Since the introduction of shockwave lithotripsy in 1980 for the management of renal stones, minimally invasive therapy for urolithiasis has improved and various new techniques have been introduced. Advances in extracorporeal shockwave lithotripsy and intracorporeal (transurethral or percutaneous) lithotripsy have changed the treatment of urinary stones. Previous to these developments, surgical management was the only available option for urinary stones, whereas now there are many minimally invasive modalities to select from, such as percutaneous nephrolithotomy and ureteroscopy. Moreover, the introduction of different methods of stone fragmentation has improved the rate of stone clearance. With regard to renal stones, percutaneous nephrostolithotomy is the treatment of choice in most cases.
Laparoscopic surgery via the retroperitoneal approach confers several advantages compared to the transperitoneal approach. Our clinical experience shows that retroperitoneal laparoscopic intrasinusal pyelolithotomy can be considered even when the stone is located in the intra-renal pelvis, with the exception of large staghorn renal stones. Many urologists have studied two different operative routes. Compared with the transperitoneal, the retroperitoneal approach decreases complications of injury to surrounding visceral organs, bowel paralysis, and adhesion. In addition, it is easy to obtained better exposure to the retroperitoneal anatomy.
Relevant anatomical research shows renal sinus fat,enclosing the renal vessels, between the pelvis and parenchyma has a close relationship to renal parenchyma. A layer of connective tissue (the renal pelvis membrane) exists between the sinus fat and pelvis, whose blood supply is from the pelvic muscle layer but not from renal vessels in sinus fat. Therefore, the seperation of the intrasinusal pelvis along with the pelvis connective membrane does not cause bleeding. When the pelvis has extensive adhesions with the surrounding tissues as in inflammation, and the pelvis membrane adheres with sinus fat, the dissection of the membrane can be easy and the pelvis can be exposed without serious bleeding along this route.
Perirenal inflammation can be very serious for patients with long-term obstruction or repeated extracorporeal shockwave lithotripsy. We can first isolate the ureter at the lower pole of the kidney, and then determine the location of the pelvis. The surgeon must take extra care when clamping stones after the pelvis is opened, to avoid tearing the renal pelvis. The renal pelvis mucosa where the stones are located is brittle because of edema, so do not force the suture when tension is high. The incision can be covered by renal sinus fat to reduce the risk of postoperative urinary leakage.
In the present study, retroperitoneal laparoscopic intrasinusal pyelolithotomy was successful in most patients. This technique is minimally invasive and can surpass open surgery in merit, with no injury to the nephron, less bleeding, simple manipulation, short hospitalization, and quick postoperative recovery, without incision of the renal parenchyma.
We combined laparoscopic techniques with endourology to develop a method of extracting multiple pelvic calyceal stones. The flexible ureteroscope can be guided into the renal pelvis easily after the ureteropelvic junction is resected through the 10-mm port. Irrigant is collected concurrently with a suction device passed through one of the 5-mm ports. Although other studies have described the use of the laparoscope and grasping forceps to remove renal stones, the use of the ureteroscope allows access to the periphery of the kidney, and especially lower calyceal stones. Further applications combining endourologic techniques and laparoscopic surgery are currently in development.
The retroperitoneal laparoscopic approach is a minimally invasive alternative to endourologic treatment for a variety of ablative and reconstructive indications for different pathologic conditions. After adequate training, experienced surgeons should be able to use this approach proficiently. Despite the limited working space, direct posterior access to the kidney and renal hilum makes this access attractive, as it allows early renal vessel control.
The laparoscopic approach is an established reconstructive technique in UPJO, and various studies have reported a success rate of more than 95% (up to a mean follow-up of 24 months).[7–11] In a head-to-head comparison of laparoscopic treatment and percutaneous endopyelotomy for primary UPJO, the success rates were 100 and 92%, respectively. In the present study, concomitant laparoscopic pyelolithotomy with pyeloplasty provided a 100% stone clearance rate, thereby extending the advantage of a minimally invasive approach to all such patients. Similar stone clearance rates have been shown by other studies with equivalent results (80–90%).[7–9,13,14]
Simforoosh and colleagues have reported simultaneous treatment of renal stone and retrocaval ureter with laparoscopy. Similarly, Mugiya and associates reported a case in which a retrocaval ureter and upper ureteric stones were managed during the simultaneous procedure. We believe that the laparoscopic technique should be kept as the first option for the management of retrocaval ureter, even when complicated by renal stones.
The goals of nephropexy—fixation of the kidney at a retroperitoneal position, relief of any urinary obstruction associated with nephroptosis, immobilization of the renal axis, and prevention of tension on the vessels and ureter—are all achieved with our approach.
We found that the retroperitoneal laparoscopy has great sensitivity for detecting a crossing vessel, because it allows the surgeon a view of the UPJ and related vessels in their anatomic position, laterally to medially, by simple elevation of the lower pole of the kidney. Therefore, we amputated the crossing vessel before extracting the stone in one case.
BMC Urol. 2014;14(16) © 2014 BioMed Central, Ltd.