Lingeman and colleagues report a new and better approach to the stone laden calyceal diverticulum. Specifically, they are entering the calyx directly via an infracostal approach and then dilating the tract, removing the stone, and using a roller ball electrode to fulgurate the interior of the diverticulum. Key to this approach is the use of a removable core J-tipped guidewire so that sufficient coil of the wire can be secured within the diverticiulum while providing a stiff wire shaft for the passage of sequential and balloon dilators; in addition, the part of the tract directly adjacent to the diverticulum had to be manually dilated using the 11F alligator forceps under nephroscopic control! Following stone removal, the diverticular neck is neither sought nor cannulated; no ureteral catheters are placed prior to the procedure.

As a result, much time is saved; the average procedure took only 58.5 minutes; 95% of the patients were discharged to home on postoperative day one. A drainage tube was placed just into the diverticulum; these tubes were routinely removed on the first postoperative day. Among 21 patients treated in this manner (16 with 3 month follow-up), the stone free rate was 86% (by CT scan) and the diverticulum resolution rate was 88% (by IVP). The method is more efficient and the results are equal to earlier reports of percutaneous calyceal diverticular treatment which involved treating the neck of the diverticulum. Indeed, the operative time is reduced by almost 2 hours and the hospital stay is decreased by 1-3 days. However, this is a more sophisticated approach requiring increased levels of skill, since maintaining the guidewires within the diverticulum, avoiding trauma to the delicate wall of the diverticulum (and resultant bleeding), and preventing stone fragments from lodging into the inflamed wall of the diverticulum are all challenges that must be overcome in order to have a successful outcome. To be sure, the authors are to be congratulated for their significant skill in these regards.

J. Urol. 173: 1194-1198, April 2005