Caveat

■ Beware of thin areas of the diverticular wall adjacent to the normal collecting system. This may appear as a cystic bulge or translucent membrane. Aggressive fulguration in this area may lead to urine leak and urinoma formation. Argon beam coagulation may be superior to monopolar electrocautery in this regard. Repeat retrograde instillation of methylene blue to identify any leak that may need suture closure.

FIGURE6 ■ Suture repair of the diverticular infundibulum with a figure-of-eight stitch using 2-0 or 3-0 polyglactin on a computed tomography or 2 RB-1 needle. Repeat retrograde injection of methylene blue may check the integrity of the closure.

FIGURE 7 ■ Fulguration of the diverticular epithelium with argon beam coagulation. Avoid fulguration in the area of the suture line.

FIGURE6 ■ Suture repair of the diverticular infundibulum with a figure-of-eight stitch using 2-0 or 3-0 polyglactin on a computed tomography or 2 RB-1 needle. Repeat retrograde injection of methylene blue may check the integrity of the closure.

FIGURE 7 ■ Fulguration of the diverticular epithelium with argon beam coagulation. Avoid fulguration in the area of the suture line.

TABLE 1 ■ Operative Steps for Laparoscopic Calyceal Diverticulectomy for Symptomatic Calyceal Diverticula With or Without Stones

Step 1

Cystoscopic placement of

ureteral catheter

Step 2

Laparoscopic access

Step S

Operative exposure

Step 4

Identification of calyceal

diverticulum

Step 5

Excision of overlying renal

parenchyma

Step e

Nephrolithotomy

Step 7

Identification and

management of

calyceal diverticular

infundibulum

Step B

Management of calyceal

diverticular epithelium

Step 9

Obliteration of diverticular

cavity

Step 10

Drain placement and exit

Step 11

Ureteral stent placement

FIGURE8 ■ Commercially available tissue sealant products or fibrin glue may be used to reinforce the suture repair and is particularly useful when sutures cannot be placed.

FIGURE 9 ■ The remainder of the diverticular cavity should be completely obliterated with a surrounding pedicle of fat from the perinephric tissue or omentum.

FIGURE8 ■ Commercially available tissue sealant products or fibrin glue may be used to reinforce the suture repair and is particularly useful when sutures cannot be placed.

FIGURE 9 ■ The remainder of the diverticular cavity should be completely obliterated with a surrounding pedicle of fat from the perinephric tissue or omentum.

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