter,with the complete obstruction, due to uric acid stone inthe distal third of the left ureter (Figure 2).

Five days after PCN, irrigation with 1.6% sodium bi-carbonate solution was initiated. However, due to com-plete ureteral obstruction, continuous irrigation was im-possible. Therefore, the "Y" extension with the valve wasconnected to PCN: one channel was connected with the ir-rigating system, up, and the other with the urine bag,

down. The patient was instructed how to open the valvefor irrigation and to close it, when she feels the pain, andto permit the fluid to flow down, in the bag. After 10 daysof irrigation and peroral administration of allopurinol (300mg daily), antegrade urography showed complete dissolu-tion of all kidney stones and the reduced size of the lowerureteral stone (Figure 3).

After 12 days of irrigation, obstruction ceased and thecontrast dye entered the bladder (Figure 3a).

Due to radiographic appearance of UPJ stenosis, Whit-taker‘s test was done: with the irrigation rate of 10mL/min through PCN, median renal pelvis pressure wasnormal, 10cm H2O. After retrograde urography, urinarycatheter and PCN were removed and the patient dis-charged (Figure 4).

CONCLUSION

In the era of ESWL, PCNL and ureterorenoscopy, PCN-dissolution of urinary stones is rare procedure. In fact, thedescribed case was happened 15 years ago. However, this

FIGURE 2. ANTEGRADE UROGRAPHY SHOWING MARKEDURETEROHYDRONEPHROSIS AND THE 2CMLARGE STONE, 1CM BENEATH THE LOWER EDGEOF THE LEFT SIJ. SMALL AMOUNT OF CONTRASTDYE PASSED INTO THE BLADDER.

FIGURE 1.

ANTEGRADE UROGRAPHY SHOWING TWO DEFECTSIN CONTRAST, SUGGESTIVE FOR URINARY STONES:ONE, 3CM LARGE IN THE RENAL PELVIS AND THEOTHER, 2CM LARGE, IN THE URETEROPELVIC JUNC-TION (UPJ).

94 Pej~i} T. et al. ACI Vol. LIX

minimally invasive procedure could be successfully per-formed in selected cases.

SUMMARY

KOMPLETNA DISOLUCIJA MULTIPLIH URATNIHKONKREMENATA KROZ PERKUTANU NEFROS-TOMIJU KOD BOLESNICE SA JEDINIM BUBREGOM

Uvod: Disolucija urinarnih konkremenata kroz perku-tanu nefrostomiju (PCN) mo‘e da se izvede kod boles-nika sa urinarnom opstrukcijom izazvanom fosfatnim, iliuratnim konkrementima.

Prikaz slu~aja: Prikazan je slu~aj uratne kalkuloze kodbolesnice stare 27 godina, koja je dovela do potpune op-strukcije uretera i do anurije. Pet dana posle plasiranjaPCN, zapo~eto je ispiranje kroz PCN, rastvorom 1.6%Na- bikarbonata. S obzirom na kompletnu opstrukciju, naPCN je montiran "Y" nastavak, koji je bolesnici omo-gu}avao da sama zapo~inje ispiranje, odnosno da zatvorislavinicu kada oseti bol i da isprazni rastvor u urinarnu

kesu spojenu sa drugim krakom "Y" nastavka. Posle 12dana irigacije, svi konkrementi su se istopili.

Zaklju~ak: U eri ESWL, PCNL i ureterorenoskopije,disolucija urinarnih konkremeneta kroz PCN je veomaretka. Ipak, ova minimalno invazivna procedura mo‘e us-pešno da se sprovede u biranim slu~ajevima.

Klu~ne re~i: uratni kamen, PCN, disolucija kamenakroz PCN, alkalizacija urina

REFERENCES

1. Stephen P. Dretler and Richard C. Pfister. Percutane-ous Dissolution of Renal Calculi Annual Review of Medi-cine Vol. 34: 359-366 (Volume publication date February1983)

FIGURE 4.

ANTEGRADE UROGRAPHY SHOWING MODERATEURETEROHYDRONEPHROSIS, NARROWED UPJ ANDTHE URETERAL STONE APPROXIMATELY 5CM BE-NEATH THE LOWER EDGE OF THE LEFT SIJ.

FIGURE 3. RETROGRADE UROGRAPHY SHOWING NORMALPELVIC PORTION OF THE LEFT URETER, THESTONE BENEATH THE LEFT SIJ AND DILATEDPROXIMAL URETER.

Br. 3 The dissolution of multiple renal uric acid stones via 95percutaneous nephrostomy in the pts with a solit. kidney

2. Tiselius, D. Ackermann, P. Alken, C. Buck, P.Conort, M. Gallucci Guidelines on Urolithiasis 1 H.GWorking Party on Lithiasis, Health Care Office, EuropeanAssociation of Urology 2001;40:362-371

3. Dretler SP, Pfister RC, Newhouse JH. Renal-stonedissolution via percutaneous nephrostomy. N Engl J Med.1979 Feb 15;300(7):341-3.

4. Wall I, Tiselius HG, Larsson L. Hemiacidrin: a usefulcomponent in the treatment of infectious renal stones. EurUrol. 1988;15(1-2):26-30.

5. Sayera J, Moochhalab S, Thomas D. The medicalmanagement of urolithiasis. British Journal of Medicaland Surgical Urology 3, (3), May 2010, 8795.

6. Matlaga BR, Jansen JP, Meckley LM, Byrne TW,Lingeman JE. Treatment of ureteral and renal stones: asystematic review and meta-analysis of randomized, con-trolled trials. J Urol. 2012 Jul;188(1):130-7. doi:10.1016/j.juro.2012.02.2569. Epub 2012 May 15.

7. Cicerello E, Merlo F, Maccatrozzo L. Urinary alkali-zation for the treatment of uric acid nephrolithiasis. ArchItal Urol Androl. 2010 Sep;82(3):145-8.

8. Laville M, Pelle-Francoz D, Maillet PJ, Fournet D,Martin X, Labeeuw M. Local treatment of obstructive uricacid calculi. Nephrologie. 1987;8(2):59-63.

FIGURE 5.

ANTEGRADE UROGRAPHY SHOWING MODERATEURETEROHYDRONEPHROSIS, NARROWED UPJ ANDCOMPLETELY PASSABLE LEFT URETER. DUE TO RA-DIOGRAPHIC APPEARANCE OF UPJ STENOSIS, WHIT-TAKER‘S TEST WAS DONE: WITH THE IRRIGATIONRATE OF 10 ML/MIN THROUGH PCN, MEDIAN

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