Marshall L. Stoller, Maxwell V. Meng-Urinary Stone Disease
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Chapter 33 / Open Stone Surgery 649
open surgery for a distal calculus (30). Ureteral stricture formation can occur with
calculus disease after any form of manipulation. This complication has decreased from
5% to less than 1% with refinement of technology. Risk factors that have been associated
with strictures are ureteral perforation, incomplete stone removal, and impaction greater
than 2 mo (31).
CONCLUSIONS
When performed for appropriate indications and with meticulous technique, open
stone surgery can achieve successful removal of all calculi, preservation of renal func-
tion, improved urinary drainage, and eradication of infection. Stone-free rates greater
than 90% should be achieved. Stone recurrence rates following anatrophic nephrolitho-
tomy have been reported from 5% to 30% (28). Recurrent calculi usually form in those
with persistent urinary tract infections, persistent urinary drainage impairment, and
those with previously unidentified or refractory metabolic disturbances (32).
We believe that for large or complex staghorn calculi, especially those associated with
some anatomic abnormality leading to impaired urinary drainage, open stone surgery
remains an important treatment option. This modality achieves comparable or better
stone-free rates and the achievement of a stone-free state with a single operative proce-
dure. In the long term, treatment of these complex calculi with anatrophic nephrolitho-
tomy, pyelolithotomy, or ureterolithotomy should preserve renal function in the involved
kidney and, in a majority of patients, eradicate stone disease and chronic urinary tract
infection.
REFERENCES
1. Clendening, L. Source Book of Medical History. Dove Publications, New York, NY, 1942.
2. Van Arsdalen KN, Banner MP, Pollack HM. Radiographic imaging and urologic decision making
in the management of renal and ureteral calculi. Urol Clin North Am 1990; 17(1): 171.
3. Smith MJV, Boyce, W.H.: Anatrophic nephrotomy and plastic calyrhaphy. J Urol 1968; 99: 521.
4. Gil-Vernet JM. New surgical concepts in removing renal calculi. Urol Int 1965; 20: 255.
5. Blandy JP, Singh M. The case for a more aggressive approach to staghorn stones. J Urol 1976; 115:
505.
6. Segura JW, Preminger GM, Assimos DG, et al. Nephrolithiasis Clinical Guidelines Panel sum-
mary report on the management of staghorn calculi. J Urol 1994; 151: 1648.
7. Assimos DG. Should one perform open surgery in 1994? Semin Urol 1994; 12: 26.
8. Cohen JD, Persky L. Ureteral stones. Urol Clin North Am 1983; 10(4): 699.
9. Liong ML, Clayman RV, Gittes RF, Lingeman JE, Huffman JL, Lyon ES. Treatment options for
proximal ureteral urolithiasis: Review and recommendations. J Urol 1989; 141: 504.
10. Hofmann R, Stoller ML. Endoscopic and open stone surgery in morbidly obese patients. J Urol
1992; 148: 1108.
11. Caldwell TC, Burns JR. Current operative management of urinary calculi after renal transplanta-
tion. J Urol 1988; 140: 1360.
12. Paik ML, Resnick MI. Is there a role for open stone surgery? Urol Clin North Am 2000; 27(2): 323.
13. Paik ML, Wainstein MA, Spirnak JP, Hampel N, Resnick MI. Current indications for open stone
surgery in the treatment of renal and ureteral calculi. J Urol 1998; 159: 374.
14. Snyder JA, Smith AD. Staghorn calculi: percutaneous extraction vs anatrophic nephrolithotomy.
J Urol 1986; 136: 351.
15. Brown MW, Carson III CC, Dunnick NR, Weinerth JL. Comparison of the costs and morbidity of
percutaneous and open flank procedures. J Urol 1986; 135: 1150.
16. Fitzpatrick JM. Pyelolithotomy. In: Glenn’s Urologic Surgery, (Graham SD, Jr, Glenn JF, eds.).
Lippincott-Raven, Philadelphia, PA, 1998, pp. 155–161.
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17. Novick AC. Posterior surgical approach to the kidney and ureter. J Urol 1980; 124: 192.
18. Myers RP. Brodel’s line. Surg Gynecol Obstet 1971; 132: 424.
19. Redman JF, Bissada NK, Harper DL. Anatrophic nephrolithotomy: experience with a simplifica-
tion of the Smith and Boyce technique. J Urol 1979; 122: 595.
20. Morey AF, Nitahara KS, McAninch JW. Modified anatrophic nephrolithotomy for management
of staghorn calculi: Is renal function preserved? J Urol 1999; 162: 670.
21. McDougal WS. Renal perfusion/reperfusion injuries. J Urol 1988; 140:1325.
22. Spirnak JP, Resnick MI. Pyelolithotomy. In: Stewart’s Operative Urology, (Novick AC, Streem
SB, Pontes JE, eds.). Williams & Wilkins, Baltimore, MD, 1989, pp. 184–190.
23. Hodge EE. Operations on the Ureter. In: Stewart’s Operative Urology, (Novick AC, Streem SB,
Pontes JE, eds.). Williams & Wilkins, Baltimore, MD, 1989, pp. 368–380.
24. Winfield HN, Clayman RV, Chaussy CG, Weyman PJ, Fuchs GJ, Lupu AN. Monotherapy of
staghorn renal calculi: a comparative study between percutaneous nephrolithotomy and extracor-
poreal shock wave lithotripsy. J Urol 1988; 139: 895.
25. Razvi HA, Dendstedt JD, Chun SS, Sales JL. Intracorporeal lithotripsy with the holmium:YAG
laser. J Urol 1996; 156: 912.
26. Assimos DG, Wrenn JJ, Harrison LH, et al. A comparison of anatrophic nephrolithotomy and
percutaneous nephrolithotomy with and without extracorporeal shock wave lithotripsy for man-
agement of patients with staghorn calculi. J Urol 1991; 145: 710.
27. Segura JW, Preminger GM, Assimos DG, et al. Ureteral Stones Clinical Guidelines Panel sum-
mary report on the management of ureteral calculi. J Urol 1997; 158: 1915.
28. Spirnak JP, Resnick MI. Anatrophic nephrolithotomy. Urol Clin North Am 1983; 10(4): 665.
29. Assimos DG, Boyce WH, Harrison LH, Hall JA, McCullough DL. Postoperative anatrophic neph-
rolithotomy bleeding. J Urol 1986; 135: 1153.
30. Braslis KG, Stephens DA. Uretero-fallopian fistula: An unusual complication of open ureteroli-
thotomy. J Urol 1993; 150: 1900.
31. Roberts WM, Cadeddu JA, Micali S, Kavoussi LR, Moore RG. Ureteral stricture formation after
removal of impacted calculi. J Urol 1998; 159: 723.
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tomy. J Urol 1981; 125: 471.
Chapter 34 / Laparoscopic Approach 651
651
From: Current Clinical Urology, Urinary Stone Disease:
A Practical Guide to Medical and Surgical Management
Edited by: M. L. Stoller and M. V. Meng © Humana Press Inc., Totowa, NJ
34
Laparoscopic Approach
to Urinary Stone Disease
Anup P. Ramani MD and Inderbir S. Gill MD, MCH
CONTENTS
INTRODUCTION
PATIENT EVALUATION
LAPAROSCOPIC PYELOLITHOTOMY
LAPAROSCOPIC URETEROLITHOTOMY
LAPAROSCOPIC MANAGEMENT OF CALICEAL DIVERTICULAR CALCULI
LAPAROSCOPIC URETEROCALICOSTOMY
LAPAROSCOPIC ANATROPHIC NEPHROLITHOTOMY CONCLUSIONS
REFERENCES
Key Words: Laparoscopy; calculus; kidney; ureter
INTRODUCTION
Minimally invasive antegrade and retrograde techniques combined with extracorporeal
shockwave lithotripsy (SWL) have virtually eliminated open surgery for stone disease.
Success rates for treating renal calculi with the above combination approach 100%. The
availability of finer instruments with better optical resolution has made the endourological
approach the standard of care today. Nevertheless, there exists a category of stones that fail
endourologic therapy and thus are candidates for open surgical intervention.
The advantages of laparoscopy over open surgery have been described before and
include reduced operative time, blood loss, hospital stay, morbidity, and faster return to
activities of daily living. Laparoscopy has been successfully applied to the management
of almost every aspect of urinary tract disease and can be equally efficacious in patients
failing endourologic therapy or in whom endourologic therapy is contraindicated because
of size or location characteristics of the stone. The spectrum of options with the laparoscopic
approach varies with the stone size, location, and status of the contralateral kidney and
includes laparoscopic pyelolithotomy with or without pyeloplasty, laparoscopic ure-
652 Ramani and Gill
terolithotomy, laparoscopic anatrophic nephrolithotomy, laparoscopic calyceal diver-
ticular repair, and laparoscopic ureterocalycostomy. All steps of open surgery are dupli-
cated with strict adherence to principles of stone surgery.
PATIENT EVALUATION
Laboratory Studies
Recurrence rates for renal stones vary from 50% to 100%. Given this high probability
of subsequent stone formation, it is plausible to argue that all patients with renal stone
should undergo a complete evaluation. Metabolic work-up forms an important part of the
evaluation. Certainly, men between the ages of 20 and 50, patients with a strong family
history, nephrocalcinosis, and gout deserve a through metabolic work-up before treat-
ment can be initiated. Typical strategies to evaluate stone formers are well documented
in literature and are beyond the scope of this chapter (1).
Imaging Studies
Radiographic evaluation of the patient has to be tailored to provide accurate information
on size and location of calculi and the degree of renal functional and morphologic impair-
ment. Other causes of urinary obstruction, such as tumor, intraluminal blood clot, sloughed
papillae, or infected aggregates must always be considered in the differential diagnosis.
The standard radiographic evaluation revolves around the plain radiograph, the intra-
venous urogram, computerized tomographic scan, and the ultrasound evaluation. The
plain film of the abdomen or kidneys, ureter, bladder (KUB) is usually the first inves-
tigation in many scenarios. Most but not all calcifications are visible in the plain film.
These however also show non renal calcifications, which may cloud the issue. Typical
examples include gallstones, calcified mesenteric lymph nodes, phleboliths, and other
artifacts. About 90% of calculi greater than 2 or 3 mm can be picked up on the plain film.
Intravenous urography is a standard and well accepted investigation to document urinary
obstruction and renal function in patients with renal lithiasis. Sonography is quick, cost
effective, and can demonstrate renal parenchymal and collecting system pathology
without injecting contrast. Indeed in patients with acute abdominal pain, sonography is
invaluable as an initial investigation to rule out a majority of other abdominal causes.
Noncontrast helical or spiral CT today is the most innovative and cost effective inves-
tigation for a renal colic. With a sensitivity and specificity of over 97% it easily outper-
forms other modalities of investigation (1).
As such a combination of these tests as well as other tests are routinely employed in
evaluating a patient. Investigations are tailored to each individual depending on stone
characteristics.
LAPAROSCOPIC PYELOLITHOTOMY
Introduction
Pyelolithotomy is occasionally necessary in patients with pelvic and renal calculi who
fail ESWL and percutaneous nephrolithotomy (PCNL) or have a complex stone. About
4–6% patients with renal stones fall into this category. Laparoscopic pyelolithotomy
combines the advantages of open surgery with the minimally invasive nature of
laparoscopy. Laparoscopic pyelolithotomy can be performed by either the transperitoneal
Chapter 34 / Laparoscopic Approach 653
or the retroperitoneal route. In addition, concurrent pyeloplasty can be performed at the
same time if needed.
Gaur et al. reported the first laparoscopic pyelolithotomy in 1994, a series of eight
patients with a 62.5% stone clearance (2). Literature is scant about long term results of
laparoscopic pyelolithotomy given the fact that only a small percentage of patients
require a formal pyelolithotomy in the era of SWL and PCNL. However the success of
laparoscopy with other pathologies of the urinary tract points to favorable outcomes in
this category of patients.
Transperitoneal Laparoscopic Pyelolithotomy
PATIENT POSITION
After general anesthesia, the patient is placed in the 45–60 ° flank position. Extreme
care is taken with padding and positioning. The table is flexed somewhat, an axillary roll
placed and the patient is secured to the table with 6-in cloth tape and safety belt.
P
ORT PLACEMENT
Peritoneal access is gained using a Veress needle. The abdomen is insufflated with
carbon dioxide to a pressure of 25 mmHg. The first port (10 mm) is placed mid way
between the umbilicus and the anterior superior iliac spine, at the level of the umbilicus.
The second port (5 mm) is placed at the angle between the costal margin and the lateral
border of the ipsilateral rectus muscle. The third port (10 or 12 mm) is placed between
these two ports, closer to the upper port than the lower one, so as to allow a direct vision
of the renal hilum. This port, which houses the 30 ° laparoscope, may alternatively be
placed in the umbilicus.
I
DENTIFICATION OF THE PELVIS
Mobilization of the colon is performed by incising along the line of Toldt, up to the
liver on the right and the splenic ligaments on the left. This allows the colon, spleen, and
pancreas to be reflected away from the left kidney. On either the left or the right side, the
anterior surface of Gerota’s fascia is visualized by reflecting the mesocolon in an avas-
cular plane. The psoas muscle is an important landmark, which guides the laparoscopic
surgeon’s orientation and must always be visualized horizontally at the base of the field.
As such the psoas muscle must be identified between the ureter and gonadal vein (lateral)
and the ipsilateral great vessel (medial). The ureter is now identified above the psoas
muscle and dissected up to it’s insertion in the renal pelvis. The renal pelvis is dissected
free from adjacent tissues so that the anterior and the posterior aspects of the pelvis are
exposed. A U-shaped pyelotomy is created on the pelvic wall and the pelvis opened. The
stone is identified and gently grasped with a laparoscopic grasper and delivered out.
The stone is placed in an endo-catch bag and positioned aside for later removal. After
confirming complete removal of the stone, the pelvic defect is sutured with interrupted
Vicryl 3-0 sutures. All sutures are free hand. Placement of a double-J stent is only
necessary in patients with an unsatisfactory closure of the pelvis or severe pelvic wall
edema. A Jackson-Pratt drain is inserted with its tip away from the anastomotic site. The
endo-catch bag is delivered out from one of the port sites. The port site incision may be
enlarged if necessary to facilitate delivery of the stone. Once the procedure is complete,
laparoscopic exit is performed. The port sites are closed with the help of a Carter
Thomasson needle and skin approximated with subcuticular sutures.
654 Ramani and Gill
Perioperative antibiotics are administered for 24 h after surgery. Analgesics are ad-
ministered as required. The patient is usually discharged within 24 h. The Jackson-Pratt
drain is removed after drainage reduces to less than 60 mL/d.
Patients with a coexisting ureteropelvic junction obstruction (primary or secondary),
may also undergo concomitant laparoscopic pyeloplasty. One of the advantages of
laparoscopic pyeloplasty over antegrade and retrograde endourologic techniques is that
it can address anatomical nuances like high inserting ureter, crossing vessel, and redun-
dant pelvis at the same time. Laparoscopic pyeloplasty entails mobilization of the pelvis
and the upper ureter, excision of the pathologic segment of the pelvis and the ureter,
spatulation of the ureter laterally, free hand suture of the ureter to the pelvis with two
continuous 3-0 monocryl sutures on a CT-1 needle, over a double-J stent.
Retroperitoneal Technique
PORT PLACEMENT
Our standard three-port retroperitoneal laparoscopic access is achieved. A 1-cm incision
is made at the tip of the 12th rib in the midaxillary line. The incision is deepened up to the
dorsolumbar fascia. An incision is made in the dorsolumbar fascia and a finger inserted
into the retroperitoneal space. This is confirmed by palpating the psoas muscle and the
lower pole of the kidney. A balloon dilator is introduced into the retroperitoneal space
and the balloon inflated 50 mL. The balloon is now hitched up against the abdominal wall
and inflated an additional 700 mL. This maneuver pushes the peritoneum forward and
out of the operative field. The balloon is removed and replaced by a 10- or 12-mm port.
The retroperitoneum is now inspected and correct access confirmed. Insufflation is
initiated at 25 mmHg. The second port (5 mm) is placed at the angle of the 12th rib and
the paraspinal muscles. The third port (5 mm) is placed in the anterior axillary line, three
fingerbreadths above the anterior superior iliac spine.
M
OBILIZATION OF THE KIDNEY
The initial step is to identify the ureter below the lower pole of the kidney as it lies
above the psoas. The ureter is then dissected cephalad, leaving a good amount of peri-
ureteral tissue, till the ureteropelvic junction is reached. The peripelvic fat and the
Gerota’s fascia are opened and the pelvis exposed. The pelvis is completely freed and
pyelolithotomy is carried out in the above fashion.
Results of Laparoscopic Pyelolithotomy
Jordan et al. in 1997, reported an operative time of 2.5 h (3). Blood loss was 5 mL.
Patients were discharged within 24 h. Ramakumar et al. reported a combination of
laparoscopic pyelolithotomy and pyeloplasty with a mean operating time of 4.6 h, blood
loss of 145 mL (4). Mean hospital stay was 3.4 d and patients returned to activity by 3
wk. They had no intraoperative complications.
LAPAROSCOPIC URETEROLITHOTOMY
Introduction
As for pelvic calculi, the advent of endourological techniques and SWL has almost
eliminated the need for open surgery in patients with ureteral calculi. Success rates of
ureteroscopy for lower and middle third ureteral calculi approach 100%. Success rates
Chapter 34 / Laparoscopic Approach 655
of percutaneous surgery and SWL for upper third calculi are similar. Open or laparo-
scopic ureterolithotomy is still however indicated in patients with large, long-standing
and hard ureteral calculi, particularly those that cross into the pelvis. As mentioned
before, the laparoscopic option has significant advantages over open surgery.
The first laparoscopic retroperitoneal ureterolithotomy was described by Wickham in
1979 and popularized by Gaur in the 1990s (5–7). The first transperitoneal laparoscopic
ureterolithotomy was performed by Raboy et al. in 1992 (8). Success rates of 88–100%
have been quoted in literature. With the retroperitoneal route, the risk of visceral injury
is lower, abdominal adhesions from previous surgeries do not interfere with the surgery
and there is no need to mobilize the colon. At the author’s institution, the retroperitoneal
route is preferred.
Technique
Patient position, access via the transperitoneal or the retroperitoneal route and initial
mobilization are performed in the standard fashion as described before. In the
transperitoneal approach, once the colon has been mobilized, the ureter is identified
above the psoas muscle. The segment of the ureter with the stone is approached and freed
of the overlying fat. Careful dissection is necessary at this juncture to avoid stripping the
ureter of its investing layers for a long segment. This jeopardizes ureteral vascular
supply.
The stone, if not immediately apparent, can be localized by sounding the ureter with
the tip of a grasper. Once the stone is localized, the ureter over the stone is incised in a
linear fashion for adequate length. The stone is carefully freed from its attachments to
the ureteral mucosa and delivered out. A double-J stent is then inserted over a guide wire,
which has been passed down the ureter from one of the ports. After the stent is in position,
the ureteral defect is closed with interrupted 3-0 vicryl or monocryl sutures. The sutures
are just tight enough to approximate the edges of the defect without undue tension.
Hemostasis is confirmed. A Jackson-Pratt drain is usually not necessary if the suture line
is satisfactory, however it can be left in place if there is any doubt about the integrity of
the anastomosis. The stent can be removed between 4 and 6 wk after surgery.
Laparoscopic exit is performed in the standard fashion.
Result
Harewood et al. in their experience of nine patients reported a mean patient age of 55.5 yr,
mean stone size of 13.2 mm (5). The mean operative time was 158 min. One patient devel-
oped a postoperative urine leak. The mean hospital stay was 5.2 d. Feyaerts et al. reported
a series of 24 patients who underwent laparoscopic ureterolithotomy (6). The mean
operating time was 140 min. There was no intraoperative complication and no blood
transfusions were required. Mean hospital stay was 3.8 d. All patients were followed up
with intravenous pyelogram and demonstrated success at 6-mo intervals.
LAPAROSCOPIC MANAGEMENT OF CALYCEAL DIVERTICULAR
CALCULI
Introduction
A calyceal diverticulum is a cystic intrarenal cavity lined by nonsecretory urothelium
that communicates with the collecting system via a narrow neck and is typically located
656 Ramani and Gill
at a calyceal fornix or infundibulum. Although usually asymptomatic, they are prone to
urinary stasis and stone formation. Although over the last decade, shockwave lithotripsy,
ureterorenoscopy, and percutaneous endoscopic techniques have been highly successful
in treating this entity, laparoscopy has emerged as an attractive treatment option for
caliceal diverticular stones. Apart from stone extraction, laparoscopy allows plastic
repair of the caliceal diverticulum to prevent a caliceal fistula.
Technique
LAPAROSCOPIC ACCESS
With the patient in the dorsal lithotomy position a 6 Fr open-ended ureteral catheter
is inserted into the renal pelvis via cystoscopy and secured to a 16 Fr urethral catheter.
The patient is then placed in the standard flank position with the kidney rest elevated and
the table flexed. Our standard three-port retroperitoneoscopic approach is used as pre-
viously described.
S
TONE LOCALIZATION AND EXTRACTION
Gerota’s fascia is incised to identify and mobilize the kidney. Complete examination
of the kidney surface is then done via laparoscopy. If the diverticulum is not immediately
apparent, indigo carmine dye may be injected through the ureteral catheter. This discol-
ors the thin parenchyma over the diverticulum. Alternatively, either intraoperative fluo-
roscopy or intraoperative ultrasonography with a laparoscopic, flexible, color Doppler
probe may be used to localize the stone. Using electrosurgical scissors or J-hook elec-
trocautery a longitudinal nephrotomy incision is made perpendicular through the thin-
nest area of the parenchyma over the stone or along the avascular plane of Brodel’s line
at the posterior lateral aspect of the convex surface of the kidney. The calculus or calculi
are gently extracted using endoscopic graspers. They are then immediately entrapped in
an endoscopy bag and the area is then copiously irrigated with 2–3 L of antibiotic
solution. The diverticulum is inspected to rule out residual stone or a tumor.
D
EFINITIVE MANAGEMENT OF CALYCEAL DIVERTICULUM
Indigo carmine is now injected through the ureteral catheter to identify the site of
communication with the pelvicalyceal system or the diverticular neck. This site is then
either fulgurated if small or sutured using interrupted figure-eight sutures with 3-0
polyglactin on a CT-1 needle. Repeat injection of indigo carmine dye is performed to
ensure closure of the fistula. The rest of the diverticular epithelium is then fulgurated
using the argon beam or the J-hook. Adjacent perirenal fat is mobilized to fill the defect
in the parenchyma. Gerota’s fascia is re-approximated with interrupted sutures. A Jack-
son-Pratt drain is positioned outside the Gerota’s fascia, exiting the anterior port. The
stone is extracted in the endoscopy bag through the 12-mm port site. The patient is then
repositioned in the dorsal lithotomy position and the ureteral catheter exchanged for a
double-J stent. A urethral Foley catheter is then placed.
Results
Miller et al. reported a series of five patients who underwent laparoscopic extraction
of calyceal diverticular calculi (9). The mean age was 47.4 yr, mean operative time was
133.8 min and the mean blood loss was less than 50 mL. Average hospital stay was 36.4 h.
There were no intraoperative complications.
Chapter 34 / Laparoscopic Approach 657
LAPAROSCOPIC URETEROCALICOSTOMY
Introduction
Ureterocalicostomy is a reconstructive option in the rare patient with a failed, difficult
ureteropelvic junction obstruction secondary to stones and an intrarenal pelvis.
Laparoscopy is a viable option for the surgical management of this entity. Gill et al.
reported the first laparoscopic ureterocalycostomy in 2004 (10).
Technique
Under general anesthesia, a 4.7-Fr, 26-cm J-stent is cystoscopically inserted into the
ipsilateral renal pelvis. With the patient positioned in a 45–60 flank position, a three-
or four-port transperitoneal approach is employed as described previously. Colon is
reflected medially and the renal hilar vessels are mobilized en bloc for possible Satinsky
clamping subsequently. The kidney is mobilized within Gerota’s fascia, and the thinned
lower pole parenchyma is exposed. The ureter with adequate periureteral tissue is dis-
sected cephalad towards the renal pelvis. A circular rim of the tip of the lower pole renal
parenchyma is excised using J-hook electrocautery exposing the dilated lower calyx.
The calculi are immediately collected in an endoscopic bag and the area flushed with an
antibiotic (gentamycin) solution.
Laparoscopic ultrasonography is performed to rule out any residual calculi. The ure-
teropelvic junction is now transected and the pelvis is suture ligated. The ureter is
spatulated laterally taking care to preserve the J-stent. End-to-end ureterocalyceal anas-
tomosis is performed in a mucosa-to-mucosa fashion using two hemi-circular running
sutures (3-0 vicryl on RB-1 needle). Free-hand intracorporeal suturing and knot-tying
techniques are employed. At this point, intravenous indigo carmine dye is injected to
confirm a watertight repair. A Jackson-Pratt drain is inserted and laparoscopic exit
performed.
LAPAROSCOPIC ANATROPHIC NEPHROLITHOTOMY
Introduction
Anatrophic nephrolithotomy was first described by Boyce and Smith, who used renal
anatomic and physiologic principles and reconstructive surgical techniques to perform
this surgery. The procedure involves incising the renal parenchyma along an avascular
plane to remove a large, complex renal stone. Open surgical anatrophic nephrolithotomy
provides 91–94% stone free rates. Because the advent of minimally invasive techniques,
anatrophic nephrolithotomy is today reserved for a small group of patients with complex
staghorn renal calculi.
The American Urological Association’s guideline panel has laid down the current
indications for this surgery (11). These include struvite staghorn calculi not expected to
be removed by a reasonable number of percutaneous lithotripsy and/or ESWL. These
patients usually have a large stone load as well as complex collecting systems. Another
group of patients considered candidates for anatrophic nephrolithotomy are obese indi-
viduals (600 lb or greater) with staghorn calculi, as in these patients access may be
difficult or impossible.
With increasing experience, laparoscopy is today being applied to almost every uro-
logical pathology at many centers in the world. Certainly, the advantages of laparoscopy
658 Ramani and Gill
over open surgery are well documented in literature. Laparoscopic anatrophic nephroli-
thotomy provides all the advantages of minimally invasive surgery coupled with the
success rates of open surgery.
Anatrophic nephrolithotomy is contraindicated in patients with uncorrected coagulopathy
and sepsis. Severe chronic renal insufficiency is a relative contraindication.
Technique
LAPAROSCOPIC ACCESS
After general anesthesia, patient is placed in the flank position and secured to the
operating table. A four-port transperitoneal approach is employed.
R
ENAL HILUM CONTROL
The kidney is mobilized circumferentially, and the renal hilum is dissected so as to
allow optimal application of a Satinsky clamp. After adequate hydration, 12.5 g of
manitol and 10 mg of Lasix are administered intravenously. En-bloc clamping of the
renal artery and vein is achieved using a laparoscopic Satinsky clamp.
L
ATERAL INCISION OF RENAL PARENCHYMA AND COLLECTING SYSTEM
Intraoperative laparoscopic ultrasonography may be used to identify the site of thin-
nest parenchyma along the lateral border of the kidney. Doppler signal can be used to
locate further an avascular plane through the thinned parenchyma. The incision is carried
deep into the renal calyces.
S
TONE EXTRACTION
The staghorn calculus is fragmented using either a mechanical or an ultrasonic
lithotriptor. The stone fragments are extracted and retrieved within a 10-mm endo-catch
bag. Laparoscopic ultrasonography is repeated or flexible endoscopy of the calyceal
system and upper ureter is performed to identify and retrieve any residual stones to
achieve complete stone clearance.
I
NTRACORPOREAL WATERTIGHT SUTURE-REPAIR OF THE INCISED COLLECTING SYSTEM
AND
RENAL PARENCHYMA
The collecting system is continuously sutured (No. 2.0 polygalactic acid-absorbable
suture on a GS-21 needle) in a watertight manner. In a second layer, the renal paren-
chyma is reconstructed using interrupted sutures (No. 1 polygalactic acid absorbable
suture on a GS-25 needle) placed in a hemostatic fashion.
A nephrostomy tube is positioned to drain the kidney only if there is any doubt about
the integrity of the anastomosis. Usually, a double-J stent is considered enough to secure
adequate renal drainage for 4–6 wk post surgery. An abdominal drain is kept for 24–48 h
depending on the drainage.
Results
Kaouk et al. described the first laparoscopic anatrophic nephrolithotomy in 2003 (12).
This was performed based on studies in a porcine model (13). After injection of poly-
urethane into the renal pelvis to simulate a complete staghorn calculus, laparoscopic
anatrophic nephrolithotomy was performed. The mean warm ischemia time was 30 min