Percutaneous Nephrolithotomy for Large Renal Pelvic Calculus in a High-Risk Patient: Large renal pelvic calculi can lead to obstruction, pain, and progressive renal damage, especially in patients with multiple comorbidities. Percutaneous Nephrolithotomy remains the gold standard for managing large renal stones. We present a case of a middle-aged male with a large left renal pelvic calculus and mild hydronephrosis, successfully treated with PCNL and DJ stenting. Despite associated comorbidities including diabetes mellitus, hypertension, coronary artery disease, and cholelithiasis, the patient had an uneventful recovery with complete stone clearance.
Introduction
Renal stone disease is a prevalent urological condition that can range from asymptomatic calculi to large obstructive stones causing significant morbidity. Large renal pelvic stones often require surgical intervention, particularly when associated with hydronephrosis.
Management becomes more challenging in patients with systemic comorbidities such as diabetes mellitus, hypertension, and coronary artery disease (CAD). Minimally invasive approaches like PCNL have revolutionized treatment by offering high success rates with reduced morbidity.
Case Presentation
A 51-year-old male presented with complaints of intermittent left flank pain and episodes of vomiting over the past few days. There were no associated urinary complaints such as hematuria or dysuria.
The patient was a known case of:
- Diabetes mellitus
- Hypertension
- Coronary artery disease (CAD)
He was on regular medication and had been taking antiplatelet therapy (Ecosprin 75 mg), which had been discontinued three months prior to presentation.
There was no prior history of surgical intervention.
Investigations
Laboratory evaluation revealed:
- Serum creatinine: 1.1 mg/dL
Ultrasonography findings included:
- Large left renal pelvic calculus
- Mild hydronephrosis of the left kidney
- Cholelithiasis
- Prostatomegaly (Grade II, approximately 37 grams)
- Mild post-void residual urine (35 ml)
Intravenous pyelography (IVP) showed:
- Normally functioning right kidney
- Large left renal pelvic calculus with mild hydronephrosis
Preoperative cardiac and pulmonary assessments:
- Chest X-ray: Normal
- ECG: Within normal limits
- 2D echocardiography: Normal study with LVEF of 60%
Diagnosis
- Large left renal pelvic calculus
- Mild left hydronephrosis
- Diabetes mellitus
- Hypertension
- Coronary artery disease
- Cholelithiasis
Treatment Plan
Given the size of the stone and associated symptoms, surgical management using a minimally invasive approach was planned after thorough evaluation and counselling.
Surgical Procedure
The patient underwent:
- Cystoscopy
- Left retrograde pyelography (RGP)
- Percutaneous Nephrolithotomy with Double J (DJ) stenting
under general anesthesia.
Intraoperative Findings
- High bladder neck, making entry into the bladder technically challenging
- Large left renal pelvic stone
Procedure Details
- Cystoscopy was performed; the bladder was accessed with some difficulty due to a high bladder neck
- A ureteric catheter was placed
- The patient was positioned prone
- RGP confirmed stone location and pelvicalyceal anatomy
- Percutaneous access was obtained via the lower posterior calyx
- A 22 Fr tract was created
- Stone fragmentation was performed using a lithoclast
- Complete stone clearance was achieved
- DJ stent was placed for drainage
- A nephrostomy tube was placed at the conclusion of the procedure
- Foley catheterization was done
The patient tolerated the procedure well without intraoperative complications.
Postoperative Course
The postoperative period was uneventful.
Follow-up imaging (USG/X-ray) demonstrated:
- No residual large calculi
- Mild fullness of the pelvicalyceal system
- DJ stent and nephrostomy tube in situ
- No perinephric collection
The nephrostomy tube was removed on postoperative day 1. The patient showed good recovery with relief of symptoms and was discharged in stable condition.
Discussion
Large renal pelvic stones are best managed with Percutaneous Nephrolithotomy, which provides:
- High stone-free rates
- Direct access to the renal collecting system
- Effective fragmentation of large calculi
This case highlights several important considerations:
1. Management in High-Risk Patients
Patients with diabetes, hypertension, and CAD require careful perioperative planning. Preoperative optimization and multidisciplinary evaluation are crucial for safe outcomes.
2. Technical Challenges
The presence of a high bladder neck can make cystoscopic access difficult, requiring expertise and careful instrumentation.
3. Efficacy of PCNL
Despite comorbidities and anatomical challenges, complete stone clearance was achieved in a single session, demonstrating the effectiveness of PCNL.
4. Importance of Drainage
DJ stenting and nephrostomy placement ensured adequate postoperative drainage and minimized complications.
Conclusion
PCNL is a safe and effective treatment for large renal pelvic calculi, even in patients with multiple comorbid conditions. With proper planning and surgical expertise, excellent outcomes can be achieved with minimal complications.
Clinical Message
- Large renal stones should be managed promptly to prevent complications
- PCNL remains the gold standard for large renal calculi
- Patients with comorbidities can be safely treated with appropriate perioperative care
- Surgical expertise is critical in managing anatomical and technical challenges
About the Institute
This case was successfully managed at the Institute of Urology, Jaipur, a center equipped with advanced endourological and minimally invasive surgical facilities. Under the expert care of Dr. M. Roychowdhury and Dr. Rajan Bansal, complex urological cases are handled with precision and safety. The institute provides comprehensive services including consultation, diagnostics, surgical management, and follow-up care under one roof, ensuring optimal patient outcomes.
