04 June 2023: Articles
Incidental Finding of Intrarenal Foreign Guidewire During Percutaneous Nephrolithotomy: A Case Report and Literature Review
Challenging differential diagnosis, Unusual or unexpected effect of treatment, Diagnostic / therapeutic accidentsLin Xiong 1ABCDEF*, Kristine J.S. Kwan 2BCDEF, Jian Hou1CD, Zhen-Quan Lu1A, Geng-Geng Wei1BD, Xiang Xu1BD
Am J Case Rep 2023; 24:e939700
BACKGROUND: Percutaneous nephrolithotomy (PCNL) is indicated for large renal calculi (≥2 cm) and is often the treatment of choice due to its high success rate. Guidewire fragmentation is a rare procedural accident that can occur in PCNL but may be missed. Retention of the fragment within the upper urinary tract can lead to further complications, such as recurrent nephrolithiasis or impairment of renal function.
CASE REPORT: We present the case of a 54-year-old man who experienced right flank pain for 5 days. His history was significant for recurrent nephrolithiasis, managed by PCNL in other hospitals. The most recent procedure was conducted 4 years ago, and his perioperative course was uneventful. Preoperative computed tomography revealed right renal calculi and a C-shaped foreign body. He was scheduled for an elective PCNL. The foreign body was intraoperatively identified as a guidewire fragment and removed.
CONCLUSIONS: Currently, there is no standard management for intrarenal foreign bodies. Suspicion should be raised in young patients with recurrent stones within a short period of time. A thorough history on past urological interventions should be obtained. Symptoms can also have an insidious onset that could mimic nephrolithiasis or urinary tract infections. Extraction can be done via a standard minimally invasive approach. It is also the surgeon’s responsibility to check the integrity of intraoperative instruments so as to minimize risks of complication and reassure the patient.
Keywords: case reports, Foreign Bodies, Nephrolithotomy, Percutaneous, Postoperative Complications
Foreign bodies of the upper urinary tract are rare. Gondos classified this phenomenon into 3 types based on the route of entry, including direct penetration through traumatic injury, penetration via the adjacent gastrointestinal tract due to perforation, and retrograde migration from the lower urinary tract . Patients remain asymptomatic until the foreign object complicates into sepsis or migrates into other organs .
Percutaneous nephrolithotomy (PCNL) is the standard treatment for large renal stones and is generally accepted as a safe procedure. Common complications include extravasation, transfusion, and fever, which can be managed conservatively . We report a case of a 54-year-old man with a 5-day history of right flank pain. He underwent elective PCNL. Intraoperative findings were an intrarenal foreign body that resulted from a previous PCNL procedure and multiple renal calculi.
A 54-year-old man was admitted to our department due to an abrupt onset of right flank pain that persisted for 5 days. He was afebrile and his vital signs were stable. His history was significant for recurrent nephrolithiasis that was previously managed by PCNL in other hospitals. The most recent procedure was 4 years ago. Physical examination revealed right costovertebral angle tenderness. Biochemical results revealed an elevated white blood cell count (12.42×109/L), serum creatinine level (1.6 mg/dL), and C-reactive protein level (70.4 mg/L). Urinalysis detected large amounts of white blood cells (3771.9/uL) and red blood cells (174.7/uL).
Preoperative computerized tomography (CT) urogram revealed multiple stones in the right renal calyces (largest measuring approximately 25.8×15.9 mm; mean density 1013.9 HU, maximum density 1429.0 HU) and hydronephrosis. A hyperdense unidentified curved object was found in the inferior pole calyx (Figure 1). The patient denied a history of trauma, ingestion of sharp objects, or self-inserting foreign object via the lower urinary tract. He was scheduled to undergo elective PCNL for the removal of his stones and the foreign object.
Under general anesthesia, the patient was placed in a prone position. The puncture point was selected under ultrasound guidance, and a vertical incision was made through the skin into the lower pole of the right kidney. Using an 18 French fascial dilator to establish a clear PCNL passage, the flexible ureteroscope (Redpine, Guangzhou, China) was inserted to access the pelvis and found multiple renal calculi (largest 19×10 mm). The calculi were initially fragmented by a pneumatic lithotripter (Swiss Lithoclast, EMS, Le Sentier, Switzerland) and extracted with stone forceps. The foreign body was identified among the remaining stone debris and was carefully removed. The remaining calices had to be fragmented by holmium laser lithotripsy (Lumenis Pulse, Boston Scientific, NJ, USA) so as to achieve better stone clearance. The operation was completed after insertion of a double J stent. Postoperative inspection identified the foreign body as the soft tip of a guidewire, presumably from his last PCNL procedure (Figure 2). The stones were sent for component analysis and returned as 100% calcium oxalate monohydrate.
The patient’s postoperative course was uneventful, and he was discharged as soon as his right flank pain resolved. He was scheduled for follow-up 1 month later to have the double J stent removed, which was done successfully.
In the past, it was thought that retrograde migration of foreign bodies from the lower urinary tract was the least common reason for the introduction of an intrarenal foreign body. However, minimally invasive techniques have proliferated over the past several decades in the field of urological intervention . Although the delicate instruments are made of durable materials, fragmentation can occur on rare occasions. Hence, the increasing frequency of intrarenal endoscopic surgery for upper urinary tract renal pathologies have shifted to the most common etiology. Eisenberg et al retrospectively reviewed 21 patients with retained renal foreign bodies from previous endoscopic and/or percutaneous manipulation, most of which belonged to renal stents, followed by nephrostomy tubes, and a guidewire fragment .
Intrarenal foreign bodies can serve as a nidus for stone formation under extended exposure to urine . In this patient, we found a guidewire fragment that may have been retained in the renal pelvis ranging from 4 to 10 years among the multiple renal stones. We were unable to determine the exact duration as there was no previous radiographic record. In the literature, only 7 cases of a ruptured guidewire in the upper urinary tract were identified [5,7–11]. All patients had undergone prior urological intervention. Individuals can remain asymptomatic for years or demonstrate irritative symptoms. Hematuria and flank pain are the most common symptoms, especially for upper urinary tract foreign bodies . In severe cases, patients can present with hydronephrosis and urosepsis.
The mechanism of retrograde migration of the foreign body has not been elucidated. Guidewire fragments may simply penetrate and embed the renal parenchyma with their sharp edges. Several hypotheses have been proposed for patients whose prior procedure involved anastomosis: (1) excessive suture tension promotes chronic continuing erosion ; (2) delayed anastomotic site healing due to underlying chronic renal disease and diabetes ; and (3) erosion occurring alongside sheer stress within the body . Atypical presentations, such as a foreign body granuloma mimicking renal tumor, have also been documented . In such cases, granulomatous hypertrophic evolution can be facilitated by cell-mediated immunologic reaction against the foreign body .
There is no standard management for retrieval of an intrarenal foreign body. Management can be challenging depending on its size, shape, mobility, and location [5,11]. PCNL is the criterion standard for stones larger than 2 cm and is therefore a viable option for the removal of foreign bodies of a similar size. Extensive fragmentation and retrieval of nearby renal stones can be necessary, as demonstrated in our patient. Retrograde intrarenal surgery and flexible ureteroscopy were also feasible methods [7,18]. In severe cases in which the patient’s renal function has been compromised, nephrectomy may be the best solution . Regardless, minimally invasive procedures remain a better choice.
Sahai et al described encountering 4 cases of a retained foreign body in their 650 flexible ureteroscopy procedures, making its incidence 0.6% . However, such incidents can be largely prevented by checking the integrity and completeness of the intraoperative instruments before and after their application. According to Smith, wire fragmentation can occur after wire is over rotated, entrapped, or wedged in stenotic segments, or during excessive bending . Therefore, the possibility of wire damage should be considered when resistance is met during withdrawal.
There is no standard management for intrarenal foreign bodies. Preoperative assessment of patient status is necessary, especially the patient’s renal function. A thorough history on past urological interventions should be obtained. Symptoms can also have an insidious onset that could mimic nephrolithiasis or urinary tract infections. Extraction can be done via a standard minimally invasive approach, similar to that of stone removal. It is also the surgeon’s responsibility to check the integrity of intraoperative instruments so as to minimize risks of complication and reassure the patient.
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