Achieving stone-free status and preventing recurrence in calyceal diverticular stones poses a significant challenge. Advances in suction technology improve stone-free rates and reduce morbidity. This report details the treatment of lower pole calyceal diverticular stones in a transplanted kidney using a suction sheath.

A 44-year-old Thai female, who had a kidney transplant in July 2023, presented with recurrent complicated UTIs. CT imaging revealed multiple calyceal diverticular stones up to 1.1 cm in size in the lower pole of the transplanted kidney. After discussing treatment options, the patient opted for mini-ECIRS with a suction sheath. Under general anesthesia, the patient was positioned in lithotomy. Attempts at flexible ureteroscopy with an access sheath failed to visualize the ostium of the diverticulum. Using ultrasound and fluoroscopic guidance, percutaneous access was achieved directly into the lower pole diverticulum with an 18G needle. A guidewire was inserted, and the tract was dilated with 8Fr and 12Fr fascial dilators. A 16Fr working channel was created with a Clear Petra nephrostomy tube. A mini-percutaneous nephroscope was introduced, and laser lithotripsy was performed using a 60W, 550-micrometer TFL (1J, 15Hz). Stone fragments were suctioned away. After confirming stone clearance, the diverticular lining was fulgurated, and the diverticular neck was incised (1J, 10Hz). A 6Fr double-J stent was placed retrogradely, and a 16Fr Foley catheter was inserted.

The procedure achieved stone-free status, diverticular fulguration, and neck incision in single attempt. The total access time was 30 minutes, with 30 minutes of laser time. The patient was discharged on postoperative day 2, and the stent was removed one week later.

This case demonstrates that using a suctioning access sheath in kidney transplant patients with calyceal diverticular stones can achieve a stone-free result without complications, even in complex procedures.