The Combination of Laparoscopy and Nephroscopy for Treatment of Stones in Pelvic Ectopic Kidneys

Abstract

Introduction: Minimally invasive treatment modalities for patients with large stone burden within pelvic kidneys present a special challenge. Interposing bowel loops between the kidney and the anterior abdominal wall, abnormalities in the vascular supply, and mal-rotation of the caliceal system are reasons of difficulties in percutaneous nephrolithotomy (PNL). Minimally invasive treatment modalities of large stones in ectopic pelvic kidneys have included pure laparoscopic pyelolithotomy,1–3 laparoscopy-assisted PNL,4–7 and ultrasound-guided PNL.8 These are attractive treatment options because they have the advantages of reduced analgesic requirement, shorter hospital stay, early convalescence, and better cosmoses in addition to high safety and efficacy profiles. The combination of laparoscopic and percutaneous approaches allows the establishment of the percutaneous tract into the kidney under direct vision, thus avoiding the risk of injury to abdominal viscera and blood vessels. This video presents the technique of the combination of laparoscopy and nephroscopy for treatment of stones in pelvic ectopic kidneys. Patients and Methods: The study included seven men and four women (mean age, 43 ± 9 years). Laparoscopy-assisted PNL was performed for caliceal stones in five patients after failure of shockwave lithotripsy. Laparoscopic pyelolithotomy was performed for six patients with large or branched renal pelvic stones. The patient was placed in the Trendelenburg position with slight lateral elevation of the side to be operated. In laparoscopy-assisted PNL the primary surgeon stands on the same side of the affected kidney and the assistant on the opposite side, whereas in laparoscopic pyelolithotomy the surgeon stands on the opposite side of the affected kidney. Three or four transperitoneal ports were placed in a fan-shaped distribution. The stone or the renal pelvis was identified using intraoperative fluoroscopy. Intermittent fluoroscopy was used to identify the point of entry to the desired calix during dilatation and during fixation of the nephrostomy tube. Results: The average preoperative stone length was 3 ± 1 cm (range, 1.1–4.2). There were some adhesions between the intestinal loops and the peritoneum on the anterior surface of the kidney in three patients (27%). There were neither intraoperative nor postoperative complications, and conversion to open surgery was not required. The mean hospital stay was 3.5 ± 0.7 days (range, 2–4). The stone-free rate was 91% as all stones were removed completely in 10 patients, whereas 1 patient had residual caliceal fragment that was treated with shockwave lithotripsy. After a mean follow-up of 27 ± 6 months, two out of the five patients who underwent laparoscopy-assisted PNL showed stone recurrence and were treated with extracorporeal shockwave lithotripsy. Conclusion: The combination of laparoscopy and nephroscopy for treatment of stones in pelvic kidneys is feasible, safe, and effective. The authors has nothing to disclose. Runtime of video: 8 min 24 sec