Treatment of Kidney Stones in a Duplicated Collecting System: Totally Tubeless Dual Tract Supine Mini-Percutaneous Nephrolithotomy—A Feasible Option

Introduction: Managing stones in duplicated kidneys is complex. In percutaneous nephrolithotomy (PCNL), superior calyces cannot be accessed from inferior punctures. We present a case of totally tubeless mini-PCNL with separate large stones in both upper and lower pole kidney duplicated moieties. Case History, Examination, and Investigations: A 74-year old gentleman presented with left renal colic and gross hematuria. Contrasted Computed Tomography Urogram revealed a partially duplicated left renal system with a 3900 mm 3 stone in the upper moiety and 609 mm 3 stone in the lower moiety. Intervention: After discussing treatment options, mini-PCNL was chosen. Cystoscopy was normal. Intraoperative ureteroscopy confirmed a duplex system with the ureter merging in the distal ureter and tight opening to lower pole moiety. Dual puncture tracts were made via ultrasound—17.5 Fr sheath to the upper pole moiety, and 16 Fr sheath to lower pole moiety. Lithotripsy was performed through a Karl Storz 12 Fr Nephroscope. with a Dornier Medilas H Solvo 35 W holmium:YAG laser at fragmentation settings of 1.2 J × 10 Hz. The patient was endoscopically stone free at the end of procedure. A totally tubeless approach was employed due to minimal bleeding and good antegrade contrast flow. Follow-Up/Outcome: Postoperative hemoglobin and creatinine levels were stable, with discharge on postoperative day 2. Postoperative X-rays at day 1 and 3 months had no residual fragments. Conclusion: Dual tract mini-PCNL is feasible in duplex kidneys with careful planning and counseling. Consideration of tract number, size, possible retrograde access, and exit strategy (tubeless or totally tubeless) is crucial for optimizing treatment efficacy and minimizing complications. Disclosure Statement: There are no conflicts of interest or obligations from the source of this work. Source of Work: Author(s) have received and archived patient consent for video recording/publication in advance of video recording of the procedure. Source of Music: https://motionarray.com/royalty-free-music/autumn-garden-1199574/ . Runtime of video: 5 min 00 sec.