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D. Assimos

Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A.

Laparoscopic stone removal currently has a limited role in the management of patients with nephrolithiasis. The indications should be similar to those for the pool of subjects who are candidates for open surgical stone removal. The latter comprises less than 1% of patients undergoing a stone-removing procedure, even at tertiary medical centers (1). Laparoscopic stone removal should not be undertaken in patients in whom shock wave lithotripsy or an endourological approach is anticipated to be successful. Failure of the aforementioned therapies may be a valid reason to consider laparoscopy. However, current endoscopic technology and the skills of contemporary urologists have made this rarely necessary (1).

Laparoscopic nephrectomy is appropriate in subjects with a nonfunc-tioning renal unit due to a stone-related problem. While some have reported successful laparoscopic removal of xanthogranulomatous pyelonephritic kidneys, I concur with the author that this is not advisable in most cases (2). Laparoscopic partial nephrectomy may be considered for patients with stones in a polar area having no or minimal function. Combined pyeloplasty and pyelolithotomy is indicated for those patients in whom endopyelotomy performed in conjunction with percutaneous nephrolithotomy is not likely to be successful. These include patients with severe hydronephrosis, diminished renal function, and crossing vessels (3,4). Patients with isolated stones in an anterior calyceal diverticulum not accessible or too large for a retrograde ureteroscopic management may benefit from a laparoscopic approach. The same holds true for those having stones located in a type II diverticulum— one that communicates directly with the renal pelvis or an infundibulum. These cavities typically have no overlying renal parenchyma. Laparoscopy can also allow safe percutaneous access for removing stones in pelvic and other types of ectopic kidney (5).

Laparoscopic ureterolithotomy is rarely indicated as retrograde and antegrade ureteroscopic approaches and shock wave lithotripsy are less invasive and highly effective. In most cases, it should only be employed as a salvage procedure. It has been undertaken in some countries where the aforementioned technology is not readily available. Percutaneous nephrolithotomy is the procedure of choice for the majority of patients harboring staghorn calculi (6). Anatrophic nephrolithotomy should be reserved for patients with extremely large staghorn calculi in kidneys with complex collecting system anatomy. While this has been done via laparoscopy in a porcine model and select patients with more favorable anatomy, it is not anticipated that this will supplant the open approach in the aforementioned setting.

Laparoscopy will continue to play an extremely small role in the management of patients with nephrolithiasis. In addition, future improvements in endoscopic technology are likely to further narrow its application.

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