Laparoscopic anatrophic nephrolithotomy for managing large staghorn calculi

Robot-assisted anatrophic nephrolithotomy for complete staghorn stone

To assess the efficacy and safety of robot-assisted anatrophic nephrolithotomy (RANL) as a choice of minimally invasive treatment for patients with complete staghorn stone. In a single-tertiary referral center retrospective study, 10 consecutive patients underwent RANL for complete staghorn stone. After dissection to the renal hilum and clamping of the renal vessels, an incision was made along the Brodel line and exposed the collecting system to extract the stone. Then, the collecting system and parenchyma were closed in layers. The outcomes included reduction of the stone burden, short- and long-term postoperative kidney function, and pain score. The average age of patients was 54.6 years and body mass index was 27.58 kg/m2. Mean warm ischemia time was 28.40 minutes, mean robotic console time was 137 minutes, and mean estimated blood loss was 83 mL. The mean length of stay was 5.4 days and there were no severe perioperative complications. Eight of 10 patients had >90% reduction in stone burden and 5 (50%) patients were completely stone-free. There was no significant decrease in postoperative estimated glomerular filtration rate compared with preoperative values after 1 month and 1 year. Our experience with RANL demonstrated efficacy and safety in the minimally invasive treatment of complete staghorn stone in short- and long-term follow-up periods.

Urinary lithiasis - conventional open surgery

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Management of unilateral staghorn renal stones with concurrent urinary tract infections by retroperitoneal laparoscopic pyelolithotomy with prolonged renal posterior lower segment incision

The present study evaluated the effectiveness and safety of the removal of unilateral staghorn renal stones with concurrent infections by retroperitoneal laparoscopic pyelolithotomy (RLP) with prolonged renal posterior lower segment incision. Patients with staghorn renal stone and concurrent urinary tract infection (UTI) who underwent RLP with prolonged renal posterior lower segment incision as the primary, one-session treatment at our institution between March 2014 and December 2017 were retrospectively reviewed. Routine laboratory tests were performed and the patients received broad-spectrum intravenous antibiotics from at least 3 days prior to the operation. All patients were examined pre-operatively by urinary ultrasonography, computed tomography or intravenous urography. UTI was confirmed by laboratory tests with or without radiographic evidence by an experienced urologist. All patients (18 females and 10 males) successfully underwent the procedures and there was no conversion to open surgery in any case. The mean age was 57.0±10.81 years (age range, 40–74 years) and the mean calculus size was 3.3±0.79 cm. The mean operation time, warm ischemia time and post-operative hospital stay were 114.4±12.09 min, 28.1±4.23 min and 5.8±1.42 days, respectively. The mean hemoglobin drop on day 3 following surgery was 0.5±0.38 g/dl and there was no requirement for blood transfusion in any patient. The mean change of serum creatinine levels between pre-operative baseline and post-operative day 3 or post-operative month 6 was 6.0±20.03 or −4.5±15.13 µmol/l, respectively. The stone-free rate was 100% at 3 days and at 6 months. Mild post-operative complications (Grade I or II) occurred in 6 patients, including temporary and constant elevated body temperature (>38.5°C). No severe complications, including urine leakage, sepsis, residual stones requiring auxiliary procedures, were noted and there were no circumstances requiring further surgical intervention in any of the patients. In conclusion, RLP with prolonged renal posterior lower segment incision is an effective and safe procedure for patients with staghorn renal stones and concurrent UTI, and its feasible application as a single-session monotherapy is particularly convenient considering the financial and medical situation, as well as the patients' preference.

The Urological Association of Asia clinical guideline for urinary stone disease

The Urological Association of Asia, consisting of 25 member associations and one affiliated member since its foundation in 1990, has planned to develop Asian guidelines for all urological fields. The field of stone diseases is the third of its guideline projects. Because of the different climates, and social, economic and ethnic environments, the clinical practice for urinary stone diseases widely varies among the Asian countries. The committee members of the Urological Association of Asia on the clinical guidelines for urinary stone disease carried out a surveillance study to better understand the diversity of the treatment strategy among different regions and subsequent systematic literature review through PubMed and MEDLINE database between 1966 and 2017. Levels of evidence and grades of recommendation for each management were decided according to the relevant strategy. Each clinical question and answer were thoroughly reviewed and discussed by all committee members and their colleagues, with suggestions from expert representatives of the American Urological Association and European Association of Urology. However, we focused on the pragmatic care of patients and our own evidence throughout Asia, which included recent surgical trends, such as miniaturized percutaneous nephrolithotomy and endoscopic combined intrarenal surgery. This guideline covers all fields of stone diseases, from etiology to recurrence prevention. Here, we present a short summary of the first version of the guideline - consisting 43 clinical questions - and overview its key practical issues.

Long-term effects of anatrophic nephrolithotomy on selective renal function

To evaluate the long-term changes of selective renal function after anatrophic nephrolithotomy (ANL). A retrospective study was conducted for patients who underwent ANL between January 1995 and December 2016. Inclusion criteria were availability of preoperative and follow-up (1 year or more) radio-isotopic renal scans. Stone-free status was evaluated after 1 month with KUB and ultrasonography or NCCT. Renal isotope scans using 99mTc MAG3 were performed to measure the changes in selective function of the affected kidney (GFR%). Eligible patients were classified into two groups, group 1 patients with stable or improved function and group 2 patients with deteriorated function (> 5% decrease in GFR%). Univariate and multivariate analyses were performed to determine risk factors for deterioration of renal function. The cutoff value for any significant variable was determined using ROC curve. The study included 50 patients with mean age 43.8 + 13.9 years. Complications developed in 26 patients (52%), and stone-free status was documented in 42 patients (84%). After a median follow-up of 2.7 years (range 1-11), mean GFR% of all cases significantly decreased from preoperative value of 52.7% + SD 20 to 45.4% + SD 25% during follow-up (P < 0.001). Deterioration of GFR% was documented in 21 kidneys (42%). Cold ischemia time with a cutoff value 50 min was the independent risk factor (RR 3.986, 95% CI 1.069-14.869, P 0.039). The results of this study support limiting ANL to a selected group of patients and taking all the possible efforts to minimize cold ischemia time below 50 min.

Anatrophic Nephrolithotomy in the Management of Large Staghorn Calculi - A Single Centre Experience

INTRODUCTION

With advances in endourology, open stone surgery for staghorn calculi has markedly diminished. Anatrophic Nephrolithotomy (AN) is performed for complex staghorn stones which cannot be cleared by a reasonable number of Percutaneous Nephrolithotomy (PNL) attempts.

AIM

To assess the indications and outcomes of AN in the modern era.

MATERIALS AND METHODS

Between April 2008 and July 2015, AN was done in 14 renal units in 13 patients. In this retrospective study, demography, stone characteristics, operative details, clearance and long term outcomes were assessed.

RESULTS

AN was performed for complex staghorn calculi involving pelvis and all calyces in 10 patients, infundibular stenosis in two patients and failed PNL in one patient. Mean (SD) in situ cold ischemia time was 47.64 (5.27) minutes. Retroperitoneal drain and double J stent were placed in all 13 patients. Median (IQR) estimated blood loss was 130 (75) ml. There was no perioperative mortality. Surgical site infection was seen in 2 patients and urosepsis in 2 patients. Drain was removed at a mean (SD) of 9.11 (6.15) days. Mean (SD) postoperative length of hospitalization was 15.44 (7.14) days. Stent removal was done in all patients between 2-8 weeks. Median (IQR) clearance was 95 (7.5%). There was no renal failure or new calculi during the follow up period {median (IQR): 1(3) years}.

CONCLUSION

AN is effective in management of large staghorn calculi failed minimally invasive approaches and achieves 80%-100% clearance without much need for secondary interventions. Renal function is preserved and with emergence of laparoscopy and robotics, postoperative stay is minimized with expedited recovery and comparable results with open surgery.

Comparison of safety and efficacy of laparoscopic pyelolithotomy versus percutaneous nephrolithotomy in patients with large renal pelvic stones: a meta-analysis

To compare percutaneous nephrolithotomy (PCNL) and laparoscopic pyelolithotomy (LP) for surgical management for large (>2 cm) renal stones. We searched MEDLINE, Cochrane, and EMBASE databases until March 11, 2015, using the following search terms: renalpelvic stone, percutaneous nephrolithotomy, laparoscopic pyelolithotomy. Randomized controlled and prospective and retrospective two-armed studies were included. Sensitivity analysis and assessment of the quality of the included studies and publication bias were performed. Nine studies were included in the study with a patient population of 622. The studies were homogeneous with respect to the primary end point of stone-free rate, but were heterogeneous with respect to operation time, length of hospital stay, and blood loss. A higher percentage of patients who received LP remained stone-free following surgery compared with patients who were treated with PCNL (p=0.001). However, the mean operation time was longer for patients with LP than for those treated with PCNL (p=0.002). There was no difference between procedures with regard to length of hospital stay or blood loss (p≥0.071). Sensitivity and quality analysis indicated that the data are reliable and the included studies are of good quality. No publication bias was observed. The study suggests that both procedures are effective and safe for removing large renal stones. However, LP may be more efficacious than PCNL in treating large kidney stones.

Robotic Anatrophic Nephrolithotomy Utilizing Near-infrared Fluorescence Image-guidance: Idea, Development, Exploration, Assessment, and Long-term Monitoring (IDEAL) Stage 0 Animal Model Study

OBJECTIVE

To test the feasibility of robotic anatrophic nephrolithotomy (RANL) using near-infrared fluorescence (NIRF) image-guidance for treating staghorn stones, in an in vivo stone surgery model.

METHODS

We developed a novel technique of RANL in a preclinical setting following guidelines on safe surgical innovation from the Idea, Development, Exploration, Assessment, Long-term monitoring (IDEAL) collaborative. We performed 2 RANL procedures on 2 live Yorkshire porcine females (IDEAL stage 0 study). The robot was docked in the flank position and a mini-GelPOINT was placed periumbilically as an assistant port. A model staghorn "stone" was created in vivo by injecting low-viscosity DenMat precision material into the renal pelvis. NIRF image-guidance, following clamping of the posterior renal artery, was used to determine if an anatrophic plane could be identified. One procedure was assessed under cold ischemia, with ice-slush injected onto the renal surface via the mini-GelPOINT.

RESULTS

Both porcine subjects underwent RANL successfully. Replica staghorn models could be created reliably (mean size 5.1 cm; solidification time 2-3 minutes). NIRF image-guidance afforded clear vascular demarcation for precise scoring of an anatrophic plane in both kidneys. The staghorn models were removed in toto through the anatrophic incision in both subjects. Mean blood loss was 160 cc. Mean console and ischemia times were 114 minutes and 34.5 minutes, respectively; ice-slush hypothermia led to a renal surface temperature of 15.4°C.

CONCLUSION

In this IDEAL stage 0 preclinical study, we demonstrated that NIRF image-guidance is able to accurately identify the renal avascular plane, thus permitting an anatrophic approach for robotic excision of staghorn stones.

The management of large staghorn renal stones by percutaneous versus laparoscopic versus open nephrolithotomy: a comparative analysis of clinical efficacy and functional outcome

The objective of this study was to analyze the outcome of percutaneous nephrolithotomy (PCNL), laparoscopic and open anatrophic nephrolithotomy (AN) for management of patients with large staghorn renal stones. We analyzed the peri-operative parameters, overall treatment costs and changes in the function of the affected kidney on technetium-99 dimercaptosuccinic acid renal scintigraphy, done before the operation and before the final follow-up visit, in 45 adults who underwent PCNL (n = 16) versus laparoscopic (n = 15) versus open (n = 14) AN for large staghorn renal stones. All three groups had statistically similar preoperative characteristics, including the function of the operated kidney on renal scan. On the discharge day, the PCNL group had the lowest stone-free rate (43.75 %) compared to the laparoscopic (80 %) and open AN groups (92.85 %) (P = 0.009). After a mean follow-up period of 12.1 months, the decrease in the function of the operated kidney was greatest in the open AN group (-8.66 ± 4.97) compared to the laparoscopic AN (-6.04 ± 6.52) and PCNL group (-2.12 ± 2.77) (P = 0.003). The need for ancillary procedures to manage residual stones was greatest in the PCNL group and lowest in the open AN group. A similar trend was seen in overall treatment costs (P < 0.001). For management of large staghorn renal stones, the more invasive the procedure, the higher the one-session stone-free rate and the lower the need for ancillary procedures; however, greater renal functional loss can be anticipated. The need for ancillary procedures is a major determining factor in the overall cost of treatment, which was highest in the PCNL group.

Combined laparoscopic pyelolithotomy and endoscopic pyelolithotripsy for staghorn calculi: long-term follow-up results from a case series

PURPOSE

Staghorn renal stones are a challenging field in urology. Due to their high recurrence rates, particularly those associated with an infective process, a complete removal is the ultimate goal in their management. We report our experience with a combined approach of laparoscopic pyelolithotomy and endoscopic pyelolithotripsy, the stone clearance rate, and long-term, follow-up outcomes.

METHODS

From June 2012 to October 2014, nine adult patients with large staghorn renal calculi (mean size, 7.2 cm; range, 6.2-9.0 cm) underwent a combined laparoscopic and endoscopic approach. The technique comprised laparoscopic pyelolithotomy and holmium-YAG laser stone fragmentation with the use of a flexible cystoscope introduced through a 12 mm trocar.

RESULTS

The average operative time was 140 min (range, 90-190 min). The mean estimated hemoglobin loss was 0.6 mmol/l (range 0.5-0.7 mmol/l). None of the patients required an open- surgery conversion. The mean hospital stay was 4 days (range, 2-6 days). A computed tomography urogram control at 6 months of follow up did not show any stone recurrence.

CONCLUSIONS

Laparoscopic pyelolithotomy combined with endoscopic pyelolithotripsy could be a therapeutic option in cases where mini-invasive procedures, that is, extracorporeal shock wave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy (PCNL) have failed. This technique has a high stone-clearance rate (75-100%) comparable with open surgery and PCNL. However, it could be technically demanding and should be performed by skilled laparoscopy surgeons.

Review on renal recovery after anatrophic nephrolithotomy: Are we really healing our patients?

The main goals for urinary stone treatment are to preserve renal function, reduce or avoid complications related to calculi, and to render the patient free of calculi as soon as possible. Anatrophic nephrolithotomy (ANL) is a valid and useful alternative for conventional staghorn calculi excision. Although excellent stone free rates can be achieved with ANL there are some drawbacks that may be of concern. Morbidity related to intraoperative and postoperative complications is one of them. Another, great concern is the possibility of reduction on renal function related to the procedure itself. This may be related to nephron injury during nephrotomy and parenchymal closure or to ischemic injury. In this review we assess functional results after anatrophic nephrolithotomy.

Robot-assisted anatrophic nephrolithotomy: description of technique and early results

PURPOSE

To assess the feasibility and report early outcomes of robot-assisted anatrophic nephrolithotomy (RAN) as a treatment modality for patients with complex staghorn calculi.

PATIENTS AND METHODS

In this single-center prospective study, seven consecutive patients underwent RAN for complex staghorn calculi. After dissection to the renal hilum and clamping of the renal vessels, a nephrotomy was made along the Brodel line and dissection carried through the collecting system to the calculus. The stone was extracted, and the collecting system and parenchyma were closed in layers; no cooling of the kidney was performed.

RESULTS

The mean patient age was 47±16 years, mean body mass index was 31.9±10.0 kg/m(2), and five of seven patients had complete staghorn calculi. Mean warm ischemia time was 35±7 minutes, mean robotic time was 158±51 minutes, and mean estimated blood loss was 121±39 mL. Mean length of stay was 3.0±1.7 days, and there was one perioperative complication. Five of seven patients had >90% reduction in stone burden, and two (29%) patients were completely stone free. Mean follow-up time was 5.1±4.3 months, and there was no decrease in postoperative estimated glomerular filtration rate compared with preoperative values.

CONCLUSIONS

Our preliminary experience with RAN demonstrates a safe procedure with encouraging outcomes as a minimally invasive treatment modality for patients with extensive stone burden. Longer follow-up to determine the effect of RAN on renal function is needed.

The history of urinary stones: in parallel with civilization

The roots of modern science and history of urinary stone disease go back to the Ancient Egyptians and Mesopotamia. Hippocrates defined the symptoms of bladder stones. The first recorded details of “perineal lithotomy” were those of Cornelius Celsus. Ancient Arabic medicine was based mainly on classical Greco-Roman works. Interestingly, the Fourth Lateran Council in 1215 forbade physicians from performing surgical procedures, as contact with blood or body fluids was viewed as contaminating to men. With Renaissance new procedures could be tried on criminals. The first recorded suprapubic lithotomy was carried out by Pierre Franco in 1561. In 1874, Bigelow developed a lithotrite, which was introduced into the bladder under anaesthesia (called as “litholopaxy”). Young was the first to report ureteroscopy (1929). With advances in intracorporeal lithotripsy techniques, ureteroscopy became the treatment of choice for ureteric stones. In 1976, Fernstrom and Johannson established percutaneous access to remove a renal stone. However, with the introduction of the first extracorporeal shock wave machine in 1980, a dramatic change in stone management was observed. Civilization in parallel with scientific developments has brought us to a point where we try not to “cut” our patients for stone disease, as Hippocrates admonishes, but rather manage them with minimal invasive alternatives.

Robot-assisted anatrophic nephrolithotomy with renal hypothermia for managing staghorn calculi

Treatment of patients with staghorn calculi with percutaneous nephrolithotomy can be challenging, often necessitating multiple tracts or sessions for complete stone clearance. Although open anatrophic nephrolithotomy can result in higher stone-free rates, it is rarely performed because of increased morbidity. To provide a minimally invasive alternative, we developed the technique of robot-assisted anatrophic nephrolithotomy (RANL) incorporating ice slush for renal hypothermia. Three patients with staghorn calculi (mean total stone volume 12887.67 mm(3)) underwent RANL with iced cold ischemia. A GelPOINT™ port was used for ice slush insertion. Intracorporeal temperatures were <9°C within 30 minutes of cold ischemia. Mean console and cold ischemia times were 167 and 56.7 minutes, respectively. Mean blood loss was 100 mL. There were no complications. Two patients had residual fragments measuring 13 mm, and two 9 mm stones, respectively. RANL with iced cold ischemia is a safe and feasible option that may be considered in patients with staghorn stones. Further study is needed to refine the technique and assess long-term functional outcomes.

Laparoscopic management in stone disease

PURPOSE OF REVIEW

While most renal and ureteral stones can be efficiently managed using endourologic techniques, the use of laparoscopy for the management of urolithiasis is increasing. The application of laparoscopy for stone removal will further reduce the need for open stone surgery.

RECENT FINDINGS

Laparoscopic ureterolithotomy, pyelolithotomy, and anatrophic nephrolithotomy are highly successful techniques with regard to their one-session, high stone-free rates. These procedures could be considered as the preferred approaches when endourologic procedures are not available or have failed. Laparoscopic stone surgery (LSS) in patients with urinary tract anomalies offers a reliable minimally invasive procedure as an alternative to a complex endourologic technique.

SUMMARY

Although laparoscopy still has a limited role in the urologist's armamentarium for the surgical management of urolithiasis, it can further reduce the need for open stone surgery in complex circumstances. LSS duplicates its open counterpart and offers a high one-session, stone-free rate in most patients with a lower morbidity and quicker convalescence. More comparative studies are needed to define the role and indications of LSS in relation to endourologic and open techniques, especially in complex circumstances.

Comparative study of laparoscopic pyelolithotomy versus percutaneous nephrolithotomy in the management of large renal pelvic stones

BACKGROUND

The aim of the study is to investigate whether laparoscopic pyelolithotomy (LPL) could be used to manage large renal pelvic stones, generally considered excellent indications for percutaneous nephrolithotomy (PNL).

METHODS

This study was performed from May 2009 to March 2012 at Al-Azhar University Hospitals (Assiut and Cairo), Egypt. It included two groups of patients with large renal pelvic stones; only patients with stones 2.5 cm(2) or greater were included. Group 1 included 40 patients treated by PNL and Group 2 included 10 patients treated by LPL. The differences between the two procedures were compared and analyzed.

RESULTS

There was no difference between the two groups regarding patient demographics and stone size. There was a statistically significant difference between the groups regarding mean estimated blood loss (65 ± 12.25 [range: 52.75-77.25] vs. 180 ± 20.74 [range: 159.26-200.74] mL, p ≤ 0001), mean hospital stay (2.3 ± 0.64 [range: 1.66-2.94] vs. 3.7 ± 1.4 [range: 2.3-5.1] days, p ≤ 0.006), rate of postoperative blood transfusion (0% vs. 4.8%, p ≤ 0.0024), and stone-free rate (80% vs. 78.6%, p ≤ 0.23). The mean operative time was significantly longer in Group 2 (LPL) (131 ± 22.11 [range: 108.89-153.11) vs. 51.19 ± 24.39 [range: 26.8-75.58] min, p ≤ 0001), respectively.

CONCLUSION

Although PNL is the standard treatment in most cases of renal pelvic stones, LPL is another feasible surgical technique for patients with large renal pelvic stones.

Laparoscopic anatrophic nephrolithotomy for management of staghorn renal calculi

BACKGROUND

Management of staghorn renal stones is still challenging. We present our experience with laparoscopic anatrophic nephrolithotomy as an alternative option for management of staghorn renal calculi.

PATIENTS AND METHODS

Twenty-four patients with staghorn renal calculi underwent 25 laparoscopic anatrophic nephrolithtomy procedures. Characteristics of patients and stones along with perioperative features such as operation time, transfusion, ischemic time, hospitalization, stone-free rate, and biochemical data were recorded prospectively. We applied the one-layer knotless technique for renorrhaphy repair.

RESULTS

The mean age of the patients was 55.1 ± 10.9 years (range, 28-74 years). Eleven (44%) operations were done on the right side, and 14 (56%) were done on the left side. Complete and partial staghorn stones existed in 17 (68%) and 8 (32%) renal units, respectively. The mean stone size was 61.5 ± 11.5 mm. Ischemic time was 30.4 ± 7.55 minutes. The stone-free rate was 88% on discharge and 92% after one session of extracorporeal shockwave lithotripsy.

CONCLUSIONS

Although percutaneous nephrolithotomy is the standard of care for treatment of staghorn stone, laparoscopic anatrophic nephrolithotomy seems to be a safe and feasible option in select patients.

Laparoscopic anatrophic nephrolithotomy for management of complete staghorn renal stone: clinical efficacy and intermediate-term functional outcome

PURPOSE

To report the clinical efficacy and intermediate-term functional outcome after laparoscopic anatrophic nephrolithotomy (LAN) as an alternative treatment modality for complete staghorn renal stone.

PATIENTS AND METHODS

The demographic and perioperative parameters as well as the intermediate outcome of 10 adults (9 men) who underwent transperitoneal LAN for complete staghorn renal stone were analyzed. Functional imaging studies consisted of intravenous urography (IVU) and technetium-99 dimercaptosuccinic acid scintigraphy (99Tc-DMSA) renal scan done before the operation and at the last follow-up visit.

RESULTS

Mean age of patients was 48.7 years (range 37-64 years). Mean stone size was 67.3 mm (50-90 mm). Mean operative time was 192 minutes (110-240 min), and mean warm ischemia time was 32.8 minutes (15-40 min). A few hours after laparoscopy, one patient underwent splenectomy because of significant hemorrhage from a splenic laceration (grade IIIb complication). During the follow-up period early after the operation, we detected an 8-mm lower caliceal stone and a 25-mm midcaliceal stone in one patient each (stone-free rate: 80%). After a mean follow-up of 11.9 months (6-19 mos), 85.5% of corresponding renal unit function was preserved; however, there was a significant mean decrease in 99Tc-DMSA uptake from 48.4%±8.83 before surgery to 41.4%±13.98 afterward (-7%±6.53; P=0.008). Nevertheless, renal units were completely functional at follow-up IVU with a significant improvement in obstruction in all patients.

CONCLUSION

LAN is an alternative minimally invasive approach for one-session management of patients with complete staghorn renal stone. It offers an acceptable rate of stone clearance and operative complications but does incur a minimal loss of function in the affected kidney.

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.

Ureteroscopy-Assisted Retrograde Nephrostomy (UARN) after Anatrophic Nephrolithotomy

Introduction. Open surgical anatrophic nephrolithotomy (ANL) had been the standard treatment for large renal calculi prior to the development of endoscopic devices and endoscopic techniques. A previous report described the efficacy of ureteroscopy-assisted retrograde nephrostomy (UARN) and presented a case of renal calculi successfully treated with UARN during percutaneous nephrolithotomy (PCNL) in a patient after ANL. Case Presentation. A 61-year-old male with left renal calculi was referred for further treatment. The patient was placed under general and epidural anesthesia, in a Galdakao-modified Valdivia position. A flexible ureteroscope (URS) was inserted, and a Lawson retrograde nephrostomy puncture wire was advanced into the flexible URS. The puncture wire then followed the route from the renal pelvis to the exit skin. Calculus fragmentation was undertaken using a pneumatic lithotripter. Conclusions. UARN for PCNL was therefore found to be a safe, effective, and appropriate treatment for a patient presenting with renal calculi after undergoing ANL.

Laparoscopic management of a large staghorn stone

Urinary calculi are prevalent and result in significant morbidity, with a marked economic impact. Various therapeutic options exist, from medical to surgical management according to stone size. Laparoscopic pyelolithotomy is a viable option for significant staghorn renal stones. We report the case of a laparoscopic pyelolithotomy performed on a 48-year-old man with a left recurrent staghorn renal stone secondary to an ureteropelvic junction obstruction following a grade IV renal trauma several years ago.

Transperitoneal laparoscopic heminephrectomy in duplex kidneys: a one centre experience

PURPOSE

The standard treatment for a duplex kidney with poorly functioning upper pole moiety is ipsilateral upper pole heminephrectomy. This procedure is usually performed by open surgery, but with recent developments in techniques of uro-laparoscopy, it can be done with it, safely. In this study we evaluated the results and safety of laparoscopic heminephrectomy in our consecutive cases.

MATERIALS AND METHODS

From February 2001 to May 2007 fourteen unilateral laparoscopic heminephrectomy were performed in our center. Patients' characteristics, presenting symptoms, operative time, and blood loss, early and late complications were all collected retrospectively. Using pre-operative ultrasonography, intravenous pyelography (IVP) and CT scanning, unilateral upper pole hydronephrosis was detected in all cases. By DMSA isotope scan hypofunctioning of ipsilateral moieties was detected in all cases.

RESULTS

Mean operative time was 203±80 minutes. No major intra-operative or early complications were identified. Mean hospital stay was 4.1 days. On mean follow-up of 32 months no disturbing symptoms or episodes of urinary tract infections (UTIs) were detected. Atrophic kidney was detected in one case in post-operative IVP.

CONCLUSION

Laparoscopic heminephrectomy is a valuable minimal invasive procedure that can be performed safely in experienced hands without any important complication. Perfect renal pedicles vascular system manipulation is important for the preservation of renal function post-operatively.

The comparison of laparoscopic pyelolithotomy and percutaneous nephrolithotomy in the treatment of solitary large renal pelvic stones

The aim of the study is to investigate whether laparoscopic pyelolithotomy (LPL) could find a place in the management of large renal pelvic stones which are generally considered as excellent indications for percutaneous nephrolithotomy (PNL). Between 2006 and 2009, 26 consecutive patients with large (>4 cm(2)) renal pelvic stones were treated by LPL and their charts were compared to 26 match-paired patients treated with PNL during the same period. The patients were matched for age, BMI, stone size and location as well as presence of congenital anomalies. Perioperative and postoperative findings were compared. The mean age, mean stone size, rate of congenital anomalies, history open renal surgery and shock wave lithotripsy were similar in both groups (p > 0.05). The mean operation time was 138.40 ± 51.19 (range 70-240) min in LPL group as compared to 57.92 ± 21.12 (range 40-110) min in PNL group (p < 0.0001). There was one (3.8%) open conversion in the LPL group due to dense perirenal adhesions making the dissection difficult. The ureteropelvic junction (UPJ) obstruction concomitant to pelvic stones was successfully repaired laparoscopically in two cases. The mean drop in postoperative hemoglobin level was 0.9 ± 0.6 (range 0-2) g/dl in LPL group and 1.7 ± 1.1 (range 0-4) g/dl in PNL group (p = 0.024). Hospitalization was significantly shorter in PNL than LPL group (p = 0.0001). Stone-free rates were similar. Laparoscopic pyelolithotomy is associated with a longer operation time, is more invasive, and requires more skills when compared to PNL. However, LPL is associated with less blood loss. Laparoscopic pyelolithotomy is indicated for congenitally anomalous kidneys and especially in patients with concomitant UPJ.

Laparoscopic and robot-assisted surgery in the management of urinary lithiasis

Objectives

To review the current role of laparoscopy and robot-assisted laparoscopy for managing urinary lithiasis.

Results

The contemporary indications for laparoscopic stone management are: anatomical variations in location or shape of the kidney (pelvic kidney, horseshoe kidney and malrotated kidney); coexisting pathologies, e.g. pelvi-ureteric junction obstruction; and stones in a renal unit with lower ureteric obstruction. The laparoscopic approach allows the simultaneous management of both the pathologies. Symptomatic stones in diverticula not amenable to endourological intervention can be treated with laparoscopy. Large impacted pelvic and ureteric calculi with a functioning renal unit are an indication for laparoscopic ureterolithotomy or pyelolithotomy. This review of current reports suggests that in a selected group of patients with complex stone disease the laparoscopic approach offers good success rates with minimal complications. There are few reports of robotic procedures in stone disease but existing data suggest that it is feasible.

Conclusion

Laparoscopic surgery is effective for complex renal stones and offers excellent stone clearance rates with minimal morbidity. Laparoscopic surgery is complementary in managing these stones. Robot-assisted laparoscopic technique of urinary tract stone management is in its early stage of implementation and randomised trials that compare robot assisted outcomes with other minimally invasive techniques are needed.

The role of laparoscopic surgery for renal calculi management

To date, most cases of renal calculi have been managed with extracorporeal shockwave lithotripsy and endoscopic procedures. However, for complex renal stone conditions, these minimally invasive procedures may require multiple operative sessions. Open surgery is usually reserved as a salvage procedure, although it is invasive in nature. Laparoscopic treatment is well accepted in renal surgery. For stone disease, it can duplicate open surgical techniques such as pyelolithotomy, pyeloplasty, anatrophic nephrolithotomy, caliceal diverticulectomy and nephrectomy. Although the laparoscopic techniques for stone treatment are quite challenging, it is both feasible and safe. Laparoscopic treatment is a viable option for large renal stone treatment with an excellent stone-free rate, especially when patients require their stones to be treated within a single session. However, it is more invasive in nature than endourology procedures and so should be reserved as the last resort option for renal stone management in the modern endourology era.

Retroperitoneal laparoscopic pyelolithotomy versus extra corporeal shock-wave lithotripsy for management of renal stones

AIM:

The purpose of this study was to evaluate the role of retroperitoneal laparoscopic pyelolithotomy (RPPL) and its comparison with extra corporeal shock wave lithotripsy in the management of renal calculi.

MATERIALS AND METHODS:

The study was carried out in the Department of surgery, Maulana Azad Medical College, New Delhi, India. The study included 86 cases of solitary renal calculi in the retroperitoneoscopic (RPPL) group and 82 cases in the shock wave lithotripsy (SWL) group. The parameters compared were stone clearance, hospital stay, number of postoperative visits, mean time to resume normal activities, number of man days lost, and analgesic requirement.

RESULTS:

The RPPL group showed better stone clearance, fewer hospital visits, low analgesic requirement, fewer number of man days lost, and early resumption of normal activities, as compared to the SWL group.

CONCLUSIONS:

Shock wave lithotripsy, being a noninvasive modality, is an established procedure all over the world. However RPPL achieves comparable or better results in high volume centers.

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.

Laparoscopic pyelolithotomy in selected patients with ectopic pelvic kidney: a feasible minimally invasive treatment option

BACKGROUND AND PURPOSE

Ectopic pelvic kidney is a rare congenital anomaly. It carries more risks for obstruction and stone formation than a normal located kidney. The treatment of renal stones in these patients is challenging. We present our experience with laparoscopic pyelolithotomy for treatment of selected patients with large and multiple renal stones in ectopic pelvic kidneys.

PATIENTS AND METHODS

After insertion of a ureteral catheter, pneumoperitoneum was achieved by Veress needle, and the kidney was exposed. The renal pelvis was identified, dissected, and opened. The stones were extracted using laparoscopic forceps. The rigid nephroscope was used to extract any caliceal stones. The renal pelvis was sutured, and the stones were removed from the peritoneal cavity. The procedure was concluded after placement of an intraperitoneal drain.

RESULTS

A total of 11 patients with large renal pelvic and/or multiple stones underwent laparoscopic transperitoneal pyelolithotomy. A transmesenteric approach was used in eight patients while the colon was mobilized off the kidney in three patients. All stones were removed except one that needed Double-J stent placement and one session of shockwave lithotripsy. After one auxiliary procedure, the stone-free rate was 100%. There were no major intraopertive or postoperative complications. Within a mean follow-up period of 23 months, no stone recurrence occurred.

CONCLUSIONS

Laparoscopic pyelolithotomy for large and multiple stones in ectopic pelvic kidneys is a feasible minimally invasive treatment option. The technique allows removal of all the stones without fragmentation, which may decrease the possibility for rapid stone recurrence.

Laparoscopic surgery for renal stones: is it indicated in the modern endourology era?

PURPOSE

To report the outcomes of laparoscopic surgery combined with endourological assistance for the treatment of renal stones in patients with associated anomalies of the urinary tract. To discuss the role of laparoscopy in kidney stone disease.

MATERIALS AND METHODS

Thirteen patients with renal stones and concomitant urinary anomalies underwent laparoscopic stone surgery combined with ancillary endourological assistance as needed. Their data were analyzed retrospectively including stone burden, associated malformations, perioperative complications and outcomes.

RESULTS

Encountered anomalies included ureteropelvic junction obstruction, horseshoe kidney, ectopic pelvic kidney, fussed-crossed ectopic kidney, and double collecting system. Treatment included laparoscopic pyeloplasty, pyelolithotomy, and nephrolithotomy combined with flexible nephroscopy and stone retrieval. Intraoperative complications were lost stones in the abdomen diagnosed in two patients during follow up. Mean number of stones removed was 12 (range 3 to 214). Stone free status was 77% (10/13) and 100% after one ancillary treatment in the remaining patients. One patient had a postoperative urinary leak managed conservatively. Laparoscopic pyeloplasty was successful in all patients according to clinical and dynamic renal scan parameters.

CONCLUSIONS

In carefully selected patients, laparoscopic and endourological techniques can be successfully combined in a one procedure solution that deals with complex stone disease and repairs underlying urinary anomalies.

Laparoscopic pyelolithotomy: optimizing surgical technique

The classic approach to renal stone disease includes shockwave lithotripsy, ureteroscopy or percutaneous nephrolithotripsy, and, in some cases, a combination of both. The usefulness of laparoscopy in this regard remains debated. In this report and video, we present our technique of laparoscopic pyelolithotomy assisted by flexible instrumentation to achieve maximal stone clearance in a selected group of patients.