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. 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.


INTRODUCTION
ized the treatment of urinary stones to the point they have rendered open stone surgery anachronistic (1).Procedures like open ureterolithotomy, open nephrolithotomy, or open pyelolithotomy have become anecdotal.However, patients with large stone burdens and associated renal malformations are prone to rehave their stones retrieved and anomalies repaired.

Clinical Urology Clinical Urology
Thus in these selected patients, open stone surgery can laparoscopy, this can be a feasible option if the goals of stone clearance and correction of malformations invasive surgery.
ence and evaluate the outcomes of laparoscopic sur-gery in combination with endourological procedures involving a variety of cases of renal stones in the setting of underlying urinary tract malformations.

MATERIALS AND METHODS
The data of twenty-nine patients who underwent laparoscopic procedures for kidney stones between January 2004 and May 2007 were retrospectively analyzed.Retrieved data included indications for intervention, stone burden, associated malformations, perioperative complications and outcomes in terms of functional results and stone free status.Fifteen patients underwent laparoscopic nephrectomy due to non functioning kidneys and were not included in the present study.One patient underwent laparoscopic pyelolithotomy without harboring un- The remaining thirteen patients underwent laparoscopic stone removal and reconstructive procedures combined with ancillary endourological assistance as needed.Preoperative stone scenario and associated anomalies are detailed in Table -

SURGICAL TECHNIQUE Laparoscopic Pyeloplasty and Pyelolithotomy / Flexible Nephroscopy
The operative room setting includes one laparoscopic cart and one endourological cart to enable simultaneous laparoscopy and nephroscopy.Using a four port transperitoneal approach, the ureter is identirenal pelvis dissected.The renal pelvis is opened above the UPJ, the ureter is spatulated on its lateral aspect and dismembered.Stones in the renal pelvis are removed with an atraumatic grasper and placed in a laparoscopic one of the 10 mm ports and guided laparoscopically through the opening in the renal pelvis.The kidney is systematically inspected and calyceal stones removed with a basket or fragmented with Holmium:YAG laser lithotripsy.A double J stent is introduced in an antegrade fashion, the renal pelvis is reduced as needed, and ureteropelvic anastomosis is performed with two (one posterior and one anterior) 4/0 polyglactin running sutures.A percutaneous drain is placed and the bag with stones removed (Figure -4).

Laparoscopic Nephrolithotomy
calyceal stones were associated with infundibular ticulum.After widely incising the renal pelvis, the nephrotomy is made in the kidney as indicated by the endoscopic light.The stone is removed and the kidney sutured with one layer 2/0 polyglactin (Figure -5).

Laparoscopic Anatrophic Nephrolithotomy
The kidney is dissected from the surrounding bloc with a laparoscopic Satinsky clamp.The renal parenchyma and collecting system are incised longitudinally on the postero-lateral aspect of the kidney; the staghorn stone is mobilized with graspers, removed and placed in an endobag.A 16 F Foley catheter is placed as a nephrostomy tube by making a small incision in the kidney away from the nephrotomy line.The kidney is sutured with a running 2/0 polyglactin single layer that includes renal capsule, parenchyma,

RESULTS
Mean age at surgery was 36 years (range 18-56), ASA score 2 (range 1-2), and average number of stones removed was 12 (range 3 to 214).Laparoscopic pyeloplasty combined with pyelolithotomy and laparoscopic pyeloplasty with pyelolithotomy and endoscopic-assisted nephrolithotomy was performed in two; and laparoscopic anatrophic nephrolithotomy was performed in one patient (Table-2).
A double J stent and percutaneous drain was left postoperatively in all patients.Additionally, a nephrostomy drain using a 16 Fr Foley catheter was placed in two patients.All the procedures were completed laparoscopically with no conversions to open patients with lost stones in the abdomen diagnosed during follow up (Figure -7) and variable degrees of copy in several others.One patient had a postoperative stent, which was not replaced at the time of surgery,

Procedure Indication
Patients with UPJO and associated pelvic and calyceal stones and most probably chronically obstructed.Leakage was discovered during early postoperative period drain.Cystoscopic replacement of the double J stent effectively treated the complication and the patient was discharged during the following days without evidence of further leakage.Stone free status was obtained in ten patients (77%), and the remaining three were rendered stone free after one ancillary procedure (shockwave lithotripsy -SWL) in two patients and retrograde nephroscopy in another).pyeloplasty was considered successful according to clinical (disappearance of pain) and diuretic renal scan parameters.The mean washout half-life time in the diuretic renal scan improved from 43 to 22 minutes.
Warm ischemia time for laparoscopic anatrophic nephrolithotomy was 43 minutes; the patient was rendered stone free and renal function remained within preoperative values.

COMMENTS
Endourology has revolutionized the treatment of urinary stones.Notwithstanding, underlying the success rate of endourological procedures (3,4).The surgical approach in these special cases should ated malformations in a single procedure.Although open surgery is an alternative, laparoscopic surgery might be a feasible option additionally conferring the advantages of minimally invasive surgery.82%).However, the laparoscopic group had higher operative time, urological complications (12% urine two patients.They concluded that indications for each belief and current practice that SWL, retrograde and minimal morbidity.The role of laparoscopy is not to replace any of these options, but to compliment them in situations where decreased success or increased showed in our series and as reported by other authors can be successfully combined in the same procedure to improve the stone free rate and simultaneously resolve synchronous anomalies.Tunc et al. published a study on 150 patients with stones in anomalous kidneys treated with SWL, 14 pelvic, and 4 crossed ectopic.The overall stonefree rate was 68%, with the worst results obtained in crossed ectopic kidneys with stone clearance of only 25% (13).Pure percutaneous approach has also been reported in anomalous kidneys.Although highly effective with an overall stone-free rate of 83%, the anterior displacement of the collecting system together with an unpredictable vascular supply and interposition of bowel between the kidney and the abdominal wall makes the procedure technically imaging system (i.e.CT guided) to minimize risk of visceral damage during kidney puncture and tract creation (14).Pure endoscopic management has also been accomplished for anomalous kidneys.Weizer et al. reported a 75% stone-free rate (15), meanwhile Braz et al. reported an 81% stone-free rate at three (16).Due to urinary stasis, these patients suffer from poor spontaneous stone passage, with persistence or growth of residual fragments in 60% of cases.useful for stones located in anomalous kidneys.Our overall stone-free rate was 77% (10/13), and reached a 100% after one ancillary treatment (i.e.SWL or nephroscopy).Additionally, anomalies to be addressed (i.e.UPJ obstruction) were successfully repaired with optimal functional outcome.
There are several operative pitfalls that need special consideration when combining laparoscopy with endourological procedures.The operating room and the space around the operating table become limited when the laparoscopic and endourological towers need to be brought to work simultaneously.The laser cart and endourological instrumentation table pose additional ergonomic problems.One serious limitation challenge in the described set-up and even if possible patient in lateral decubitus are far from informative. is unpractical and time consuming, and even after this, ability to identify small residual stones.
men during the nephroscopy is of some concern and might be a limiting factor.Although some of it can and occupy the space of the pneumoperitoneum.As placing the patient in a "head down" position for two diaphragm where it becomes easily aspirated with the laparoscopic suction.can be useful in these situations (9) however; it poses additional restrictions to the already cumbersome operative scenario.We found a solution relying on cases performed, the light of the endoscope precisely delineated the place for the nephrotomy ( was placed.We performed a laparoscopic anatrophic system and a complete staghorn of the lower moiety with optimal results and no perioperative complications.The kidney was repaired with one running suture including parenchyma and collecting system An interesting aspect of laparoscopic pyeloli-have them fall out of the renal pelvis or the endobag, and locating them in the abdomen is challenging and time consuming.There is no report in the urological literature regarding this issue; however there are well described complications of lost stones in the abdomen after laparoscopic cholecystectomy.They include inprolonged fever (20).Regarding the infectious status of struvite staghorn stones, lost stones should remain of concern.However, two patients in our series had lost stones in the abdomen and after completing more than two years of follow-up, they remain completely asymptomatic.
We are aware of the limitations of this paper, which consist of a small, retrospective series of patients.However, considering the limited data tributes to the developing of this novel and poorly studied approach.

CONCLUSIONS
Although classical endourological procedures should remain as the gold standard for the great majority of renal stones, however patients with large stone from a combined laparoscopic and endourological disease and repairs associated anomalies.
1 and Figures-1 to

3 .
All cases were discussed with the endourology unit and considered unlikely that stones and underlying endourological procedure.Three patients had previous unsuccessful endourological procedures, with residual stones after nephroscopy among main causes of failure.Patients underwent preoperative anatomical and functional evaluation with non contrast CT scan and either intravenous pyelography or diuretic renal scans in cases of suspected ureteropelvic junction (UPJ) obstruction.Postoperative assessment consisted diuretic renal scan was performed in patients who underwent concomitant pyeloplasty.summarized below.Combinations were used to deal

Figure 1 -
Figure 1 -Patient with situs inversus and left to right crossedfussed ectopic kidney with ureteropelvic junction obstruction and multiple stones in the ectopic kidney (lower moiety).This patient underwent laparoscopic pyelolithotomy and pyeloplasty.

Figure 3 -
Figure 3 -Retrograde pyelography of a patient with an ectopic pelvic kidney, ureteropelvic junction obstruction and a 2 cm stone in the upper pole (arrow).Intraoperatively, infundibular stricture was encountered and the patient underwent laparoscopic pyeloplasty, and "cut to the light" nephrolithotomy.

Figure 2 -
Figure 2 -Left: Complete 9 cm staghorn stone in the lower moiety of a complete duplicated pelviocalyceal system.Right: Intravenous urography performed 3 months after laparoscopic anatrophic nephrolithotomy showing dye descending through both right excretory systems.

Figure 5 -
Figure 5 -Left: Endoscopic light transilluminates the location of an obstructed upper pole calyx (area inside the circle).Right: The kidney is incised over the lighted parenchyma and the stone removed laparoscopically.

Figure 7 -
Figure 7 -Lost stones in the abdomen incidentally discovered during follow-up.