Endoscopic Management of the Symptomatic Caliceal Diverticular Calculus

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Abstract
Caliceal diverticular calculi are most often asymptomatic and of little clinical significance. In certain cases they may be associated with flank pain, pyuria and chronic urinary tract infections. Treatment has evolved from open surgical techniques to a purely endoscopic approach. Percutaneous techniques are frequently used to address the diverticular stone burden and to dilate the diverticular neck, improving drainage. Small volume caliceal diverticular calculi and those in the anterior portion of the collecting system represent a greater technical challenge to the endoscopist. We describe a purely retrograde endoscopic technique for treating small stone burdens trapped in caliceal diverticula. Flexible ureteroscopy combined with 3F dilating balloons passed through the endoscopic working channel facilitated treatment. This retrograde technique was combined with a simultaneous primary percutaneous puncture into the diverticulum to treat larger stone burdens and calculi within long-necked diverticula. This combination facilitated prompt, through and through access of a percutaneously placed guide wire, increasing the overall efficiency of treatment. In conclusion, a retrograde endoscopic technique using the actively deflectable, flexible ureteroscope can successfully treat certain caliceal diverticular calculi. By combining this technique with a simultaneous percutaneous puncture, caliceal diverticular calculi throughout the collecting system may be cleared expeditiously.