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PURPOSE: We compared the characteristics and outcomes of patients treated with percutaneous nephrolithotomy in the CROES (Clinical Research Office of the Endourological Society) Global Study according to preoperative renal function. MATERIALS AND METHODS: Prospective data on consecutive patients treated with percutaneous nephrolithotomy in a 1-year period were collected from 96 participating centers. The glomerular filtration rate was estimated using the Modification of Diet in Renal Disease formula based on preoperative serum creatinine measurement. Patients were divided into 3 groups by glomerular filtration rate, including chronic kidney disease stages 0/I/II-greater than 60, stage III-30 to 59 and stages IV/V-less than 30 ml/minute/1.73 m(2). Patient characteristics, operative characteristics, outcomes and morbidity were assessed. RESULTS: Estimated glomerular filtration rate data were available on 5,644 patients, including 4,436 with chronic kidney disease stages 0/I/II, 994 with stage III and 214 with stages IV/V. A clinically significant minority of patients with nephrolithiasis presented with severe chronic kidney disease. A greater number of patients with stages IV/V previously underwent percutaneous nephrolithotomy, ureteroscopy or nephrostomy and had positive urine cultures than less severely affected patients, consistent with the higher incidence of staghorn stones in these patients. Patients with chronic kidney disease stages IV/V had statistically significantly worse postoperative outcomes than those in the other chronic kidney disease groups. CONCLUSIONS: Poor renal function negatively impacts the post-percutaneous nephrolithotomy outcome. By more aggressive removal of kidney stones, particularly staghorn stones, at first presentation and more vigilantly attempting to prevent recurrence through infection control, pharmacological or other interventions, the progression of chronic kidney disease due to nephrolithiasis may be mitigated.

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Minimally invasive dismembered pyeloplasty has become the gold-standard treatment for symptomatic pelvi-ureteric junction obstruction (PUJO) in recent years. A small proportion of patients with PUJO have horseshoe kidneys. We present two cases of robot-assisted pyeloplasty in horseshoe kidneys and describe the technical modifications for success in these cases. Two patients, aged 28 and 35 years, were diagnosed with symptomatic PUJO in horseshoe kidneys. Both had a robotic-assisted laparoscopic dismembered pyeloplasty using the da Vinci(®) surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Three-dimensional computed tomography (CT) reconstructions were performed pre-operatively to plan surgery. The transperitoneal ports were placed more caudally than usual for improved access to the PUJ. The isthmus was not divided in either case. The procedures took 190 and 90 min, respectively, with minimal blood loss and no post-operative complications. Patients were discharged on post-operative day 2 following catheter and drain removal. Follow-up diuretic renograms showed no residual obstruction and patients were symptomatically better. Our initial experience suggests that RALP is a safe and feasible option for the treatment of PUJO in horseshoe kidneys with good short-term outcomes. These are challenging cases and robust pre-operative planning combined with technical modifications has been beneficial to our success. The enhanced suturing possible with the da Vinci(®) surgical system facilitates these procedures.

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