Advanced Management of Complex Transplant Lithiasis: Low Lithotomy and Boot Stirrups Technique

BACKGROUND Transplant lithiasis may be rare but poses significant risk to the renal graft function of the recipient. Immediate management is necessitated upon first detection, to prevent further complications. CASE REPORT We report 2 cases of transplant lithiasis that were not treated immediately upon first detection. The first patient was a 42-year-old man that received a living-donor kidney from his mother, which was complicated by ureterovesical anastomotic stenosis, BK polyomavirus infection, and oliguria. He had a renal stone and 4 ureteric stones in his right allograft. The second patient was a 39-year-old man that finally received a suitable deceased donor kidney after 6 years of dialysis. A 2-3-mm stone was first detected 6 months after transplantation but was managed conservatively. He required management 8 years after transplantation, due to the presence of 2 renal stones and 4 ureteric stones in the left allograft that led to acute renal failure. Both patients required emergent percutaneous nephrolithotomy for decompression, followed by elective antegrade flexible ureteroscopic lithotripsy. Boot stirrups were used throughout all procedures to facilitate access to the lower-positioned transplant kidney. Complete stone clearance was achieved, as detected by a 1-month postoperative follow-up computed tomography scan. CONCLUSIONS Percutaneous nephrolithotomy and antegrade flexible ureteroscopic lithotripsy was a safe and effective approach for complex transplant lithiasis. Very low lithotomy with boot stirrups improved accessibility to the transplant kidney.