V6-09: Technique for Endoscopic Removal of Calcified Permanent Suture after Pyeloplasty

Video

Introductions and Objectives
In this video we demonstrate our percutaneous endoscopic approach to removal of encrusted permanent suture in the renal pelvis that was placed during pyeloplasty repair. Our index patient had a laparoscopic dismembered pyeloplasty at an outside institution 10 years prior to presenting with flank pain and non-dependent nephrolithiasis. This proved to be encrusted permanent suture material. There is limited data on incidence of nephrolithiasis after UPJ repair, but it is well documented that nonabsorbable suture lines should be avoided in the urinary tract as they may serve as a nidus for stone formation.

Methods
The split-leg prone position was utilized to allow dual access to the renal collecting system utilizing a nephroscope through the flank and ureteroscope through a ureteral access sheath. Two surgeons work in synchronization to apply tension to the permanent suture material to permit transection via holmium: YAG laser lithotripsy. Ultrasonic lithotripsy was used for reduction of stone burden and to provide exposure of suture material. A 200 micron laser fiber and laser settings of 0.3 Joules and 30 Hz were utilized for suture transection.

Results
The patient was stone free and all foreign suture material was removed from the renal pelvis. Operative time was 3 hours and blood loss was 100 ml. Stone composition was 30% calcium oxalate and 70% calcium phosphate.

Conclusions
Nonabsorbable suture lines should not be used in the urinary tract, including pyeloplasty surgery, because they may serve as a nidus for future stone formation. One should consider foreign body a possible etiology for stone formation in patients with non-dependent renal pelvis stones and previous pyeloplasty surgery. Removal of all foreign suture material from the collecting system is desired to reduce likelihood of recurrent stone formation. Endoscopic suture removal in the renal pelvis can be performed safely and effectively utilizing percutaneous access and the split-leg-prone position.

Funding: none