MORBID OBESITY AND RENAL STONE: RIRS IS A BETTER MODALITY OF TREATMENT

A30 year old gentleman came to us with right flank pain. On evaluation he had right hydroureteronephrosis and a 9 mm calculus in the upper polar calyx. 

He was morbidly obese with BMI more than 40 but otherwise he was fit for surgery. We routinely get cardiological evaluation in all obese people regardless of the age factor.

We did right URS and a small calculus at the VUJ was removed and DJ stenting was done.Follwed  by ESWL.The localization was difficult because of the adiposity. We delivered around 1000 shock waves at the optimum intensity to the calculus.

We called him after 3 weeks of the procedure and repeated the CT scan test.The stone was now 7 mm and situated at the same calyx and DJ in situ.

We did RIRS with Laser lithotripsy and cleared the calyx.

 

Considering   risk of PCNL in obese individuals ( because of the difficulty in puncture, deep seated calyces needing extra long Amplatz sheath and most important of all the risk of anesthesia in prone position) and difficulty in localization of the stone in ESWL makes them less desired option .

 

It has been noted that RIRS does give equal success in obese patients with renal stone as compared to their normal counterparts. This modality is safe in morbidly obese individuals aslo.The only problem we faced in this case of positioning on the table.

We are of the dogmatic view that these patients should not be offere

d a primary RIRS because of insurmountable difficulties in positioning, anesthesia, risk of DVT and cardiac problems ....we prefer to do DJ stenting and ESWL followed by secondary RIRS.This makes the surgery easier ( because of the ureteric dilatation), and less time consuming ( because of the ESWL the stone size becomes smaller).

Usually it has been found that in morbidly obese people RIRS can result in complications rate between 5-7 % but with due measures like following protocol what we have outlines before, and heparin prophylaxis whenever needed.

Heparinisation is a hurdle for PCNL and ESWL but for RIRS it can be given.So obese individuals who are at risk of peri-operative cardiac events like DVT/Pulmonary embolism are served better by RIRS.