Kothapalli S, Sriskandaraja T, Palaniyandi V, Sekar H, Krishnamoorthy S. Virtual reality-enabled precision in percutaneous nephrolithotomy - strategic access planning in a malrotated kidney: A case report. World J Clin Cases 2026; 14(20): 121605 [DOI: 10.12998/wjcc.121605]
Corresponding Author of This Article
Sriram Krishnamoorthy, Professor, Department of Urology and Renal Transplantation, Sri Ramachandra Institute of Higher Education and Research, 1 Ramachandra Nagar, Porur, Chennai 600116, Tamil Nadu, India. sriramuro@gmail.com
Research Domain of This Article
Urology & Nephrology
Article-Type of This Article
case-report
Open-Access Policy of This Article
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Sushmitha Kothapalli, Thalapathiraja Sriskandaraja, Velmurugan Palaniyandi, Hariharasudhan Sekar, Sriram Krishnamoorthy, Department of Urology and Renal Transplantation, Sri Ramachandra Institute of Higher Education and Research, Chennai 600116, Tamil Nadu, India
Author contributions: Kothapalli S contributed to conceptualization, data collection, literature review, manuscript drafting, and preparation of figures; Sriskandaraja T contributed to clinical data acquisition, manuscript editing, and literature review; Palaniyandi V contributed to operative management and critical revision of the manuscript; Sekar H contributed to image acquisition, data interpretation, and manuscript review; Krishnamoorthy S contributed to study supervision, surgical planning, critical revision of the manuscript, and correspondence responsibilities; and all authors read and approved the final manuscript.
AI contribution statement: Artificial intelligence-assisted language tools were used for language refinement, grammatical editing, and manuscript structuring during preparation of this article. All scientific content, clinical interpretation, figure preparation, and final manuscript approval were independently reviewed and verified by the authors.
Informed consent statement: Written informed consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Sriram Krishnamoorthy, Professor, Department of Urology and Renal Transplantation, Sri Ramachandra Institute of Higher Education and Research, 1 Ramachandra Nagar, Porur, Chennai 600116, Tamil Nadu, India. sriramuro@gmail.com
Received: March 30, 2026 Revised: May 31, 2026 Accepted: June 15, 2026 Published online: July 16, 2026 Processing time: 103 Days and 14.4 Hours
Abstract
BACKGROUND
Percutaneous nephrolithotomy (PCNL) can be technically challenging in patients with congenital renal tract anomalies, particularly when establishing safe and accurate percutaneous access. Malrotation of the kidneys is the most common type of renal anomaly and alters the spatial relation between the hilum and calyceal system relative to their normal anatomical position. The use of fluoroscopic landmarks in these cases has been shown to be unreliable because of the altered spatial relations. There is an increased risk of access-related complications secondary to abnormal anatomy. The application of virtual reality (VR) based on three-dimensional reconstruction represents a new approach for improving the surgeon’s ability to understand spatial anatomy prior to performing a procedure.
CASE SUMMARY
A 57-year-old woman was referred to our institution for right-sided loin pain of 1 year’s duration. The patient underwent computed tomography urogram, which showed a malrotated right kidney with an anterolateral hilum. There was evidence of a renal pelvic calculus measuring 2.4 cm × 1.7 cm (1569 Hounsfield units). Mild hydronephrosis was observed. Using DICOM data derived from the computed tomography images, a three-dimensional VR model was created, allowing visualisation of the renal axis, pelvicalyceal anatomy, surrounding rib cage, and major vascular structures. Utilising this immersive environment to plan the procedure allowed us to identify the posterior lower calyx as the optimal site for percutaneous access and to delineate a subcostal percutaneous trajectory to minimise procedural risks. The VR-based operative plan was successfully translated into the operative setting, where we achieved single-tract access, complete stone removal, and an uncomplicated postoperative recovery.
CONCLUSION
This case demonstrates the feasibility of VR-assisted preoperative planning for PCNL in anatomically complex kidneys.
Core Tip: Immersive virtual reality reconstruction from computed tomography DICOM data may assist with preoperative access planning during percutaneous nephrolithotomy in anatomically complex kidneys by improving appreciation of calyceal orientation and access trajectory.
