Laparoscopic Nephrectomy in a CKD Kidney with Staghorn Calculus and Pyonephrosis: Chronic kidney disease (CKD) complicated by staghorn calculus poses unique challenges in urology. When these cases are further compounded by infection and non-functionality of the kidney, timely surgical intervention becomes essential. This article highlights a remarkable case managed by expert urologists, Dr. M. Roychowdhury and Dr. Rajan Bansal, at the renowned Institute of Urology, Jaipur, where a laparoscopic nephrectomy was performed with precision and expertise.
Case Overview
A 55 year old male patient, with known CKD, presented with the following:
- Symptoms: Persistent fever and flank pain, indicating infection.
- Urine Analysis: Confirmed the presence of a urinary tract infection.
- Imaging and Diagnosis:
- Ultrasound revealed a staghorn calculus measuring 27 mm, occupying the renal pelvis and calyces.
- A CT scan indicated small kidney, severe hydronephrosis and pyonephrosis, with extensive parenchymal thinning.
- A DTPA scan showed no functional activity in the affected kidney.
When the patient came to us, a percutaneous nephrostomy (PCN) tube was was seen in situ (to drain the infected fluid). The pus from the PCN confirmed pyonephrosis, necessitating the removal of the non-functional kidney.
Decision for Laparoscopic Nephrectomy
Considering the presence of CKD, infection, and a staghorn calculus in a non-functioning kidney, laparoscopic nephrectomy was chosen for its minimally invasive nature and reduced postoperative complications compared to open surgery.
Key factors influencing the decision:
- Non-functionality: The DTPA scan confirmed that the kidney was not contributing to overall renal function.
- Infection Risk: Persistent pyonephrosis posed a risk of sepsis if left untreated.
- Minimally Invasive Approach: Laparoscopy reduces recovery time, blood loss, and postoperative pain.
The Procedure
The surgery was performed using a standard transperitoneal laparoscopic approach under general anesthesia.
Steps Involved
- Positioning and Port Placement:
- The patient was placed in a lateral decubitus position.
- Three to four ports were strategically placed to access the renal hilum and surrounding structures.
- Dissection:
- Careful dissection around the kidney was performed to avoid injury to adjacent organs.
- Adhesions caused by chronic infection and inflammation were meticulously separated.
- Securing the Renal Hilum:
- The renal artery and vein were identified and ligated using advanced laparoscopic instruments.
- The renal artery and vein were identified and ligated using advanced laparoscopic instruments.
- Removal of the Kidney:
- The kidney, along with the staghorn calculus, was placed in an endobag and retrieved through an extended port incision.
- The kidney, along with the staghorn calculus, was placed in an endobag and retrieved through an extended port incision.
- Closure:
- The surgical site was thoroughly irrigated to reduce the risk of residual infection.
- Port sites were closed securely.
Postoperative Management and Outcome
The patient had an uneventful recovery with minimal postoperative pain. Key aspects of postoperative care included:
- Antibiotic Therapy: Tailored based on culture sensitivity reports to prevent infection recurrence.
- Monitoring: Close observation of renal function and electrolyte balance to manage the single functioning kidney.
- Follow-Up: Regular follow-ups to ensure optimal recovery and manage CKD progression.
Significance of the Procedure
This case underscores the importance of a multidisciplinary approach in managing complex renal conditions:
- Expertise in Decision-Making: Identifying the need for nephrectomy based on functional and infection status.
- Minimally Invasive Techniques: Laparoscopy offers significant advantages, including quicker recovery, reduced hospital stay, and minimal scarring.
Conclusion
Laparoscopic nephrectomy for a CKD kidney with a staghorn calculus and pyonephrosis demonstrates the evolving landscape of urological surgery. Under the skilled hands of Dr. M. Roychowdhury and Dr. Rajan Bansal, this procedure exemplifies the integration of advanced surgical techniques with patient-centered care.
The Institute of Urology, Jaipur, continues to set benchmarks in managing complex urological conditions, ensuring that patients receive world-class treatment and outcomes.
