Percutaneous nephrolithotomy with renal angiomyolipomas: A rare challenge

Renal angiomyolipomas (AML) are vascular tumors associated with a risk of s pontaneous bleeding. Renal trauma may also initiate such hemorrhage, We pre sent a case in which we initially avoided direct puncture and the possible risk of bleeding through extensive renal AMLs and then subsequently perform ed a direct puncture through the tumors. A 21-year-old obese male patient w ith tuberous sclerosis and mental retardation presented to our institution with left renal colic and was found to have a staghorn calculus. A CT scan revealed extensive bilateral renal AMLs. The patient had previously undergo ne renal angioinfarction for an enlarging right-sided AML, and nuclear reno graphy demonstrated 70% function from the left side. The patient had a neph rostomy access created on the morning of a scheduled percutaneous nephrolit hotomy under three-dimensional CT guidance. There was no clinically signifi cant bleeding, Intraoperatively, a second access site was required in order to render the patient stone free. This was done using standard biplanar fl uoroscopic technique and traversed an AML. Both tracts were balloon dilated prior to placement of a 34F Amplatz sheath. Postoperatively, the patient h ad an uneventful recovery. A CT scan performed 1 day postoperatively reveal ed no retroperitoneal collection. This case demonstrates that renal access can be achieved with remarkable accuracy using 3D CT imaging. Furthermore, although this approach seems most prudent in the case of extensive renal AM Ls, fluoroscopically guided renal access and dilation to 34F was not associ ated with bleeding in this patient.