Introduction

Percutaneous nephrolithotomy is a preferred surgical procedure for especially >2cm stones and also would be performed for 1-2cm stones There are some individual factors that affect the success rate of operation. One of these factors is obesity [2].Obese patients with renal stone are not suitable for extracorporeal shock wave lithotripsy because of skin-to-stone distance and open surgery is not routinely recommended because of increased risk of complications such as greater blood loss, greater loss of renal function, increased risk of injury to other organs, longer hospitalisation and longer convalascence. Percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery are the preferred treatment options for these patients and Akbulut et al. showed the similar efficacy of mini-percutanous nephtolithotomy between obese and non-obese patients [2]. Another factor that is affecting the success rate of percutaneous nephrolithotomy is spinal deformity, especially scoliosis. Spinal deformities may increase the risk of visceral injuries during the renal puncture [3].Wang et al, showed many advantages of ultrasonographic access such as shorter access time, reduced blood loss, lower operative complications and higher stone-free rate in their study [4]. Puncture of the kidney ipsilateral to the curvature is easier than the puncture of the contralateral kidney [5]. There are typically 2 curvatures, one towards the kidney an done away from it. When the convex part of the scoliosis is towards the ipsilateral kidney, the kidney is pushed laterally and this is making pucture easier.

The vice versa is true and when the concave part is towards the ipsilateral kidney, moving the kidney away from the skin and this is making puncture more difficult.Chen et al. reported the safety and efficacy of both mini-percutaneous nephrolithotomy and standard percutaneous nephrolithotomy. Li et al. also reported the efficacy of mini-PCNL for the treatment of stone disase in patients with scoliosis but according to this study ultrasonography is only reducing the procedural risk but not improving the success rate [5]. Pelvic deformities are also affecting positioning during PCNL. In this study we aimed to present a complicated urolithiasis case that has both spinal and pelvic deformities and also severe obesity.

Case

64 year-old female patient, admitted to our clinic with left flank pain and dysuria that was lasting for 1 month. The patient had a history of congenital hip dislocation. Body mass index was 37.8kg/m². According to the laboratory analysis; biochemical results were normal but urinalysis revealed infection and due to this condition, the patient was given oral antibiotherapy. X-ray revealed semi-opac kidney stone and according to computerised tomography, there wasa 18*12mm kidney stone in left ureteropelvic junction and a 16mm-diameter stone in lower pole of left kidney

On CT, stone to skin distance was 13.2cm.Also imaging methods revealed minimal scoliosis the patient. Cobb’s angle was 14°. After 7 day of oral antibiotherapy, the urinalysis and urine culture were normal. According to the results, left percutaneous nephrolithotomy operation was planned for the patient. Before the operation left ureteral stent was inserted but during this procedure it was very difficult to give lithotomy position to the patient because of the severe pelvic deformity.After the uretheral catheter insertion, the patient was given prone position and also we had difficulty while giving the prone position because of scoliosis, pelvic deformity and severe obesity of the patient.Triangulation method was used for access and also fluoroscopy was preferred. Amplatz dilators were used for dilatation and the Access sheath size was 24Fr, 17cm. During the operation, blood loss was minimal, nearly a half unit. Total surgery time was 55 minutes and the access time was 15 minutes. The patient was stone-free after the operation and nephrostomy tube was removed postoperative 2nd day. The patient was discharged on postoperative 2nd day and was involved in routine follow-up program.

Discussion

Percutaneous nephrolithotomy(PCNL) is an effective surgical treatment for especially >2cm stones. There are lots of factors affecting the success rate of the operation [6]. Surgical volume of the operating center, stone factors such as stone size, location, hounsfield unit, patient factors such as age, associated deformities and obesity are the main factors that are affecting the success rates of PCNL [6]. There are also nephrolitometric scoring systems for predicting outcomes of PCNL [6]. Guy’s stone score, Nephrolitometric nomogram, STONE nephrolitometry, Seoul renal stone complexity score are some of these scoring systems [6,7]. Obesity is an important factor for the success and complication rates. Dauw et al. reported a study with 1152 patients and according to this study there was no significant differences for complication rates between ideal, overweight and super-obese patients [8]. Spinal deformity is another risk factor that is affecting the success and the complication rate and there are several studies in the literature that is reporting the efficacy and safety of PCNL fort he patients with spinal deformities. Izol et al. reprted a study with 16 patients and the spinal deformities of the patients were kyphoscoliosis, post polio syndrome, osteogenesis imperfecta, myotonic distrophy and ankylosing spondylitis [9]. El-Husseiny et al. reported that lateral decubitus position and regional anesthesia would improve clinical odds for high-ris patients that are performed percutaneous surgery [10]. Papatsoris et al. used Montreal mattress and Proneview protective helmet system in their study and they showed their preventive role for anesthetic and skeletal complications [11].In this study, only minor complcations were reported and PCNL was reported as safe and effective operation for these patients [9]. In another study by Kara et al. it was reported that PCNL would be used safely in patients with scoliosis, for larger and shock wave-refractory stones [12]. Ankylosing spondylitis is anotherspinal deformity type and it makes both anestesia and operation more difficult [13]. Prone and supine positions would be used for PCNL and there are several advantages and disadvantages for both positions [14]. Yuan et al. reported higher stone-free rates, shorter operative times and lower blood transfusion rates for supine position [15]. Mak et al. reported a review about patient positioning and according to this study, both postions had similar results for stone-free and complication rates [14]. As reported in our study, spinal, pelvic deformities and obesity make percutaneous nephrolithotomy more difficult and complicated but in experienced centers there are similar success and complication rates comparing with normal population.

Figure 1& 2: Computerised tomography – deformities and severe obesity.

1. Alsinnawi M, Torreggiani WC, Flynn R, McDermott TE, Grainger R, et al. (2013) Percutaneous nephrolithotomy in adult patients with spina bifida, severe spinal deformity and large renal stones. Irish journal of medical science 182:357-361.
2. Akbulut F, Kucuktopcu O, Kandemir E, Ucpinar B, Ozgor F, et al. (2016) Efficacy and safety of mini percutaneous nephrolithotomy in obese patients. SpringerPlus 5:1148.
3. Chen HQ, Zeng F, Qi L, Li Y (2013) Percutaneous nephrolithotomy in patients with scoliosis: our institutional experience. Urolithiasis 41:59-64.
4. Wang K, Zhang P, Xu X, Fan M (2015) Ultrasonographic versus Fluoroscopic Access for Percutaneous Nephrolithotomy: A Meta-Analysis. Urol Int 95:15-25.
5. Li H, Zhang Z, Li H, Xing Y, Zhang G, et al. (2012) Ultrasonography-guided percutaneous nephrolithotomy for the treatment of urolithiasis in patients with scoliosis. International surgery 97:182-188.
6. Ghani KR, Andonian S, Bultitude M, Desai M, Giusti G, et al. (2016) Percutaneous Nephrolithotomy: Update, Trends, and Future Directions. European urology 70:382-396.
7. Choi SW, Bae WJ, Ha US, Hong SH, Lee JY, et al. (2016) Prognostic Impact of Stone-Scoring Systems After Percutaneous Nephrolithotomy for Staghorn Calculi: A Single Center's Experience Over 10 Years. Journal of endourology / Endourological Society 30: 975-981.
8. Dauw CA, Borofsky MS, York N, Lingeman JE (2016) Percutaneous Nephrolithotomy in the Superobese: A Comparison of Outcomes Based on Body Mass Index. Journal of endourology / Endourological Society 30: 987-991.
9. Izol V, Aridogan IA, Borekoglu A, Gokalp F, Hatipoglu Z, et al. (2015) Percutaneous nephrolithotomy in prone position in patients with spinal deformities. International journal of clinical and experimental medicine 8:21053-21061.
10. El-Husseiny T, Moraitis K, Maan Z, Papatsoris A, Saunders P, et al. (2009) Percutaneous endourologic procedures in high-risk patients in the lateral decubitus position under regional anesthesia. Journal of endourology / Endourological Society 23:1603-1606.
11. Papatsoris A, Masood J, El-Husseiny T, Maan Z, Saunders P, et al. (2009) Improving patient positioning to reduce complications in prone percutaneous nephrolithotomy. Journal of endourology / Endourological Society 23:831-832.
12. Kara C, Resorlu B, Ozyuvali E, Unsal A (2011) Is percutaneous nephrolithotomy suitable for patients with scoliosis: single-center experience. Urology 78:37-42.
13. Sari S, Baylan B, Sezer E, Cataroglu CK, Ozok HU, et al. (2015) Percutaneous Nephrolithotomy Performed on the Kidney Stone in a Patient With Ankylosing Spondylitis: A Case Study. Urology case reports 3:123-125.
14. Mak DK, Smith Y, Buchholz N, El-Husseiny T (2016) What is better in percutaneous nephrolithotomy - Prone or supine? A systematic review. Arab journal of urology 14:101-107.
15. Yuan D, Liu Y, Rao H, Cheng T, Sun Z, et al. (2016) Supine Versus Prone Position in Percutaneous Nephrolithotomy for Kidney Calculi: A Meta-Analysis. Journal of endourology / Endourological Society 30:754-763.