Appendicocalicostomy: A case of mistaken identity
A 32-year-old female patient presented with right flank pain of 3 weeks duration. She had undergone right open pyelolithotomy 6 weeks ago at the private hospital. Intraoperatively, a double J (DJ) stent was placed, which was removed 3 weeks later. Following stent removal she had progressively increasing flank pain. Examination showed a well healed scar of pyelolithotomy and tenderness in the right flank. Her hematological and biochemical investigations were normal. Ultrasonography showed normal left kidney with hydronephrotic right kidney (parenchymal thickness of 7 mm) and 400 ml perinephric collection. A perinephric drain and right percutaneous nephrostomy (PCN) tubes were placed. A total volume of 300 ml of turbid perinephric fluid was drained stat. PCN output was ≈ 1.5 L/day. Drain was removed after 7 days. A right nephrostogram with the right retrograde ureteropyelogram (RGP) was done, which showed complete cut-off at the pelvi-ureteric junction with small intrarenal pelvis and ureter showed complete cut-off at L2 vertebral level [Figure and ]. Length of defect was ≈ 3 cm. After 1 month, right ureterocalicostomy was done. Intraoperatively, there were dense perinephric adhesions. Lower pole of the kidney could be mobilized only in the subcapsular plane and the PCN came out during the mobilization. Ureter was dissected inferomedial to the lower pole of the kidney. Lower polar parenchyma was amputated and ureter was spatulated. Ureterocalicostomy was done over DJ stent. Stent could be placed easily. However, urinary bladder was not distended prior to stent placement; hence, no attempt was made to see retrograde efflux of urine from side holes of cranial end of the stent. Post-operative X-ray showed a malpositioned lower end of stent []. Right RGP showed stent lying outside the ureter []. PCN was placed and nephrostogram was done, which showed that the contrast going into the cecum thereby establishing that the lower pole of the kidney was inadvertently anastomosed to tip of the appendix. Patient was re-explored. Ureter was identified medial to the appendix []. Ureterocalicostomy and appendicectomy was done []. Post-operatively patient made smooth recovery. PCN and DJ stent were removed after 1 week and 6 weeks respectively. Intravenous urography done 6 weeks following stent removal showed patent ureterocalyceal anastomosis with prompt drainage of contrast. Patient is asymptomatic at 1 year follow-up.