Laparoscopic Simultaneous Treatment of Peripelvic Renal Cysts and Stones: Case Series

Laparoscopic pyelotomy combined with ultrasonic lithotripsy via a nephroscope for the treatment of complex renal stones

The purpose of the study was to introduce a novel surgical approach of combining laparoscopic pyelotomy with ultrasonic lithotripsy via a nephroscope for the treatment of complex renal stones. Between May 2021 and April 2023, 32 patients underwent laparoscopic pyelotomy combined with ultrasonic lithotripsy via a nephroscope and their perioperative variables were retrospectively collected and outcomes were assessed. Dissection and incision of the anterior renal pelvis wall was performed via a laparoscope. A 19.5 F nephroscope was introduced into the renal pelvis through a laparoscopic trocar from the incision. Stones were fragmented and sucked out using a 3.3 mm ultrasonic probe placed through the nephroscope. All operations were completed successfully and the stone-free rate at 3 days after operation was 87.5% (28/32). Four (12.5%, 4/32) patients with staghorn stones had a small residual stone in the lower calyx after operation and did not require reintervention. No patient required perioperative transfusion and four (12.5%, 4/32) patients with struvite stones developed postoperative fever, which was successfully treated with intravenous antibiotics. The mean follow-up time was 14.0 ± 7.2 months, with no patient developing long-term complications. This approach offers a safe and effective treatment option for complex renal stones, as the method exhibits a high clearance rate with few complications.

Initial Experience and Evaluation of a Nomogram for Outcome Prediction in Management of Medium-sized (1-2 cm) Kidney Stones

BACKGROUND

The gold standard treatment for solitary medium-sized (1-2 cm) renal stones is not defined by recent guidelines, since management modalities including shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotomy (PNL) are recommended. Improved ability to predict patient outcomes would aid in patients' counseling and decision-making.

OBJECTIVE

To develop a nomogram predicting treatment failure, based on preoperative clinical variables, to be used in the preplanning setting.

DESIGN, SETTING, AND PARTICIPANTS

We recruited 2605 patients from 14 centers and carried out a multicenter retrospective analysis of 699 SWL, 1290 RIRS, and 616 PN L procedures performed as first-line treatment for 1-2-cm kidney stones. The variables evaluated included age, gender, previous renal surgery, body mass index, stone size, location, stone density, skin-to-stone distance, presence of urinary tract infections (UTIs), and hydronephrosis.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multivariate logistic regression was fitted to predict treatment failure, defined as the presence of residual fragments >4 mm. A nomogram was developed based on the coefficients of the logit function.

RESULTS AND LIMITATIONS

A total of 2431 (93.3%) patients were stone free; 174 (6.7%) treatment failures were recorded and considered the event to be predicted. On univariate analysis, type of procedure, preoperative hydronephrosis, stone density, stone location, and laterality turned out to be statistically significant. Skin-to-stone distance, UTIs, and previous renal surgery were predictors of failure on multivariate analysis. Each variable was given a score based on statistical relevance. The main limitation of the current study is its retrospective nature.

CONCLUSIONS

This nomogram provides a prediction of treatment failure and need of reintervention for medium-sized kidney stones. External validation is needed to determine its reproducibility and validity.

PATIENT SUMMARY

We developed a preoperative model of treatment outcomes for 1-2-cm kidney stones. Its application may assist urologists to counsel patients with regard to stone management modality.

Factors Influencing Surgical Outcome in Retrograde Management of Parapelvic Renal Cysts

Objective: To investigate the outcomes of retrograde flexible ureteroscopy in managing parapelvic renal cysts and speculate the factors affecting therapeutic efficacy. Methods: Thirty-eight patients with parapelvic renal cysts were recruited and underwent retrograde flexible ureteroscopy using holmium laser. Parapelvic cysts were divided into peripheral type and central type based on the position of cyst convex to the perirenal tissue. Feasibility and safety were retrospectively evaluated, and cases were analyzed to detect their distinctive characteristics. Independent-sample t-test and chi-square test were undertaken for continuous variables and categorical variables, respectively. Results: Radiologic evidence of success was achieved in 31 (81.58%) cases after a mean follow-up of 14.4 months (range 6-26 months). No significant perioperative complications were identified. There were seven cases with features of peripherally located parapelvic cyst. Four cysts shown as irregular protrusion were unable reduce to less half of previous size. Reductions were recorded in the other three patients with spherically peripheral protrusion. There was significant difference between these two types (p = 0.029). Among the 31 patients with centrally located parapelvic cyst, 28 of these have simple cysts that achieved radiologic success and 3 of the 31 patients were identified as failed cases indicated by renal pelvis enveloped by cyst on radiologic investigation. The success rate of simple cysts was significantly higher than that of the later type (p < 0.001). Conclusion: The location and shape of parapelvic cyst may play a critical role in the radiologic outcome of internal incision and patients with simple central or spherical peripheral cyst may benefit more from retrograde flexible ureteroscopy combined with laser incision.

Long-term outcome after flexible ureteroscopy with holmium laser for simultaneous treatment of a single renal cyst and ipsilateral renal stones

Objective

To assess the long-term outcome of simultaneous treatment of a single renal cyst and ipsilateral stones with transurethral flexible ureteroscopy (FURS) lithotripsy and internal cyst drainage.

Methods

Patients who underwent simultaneous treatment with FURS lithotripsy and internal cyst drainage in our institution between July 2014 and September 2017 were enrolled. The cyst wall was identified endoscopically and a 1–3-cm window was created in the wall using a holmium laser. The proximal end of a double-J stent was placed in the cystic cavity to facilitate internal drainage.

Results

Thirteen patients underwent simultaneous treatment. No intraoperative complications with Clavien grading score >2 were noted in any patients. Mean stone burden and cyst diameter were 1.6 (range: 0.9–2.5) cm and 5.8 (range: 3.0–7.1) cm, respectively. Stone-free rates after single and complementary procedures were 84.6% and 92.3%, respectively. During the mean 33.1-month follow-up period (range: 17–54 months), seven patients (53.8%) achieved full resolution of renal cysts, five patients (38.5%) maintained >50% size reduction, and one patient (7.6%) experienced recurrence at 18 months postoperatively.

Conclusions

FURS with a holmium laser may constitute a safe and effective alternative procedure for simultaneous treatment of a single renal cyst and ipsilateral stones.

Simultaneous treatment of parapelvic renal cysts and stones by flexible ureterorenoscopy with a novel four-step cyst localization strategy

Objective:

To assess the safety, feasibility, and efficacy of simultaneous treatment of parapelvic renal cysts and stones by flexible ureterorenoscopy with a novel four-step cyst localization strategy in selected patients.

Patients and Methods:

We retrospectively reviewed 11 consecutive cases of parapelvic renal cysts with concomitant calculi treated by flexible ureterorenoscopy and laser lithotripsy (FURSL). Marsupialization was performed subsequently with holmium: YAG laser in our institution. Fragmentation was used to manage renal stones and a novel four-step cyst localization strategy was applied in each case for marsupialization.

Results:

There were no intraoperative complications. Two cases of cystitis were reported postoperatively. The mean operative times of FURSL and marsupialization were 23.6 ± 3.9 minutes and 29.1 ± 9.7 minutes, respectively. During marsupialization, seven patients underwent the first two steps of the new strategy, two patients underwent three steps and two patients underwent all four steps. The mean reduction in hemoglobin level was 4.7 ± 1.7 g / L (range 3-8 g / L). The mean length of hospital stay was 1.2 ± 0.4 days. During a mean follow-up duration of 18 months, all cases remained stone-free and there was no stone recurrence. Parapelvic cysts became undetectable in eight cases and decreased in size by at least half in three cases.

Conclusion:

With appropriate patient selection, FURSL and marsupialization with a four-step cyst localization strategy is feasible, safe, and effective in treating parapelvic renal cysts with concomitant calculi.

Percutaneous intrarenal cyst marsupialization and simultaneous nephrolithotomy in selected patients: killing two birds with one stone?

OBJECTIVE

To assess the safety, feasibility, and efficacy of percutaneous intrarenal cyst marsupialization and simultaneous nephrolithotomy in the management of a renal cyst with ipsilateral calculi in selected patients.

MATERIALS AND METHODS

Between July 2010 and August 2013, 16 patients (11 men and 5 women; mean age, 51 years) with a solitary posterior or parapelvic renal cyst and ipsilateral calculi underwent percutaneous intrarenal cyst marsupialization and simultaneous nephrolithotomy in our center. Mean cyst size was 6.3 cm (range, 4.2-11.8 cm). Mean stone surface area was 5.8 cm(2) (range, 1.8-12.1 cm(2)). By preoperative computed tomography planning and interoperative ultrasound guidance, the optimal puncture route was selected carefully to marsupialize the cyst and approach the target calyx. The cyst was marsupialized into the collecting system at the dilation process. Subsequently, percutaneous nephrolithotomy was performed in a standard fashion.

RESULTS

The mean operative time was 68 minutes (range, 47-93 minutes), and the mean hospital stay was 4 days (range, 3-7 days). A nephrostomy tube and a double-J stent were placed for a prolonged period to ensure the channel remained opened. Nearly complete cyst regression and calculi clearance confirmed by postoperative imaging was achieved in all patients. No intraoperative or postoperative complications in Clavien grading score ≥ 2 were noted during a mean follow-up of 21 months (range, 8-25 months).

CONCLUSION

In selected patients with a posterior or parapelvic renal cyst and ipsilateral calculi, the percutaneous technique is a safe and effective option through intermediate follow-up.

The emerging role of robotics and laparoscopy in stone disease

The surgical management of urolithiasis has undergone a remarkable clinical evolution over the past three decades. The once common practice of open stone surgery has nearly been relegated to historical interest by modern technology. The introduction of minimally invasive techniques, laparoscopy and robot-assisted surgery, have emerged to complete the urologist's armamentarium. The benefits to patients when other endourologic procedures have failed include less pain, shorter hospitalization and convalescence, and improved cosmesis. This chapter explores the historical shift from open to minimally invasive management for stone disease and the unique risks and outcomes associated with these procedures in modern urology.

Indications and outcomes of laparoscopic uretero-renal stone surgery

PURPOSE OF REVIEW

Although most ureteral and urinary stones are managed using endourologic techniques or shockwave lithotripsy in daily clinical practice, stone surgery has not completely disappeared. Laparoscopy, another minimally invasive treatment, is continuously gaining place in the treatment of urinary stones, mainly replacing open surgery.

RECENT FINDINGS

Indications for open or laparoscopic stone surgery are anatomic abnormalities, such as horseshoe kidneys, malrotated kidneys, ureteropelvic junction obstruction with stones, or ectopic kidneys; symptomatic stones in diverticula; extremely large stones and all those situations in which conventional endourologic procedures and extracorporeal shock-wave lithotripsy are not available or were unsuccessful or in those conditions where laparoscopy offers a priori the best solution to an endourologic complex condition.

SUMMARY

Laparoscopic surgery is effective for complex urinary stones and allows adjunctive procedures. It complements other minimally invasive procedures, and a need for open surgery has strongly diminished.