Percutaneous Nephrolithotomy for De Novo Urolithiasis After Kidney Transplantation: A Systematic Review of the Literature

Introduction and Objective: Renal transplantation is the treatment for end stage renal disease that offers better quality of life and survival. Among the possible complications that might affect allografts, urolithiasis might have severe consequences, causing acute kidney injury(AKI) or septic events in immunocompromised patients. Allograft stones might be treated with percutaneous nephrolithotomy(PCNL). The aim of this Cochrane style review was to assess the safety and efficacy of PCNL in patients with renal transplant. Methods: A comprehensive search in the literature was performed including articles between July 1982 and June 2023, with only English original articles selected for this review. Results: The final review encompassed nine articles (108 patients). The mean age was 46.4+/-8.7 years, with a Male:Female ratio of 54:44. The average time from transplantation to urolithiasis onset was 47.54(+/-23.9) months. Predominant symptoms upon presentation were AKI(32.3%), followed by UTI and fever(24.2%), and oliguria(12.9%). The mean stone size was 20.1 mm(+/-7.3mm), with stones located in the calyces or pelvis(41%), uretero-pelvic junction(23.1%), or proximal ureter(28.2%). PCNL(22-30F) was more frequently performed than mini-PCNLs(16-20F) (52.4% vs. 47.6%). Puncture was guided by ultrasound (USS)(42.9%), fluoroscopy(14.3%), or both(42.9%). The stone-free rate (SFR) and complication rates were 92.95% (range:77-100%) and 5.5%, respectively, with only one major complication reported. Post-operatively, a ureteral stent and nephrostomy were commonly placed in 47%, with 4 patients needing a second look PCNL. During an average follow-up of 32.5 months, the recurrence rate was 3.7% (4/108), and the mean creatinine level was 1.37 mg/dL(+/-0.28). Conclusions: PCNL remains a safe and effective option in de-novo allograft urolithiasis, allowing to treat large stones in one step-surgery. A good SFR is achieved with a low risk of minor complications. These patients should be treated in an endourology centre in conjunction with the renal or transplant team.