Summary
Horseshoe kidney is a renal fusion which combines three anatomic abnormalities: ectopia, malrotation and vascular changes. These anomalies can be recognised separately to varying degrees in unfused kidneys. Necessary modifications of the standard technique for percutaneous nephrolithotomy (PNL) are directly deducible from analysis of the anatomic data of the imaging of horseshoe kidneys. We report our experience with 5 patients (7 kidneys) who underwent PNL for calculi in horseshoe kidneys. The percutaneous approach was performed under ultrasound and fluoroscopic monitoring. In situ disintegration by ultrasonic lithotripsy and nephrostomy drainage were necessary in all cases. Modifications of the standard PNL procedure are related to the anatomic changes. The lower abdominal position of a horseshoe kidney necessitates upper or middle calyceal puncture, while the malrotation necessitates a more posterior puncture. Monitoring of the puncture needle by fluoroscopy as it is advanced postero-anteriorly is more difficult and the risk of the surgeon's hand entering the radiation path is increased. The renal pelvis is deep and a long endoscope may be required. Aberrant segmental vessels may create potential hazards. The majority of problems in location can be avoided by use of an ultrasonically guided needle. Percutaneous nephrolithotomy is the treatment of choice for calculi in horseshoe kidneys for the following reasons: the high incidence of recurrent lithiasis in horseshoe kidney and the complexity of repeated surgical approaches diminish the acceptable results of open surgery; difficulties in focussing on the calculi and drainage problems militate against the success of extracorporeal shock wave lithotripsy (ESWL); PNL has a good success rate and the least morbidity.
Résumé
Le rein en fer à cheval est la malformation reconnue comme la fusion du pôle inférieur des reins. Toutefois, elle associe à des degrés divers trois types d'anomalies anatomiques qui peuvent ête reconnues sur des reins non fusionnés (ectopie, malrotation et vascularisation anormale). Ces modifications observées sur des reins en fer à cheval compliqués de calculs nécessitent une adaptation de la technique de néphrolithotomie percutanée directement déduites des corrélations radio-anatomiques. Une étude réfléchie de l'approche percutanée des reins en fer à cheval permet ainsi, une modélisation des adaptations possibles d'une technique opératoire au status anatomique observé dans diverses anomalies rénales. Nous rapportons ici notre expérience chez cinq patients (7 reins) traités pour des calculs sur rein en fer à cheval. Les modifications apportées à la technique standard de néphrolithotomie percutanée ont été principalement une ponction dorsale et une entrée par les calices supérieurs ou moyen en raison de la malrotation et de la situation abdominale basse du rein. A condition d'adaptater le geste opératoire à une bonne analyse morphologique, la néphrolithotomie percutanée nous semble le traitement de choix des calculs sur rein en fer à cheval en raison de la fréquence des interventions pour récidives lithiasiques sur ce type de malformation et des anomalies du drainage du système pyélocaliciel qui expliquent les échecs de la lithotritie extracorporelle.
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Cussenot, O., Desgrandchamps, F., Ollier, P. et al. Anatomical bases of percutaneous surgery for calculi in horseshoe kidney. Surg Radiol Anat 14, 209–213 (1992). https://doi.org/10.1007/BF01794940
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DOI: https://doi.org/10.1007/BF01794940