Patient Selection Indications And Contraindications

The laparoscopic approach should be utilized in patients who have failed extracorporeal shock wave lithotripsy, percutaneous nephrolithotripsy, and ureteroscopy or in patients with unusual anatomy such as pelvic kidney, stones with uretero pelvic junction obstruction, and renal stone resistant to fragmentation.

The indications for laparoscopic ureterolithotomy, pyelolithotomy, pyelolithotomy with repair of uretero pelvic junction obstruction, nephrectomy, or nephroureterec-tomy for calculous disease are similar to that for open surgery.

However, complex staghorn stone with multiple secondary calculi, and patients requiring multistage percutaneous nephrolithotripsy or anatrophic nephrolithotomy may not be suitable for laparoscopic intervention at this point in time except in hands of highly skilled surgeons (16).

The indications for laparoscopic nephrectomy or nephroureterectomy in calcu-lous disease are nonfunctioning kidneys due to renal stones, ureteric stones, megaureter with secondary stones, and uretero pelvic junction obstruction with stones.

TABLE 1 ■ Indications of Laparoscopic Surgery in Calculous Disease

Kidney

Ureter

Bladder

Indications Ablative Nephrectomy,

Lower-ureteral

nephroureterectomy

calculi with

for nonfunctioning

nonfunctioning

kidneys

kidneys

Reconstructive Pyelolithotomy—

Ureterolithotomy

Stone retrieval with

failure of

for large/impacted

diverticulectomy

endoscopic

upper, middle, or

management

lower ureteral

Partial nephrectomy—

calculi; and

nonfunctioning pole

stones in

requiring partial

megaureter

nephrectomy; duplex

system with one

nonfunctioning

moiety

Contraindications Xanthogranulomatous

pyelonephritis

For most surgeons, the only absolute contraindication for laparoscopic nephrectomy is xanthogranulomatous pyelonephritis.

Nephrectomy is also suitable for patients with endstage renal disease due to urolithiasis necessitating pretransplant nephrectomy. Nonfunctioning kidneys due to calculous pyonephrosis, infected pyelonephritic kidneys due to stone disease, and failed shock wave lithotripsy therapy for renal stones are relative contraindications for laparoscopic nephrectomy, because of dense peri-renal adhesions, scarring and fibrosis as a consequence of inflammatory procedure. Occasionally, in such cases laparoscopic subcapsular nephrectomy should be contemplated. Although these are not suitable cases for the novice surgeon, a substantial number of these cases can be dealt with by experienced and skilled laparoscopic surgeons.

For most surgeons, the only absolute contraindication for laparoscopic nephrec-tomy is xanthogranulomatous pyelonephritis. Various indications for laparoscopic surgery for calculous disease are summarized in Table 1.

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