Urologic Treatment Modalities

Prior to the advent of endourologic and laparoscopic techniques, the mainstays of surgical management for symptomatic calyceal diverticula with or without stones included open calyceal diverticulectomy or open partial nephrectomy. Calyceal diver-ticulectomy involved unroofing the thinned area of overlying renal parenchyma, removal of stones, figure-of-eight suture closure of the communicating neck when possible, fulguration of the diverticular surface, marsupialization of the cut diverticular edge, and obliteration of the cavity with perinephric fat. Partial nephrectomy was reserved for deeper lesions that were not amenable to diverticulectomy.

Over the last two decades, increasing experience with minimally invasive techniques has significantly changed the management of symptomatic stone-bearing calyceal diverticula. Nearly all contemporary, minimally invasive approaches have been applied to calyceal diverticula, including extracorporeal shock-wave lithotripsy, retrograde intrarenal surgery, percutaneous endoscopy, and laparoscopy.

Each minimally invasive modality has its own inherent technical limitations, such that "definitive management" of the congenital anomaly itself in the traditional sense, namely complete obliteration of the lesion, may not be possible for certain approaches. Therefore, it is apparent from the reported literature that proper patient selection is paramount to successful outcomes.

Shock-wave lithotripsy has been applied to stone-bearing calyceal diverticula with the primary goal of symptomatic relief of pain, with the understanding that the underlying anomaly remains unchanged. It has been shown that patients with a stone burden of less than 15 mm and a patent diverticular neck on X-ray can achieve symptomatic relief (86%) and stone-free status (58%) with shock-wave lithotripsy alone (8). However, recurrent symptoms and stone formation requiring secondary interventions may be more the rule (9).

The retrograde intrarenal approach allows for balloon dilation or laser incision of the narrow diverticular neck with intracorporeal lithotripsy and stone extraction in the same setting. Generally, no attempt is made to fulgurate the diverticular epithelium. This approach is technically feasible in 70% to 95% of cases, with the majority of failures due to a

The diagnosis of a calyceal diverticulum in itself is not an indication for surgery, because most lesions are found incidentally. However, urologic intervention is warranted if a patient becomes symptomatic as a result of the calyceal diverticulum.

Because it is lined with urothelium, a calyceal diverticulum may potentially harbor urothelial carcinoma, although this is exceedingly rare.

Computed tomography scan enables precise localization of the lesion as well as demonstrates its relation to surrounding structures. Most importantly, it allows for characterization of the renal parenchyma overlying the calyceal diverticulum, which is paramount in selecting patients for a laparoscopic approach.

Each minimally invasive modality has its own inherent technical limitations, such that "definitive management" of the congenital anomaly itself in the traditional sense, namely complete obliteration of the lesion, may not be possible for certain approaches. Therefore, it is apparent from the reported literature that proper patient selection is paramount to successful outcomes.

Percutaneous management of calyceal diverticula Is the most widely used endourologlc modality, providing definitive obliteration of the congenital anomaly.

Successful diverticular eradication via the percutaneous approach appears to be related to the ability to obtain direct diverticular access, performing incision of the infundibular neck, fulguration of the epithelial lining, and placement of a nephrostomy tube. With this in mind, performing a "neoinfundibulotomy" when the true diverticular neck cannot be identified may provide improved outcomes.

lower pole location. When complete stone fragmentation is achieved, with or without the aid of concurrent shock-wave lithotripsy, symptom-free and stone-free rates are more than 90% (10,11). This technique may provide improved drainage of the diverticulum; however, the adynamic cavity remains in situ as a potential source for recurrent symptoms and stones.

Percutaneous management of calyceal diverticula is the most widely used endourologic modality, providing definitive obliteration of the congenital anomaly. This technique involves accessing the diverticulum via a percutaneous tract, which can be dilated up to 30 French. Percutaneous nephrolithotomy is performed in standard fashion. The draining infundibulum, if identified, can be fulgurated, incised, or dilated with a balloon and traversed by a nephrostomy tube. Symptom-free, stone-free, and "diverticular-free" success rates of 75% to 100% have been reported (9,12-14).

Successful diverticular eradication via the percutaneous approach appears to be related to the ability to obtain direct diverticular access, performing incision of the infundibular neck, fulguration of the epithelial lining, and placement of a nephrostomy tube (12,15). With this in mind, performing a "neoinfundibulotomy" when the true diverticular neck cannot be identified may provide improved outcomes (16,17).

This technique involves creating a new direct tract from the diverticulum into the renal pelvis, which can then be dilated for placement of a nephrostomy tube. The angle of approach for the percutaneous access still remains critically important to successful outcomes. As such, a percutaneous approach may not be ideally suited for some anterior or medial diverticula.

Laparoscopic Management of Calyceal Diverticula

It is the most invasive of the closed surgical approaches.

■ Nevertheless, like the percutaneous approach, it definitively removes the underlying congenital anomaly.

■ Unlike the other minimally invasive modalities, it most closely recapitulates the standard open surgical principles, therefore providing the best chance of long-term success.

■ It includes laparoscopic calyceal diverticulectomy and laparoscopic partial nephrectomy, both of which duplicate all open surgical steps.

■ It allows for complete renal exploration and subsequent simple nephrectomy,in cases where the diverticulum causes irreversible renal functional loss.

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