BERKELEY, CA (UroToday.com) - The surgical management of urinary stone disease has developed over recent years; treatment options include extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, and rigid or flexible ureterorenoscopy. The European Association of Urology Guidelines on Urolithiasis, 2013 edition[1] indicates that laparoscopic kidney-stone surgery should be considered in these cases: complex stone burden; failed previous ESWL and/or endourological procedures; anatomical abnormalities; morbid obesity; and nephrectomy in case of non-functioning kidney. The ureteropelvic junction obstruction (UPJO) is an anatomical abnormality defined by a blockage of urine flow from the kidney to the proximal ureter. Therefore, we consider that in the case of UPJO with concomitant kidney stone, the laparoscopic pyeloplasty should be the treatment of choice, because it offers the necessary guarantees for the treatment of the UPJO and it also allows us to combine endoscopic instruments to treat the associated secondary lithiasis with a stone-free rate of 100% and a success of UPJO resolution near 95%.[2]
There are no comparative studies in this field, but it seems that laparoscopic pyeloplasties have better outcomes in UPJO with concomitant lithiasis than other minimally invasive procedures. Antegrade endopyelotomy with concomitant percutaneous stone removal has been performed with a success rate of 64% to 85% in different series,[3] and ureteroscopic endopyelotomy or endoureterotomy with a ureteral balloon device has also been used with a success rate of 78%.[3] In our department, we have performed laparoscopic pyeloplasty since 2004, and since then it has become the treatment of choice for UPJO.[4] In this article, we demonstrated that treatment of kidney stone disease using the laparoscopic approach is feasible with a high success rate.[2] Adding to our described laparoscopic pyeloplasty technique[4] once the renal pelvis is dissected and the ureteropelvic junction (UPJ) is opened, the next step is stone removal, which depends on the size, number, and location of the stone(s). If the stone lays in the renal pelvis, it may be picked up with laparoscopic grasping instruments, but if it lays in a distant calyx, a flexible instrument is more useful. A flexible cysto-nephroscope may be introduced through an available working port. Usually a port that is well aligned with the pelvis or ureter should be chosen for passing the instrument. The stones in this case are removed with a nitinol N– Circle basket (Cook Surgical, Bloomington, IN USA). The best way to understand this technique is by seeing the images in the article.[2] Our study has several drawbacks: low cohort of patients (12 patients), retrospective nature, lack of randomization, but since laparoscopic reconstructive surgery has evolved in our department, more complex cases are performed using laparoscopic approach. Our goal is to keep heading in this direction in order to contribute to the development of urology in this field. Nowadays, we are starting to treat selected cases of kidney stone disease using retroperitoneoscopic approach; the results in the first cases are promising and we hope to have the enough experience in a few years to show our results.
References:
- EAU Guidelines, edition presented at the 28th EAU Annual Congress, Milan 2013. ISBN 978-90-79754-71-7.
- Gómez Rivas, J; Alonso y Gregorio S; Cuello Sánchez, L et al. Approach to kidney stones associated with ureteropelvic junction obstruction during laparoscopic pyeloplasty. Cent Eur J Urol 2013; 66: 440-444
- Hashim, H; Woodhouse C.R.J. Ureteropelvic Junction Obstruction. European Urology Supplements 11 (2012) 25–32.
- Gómez Rivas J, Alonso y Gregorio S, Portilla Eastmond M, Tabernero Gómez A, Cisneros Ledo J, Hidalgo Togores L, et al. Transperitoneal laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction. Cent Eur J Urol. 2013; 66:361–365.
Written by:
Juan Gómez Rivas and Sergio Alonso y Gregorio as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Hospital Universitario La Paz. Department of Urology, Madrid, Spain