Results of Laparoscopic Pyelolithotomy

We compared retroperitoneoscopic pyelolithotomy (n = 16) versus percutaneous nephrolithotripsy (n = 12) in the management of a solitary renal pelvic calculus more than 3 cm in size (Table 6). The two groups were similar regarding patient age and sex. Mean stone sizes were 3.6 cm versus 4.2 cm, respectively (p < 0.006). There were two conversions in the laparoscopic group for stone migration into the calyx and dense

TABLE5 ■ Comparison of Retroperitoneoscopic and Open Ureterolithotomy

RPUL (n = 55)

OUL (n = 26)

p Value

Age in years (mean)

25-65 (43.1)

25-55 (39.8)

NS

Sex (M:F)

39:16

20:6

NS

Stone size in cm (mean)

0.7-3.3 (2.1)

0.7-3.4 (2.4)

NS

Operating time in minutes (mean)

40-275 (108.8)a

60-125 (98.8)

NS

Blood loss in mL (mean)

25-160 (58.5)a

25-100 (50.5)

NS

Analgesia-mg of pethidine

25-75 (41.1)a

50-150 (96.9)

<0.001

Hospital stay in days (mean)

2-14 (3.3)a

3-8 (4.8)

<0.001

Return to work in weeks (mean)

1-3 (1.8)a

2-4 (3.1)

<0.001

aData of 45 successful cases.

Abbreviations: RPUL, retroperitoneoscopic ureterolithotomy; OUL, open ureterolithotomy; M:F,

male:female.

TABLE 6 ■ Comparison of Retroperitoneoscopic Pyelolithotomy and Percutaneous Nephrolitho

tripsy

Procedure

RPPL

PCNL

p value

Number of cases

16

12

Mean age in years (range)

38.9 (21-60)

41.4 (20-62)

NS

Male:female

10:6

8:4

NS

Mean stone size in cm (range)

3.6 (3.2-4.5)

4.1 (3.5-5.2)

<0.006

Conversion

2

0

NS

Mean operating time in

142.2 (45-280)

71.6 (50-100)

<0.000

minutes (range)

Mean estimated blood

173.1 (60-400)

147.9 (75-200)

NS

loss in mL (range)

Mean hospital stay in days (range)

3.8 (1-10)

3 (2-5)

NS

Mean duration of return to full

12.7 (7-20)a

9.8 (7-12)

NS

activity in days (range)

aResults of nine cases only.

Abbreviations: RPPL, retroperitoneoscopic pyelolithotomy; PCNL, percutaneous nephrolithotripsy.

perirenal adhesions, making dissection difficult. Mean operating time was 142 minutes versus 72 minutes for percutaneous nephrolithotripsy (p < 0.0001). Blood loss was similar 173 cc versus 141 cc. Mean hospital stay was 3.8 days versus 3 days, although the duration of convalescence was somewhat shorter in the percutaneous nephrolithotripsy group. Laparoscopic pyelolithotomy is associated with longer operating time, longer recuperation, is more invasive, less cosmetic, and requires more skill as compared to percutaneous nephrolithotripsy. Advanced endourological facilities are required for removal of calyceal stones in the event of migration or for localization of stone such as laparoscopic ultrasound. Laparoscopy is not suitable in patients with dense peripelvic adhesions or history of previous retroperitoneal surgery.

Laparoscopic pyelolithotomy may be indicated for ectopically located, Laparoscopic pyelolithotomy may be congenitally anomalous kidneys or in patients where concomitant laparoscopic proce-

indicated for ectopically located, dure is indicated such as pyeloplasty (30-33).

congenitally anomalous kidneys or in patients where concomitant laparoscopic procedure is indicated COMPLICATIONS

such as pyeloplasty.

Acceptance of any surgical procedure depends to a large extent on the demonstration of technical efficacy and an acceptably low complication rate. However, apart from the initial cases where open conversion was required, this has not been a problem in subsequent cases. Among the major intraoperative complications, rare vascular and visceral injuries have occurred, albeit managed successfully. Among 247 cases of retroperitoneoscopic surgery for calculous disease, comprised of ureterolithotomy (n = 85), pyelolithotomy (n = 27), nephrectomy (n = 114), and nephroureterectomy (n = 31), we had 10.9% minor complications, 1.6% major complications, and 6.8% conversion to open surgery (Table 7). Unforeseen hemorrhage can occur at any time during the procedure but this does not make it any different from open surgery for calculous disease. Possible problems and tips to manage these are described in Table 8.

TABLE 7 ■ Complications in Retroperitoneoscopic Surgery for Calculous Disease

Nephrectomy (114)a;

nephroureterectomy

Ureterolithotomy

Pyelolithotomy

Total

Complications

(21)

(85)

(27)

(247)

Minor

Access and dissection

Peritoneal rent

9

3

0

12 (4.8%)

Emphysema

3

1

0

4 (1.6%)

Kidney puncture

2

0

0

2 (0.8%)

RP collection

0

1

0

1 (0.4%)

Fever

3

0

0

3 (1.2%)

Ileus

2

1

0

3 (1.2%)

Postoperative

Port site infection

2

0

0

2 (0.8%)

Total

21

6

0

27(10.9%)

Major

Vascular

0

1

0

1 (0.4%)

Visceral

1

0

0

1 (0.4%)

Collections

1

0

0

1 (0.4%)

Port site hernia

1

0

0

1 (0.4%)

Total

3

1

0

4 (1.6%)

Conversions

7

8

2

17 (6.8%)

aNumber of cases is given in parentheses.

Abbreviation: RP retroperitoneal.

TABLE8 ■ Technical Caveats and Tips

Technical caveats

Tips

Ureterolithotomy

Stone migration

Hold ureter in Babcock forceps above the stone Use of flexible nephroscope to retrieve migrated stones Use of laparoscopic ultrasound or fluoroscopy

Vascular injury

Careful dissection, and early conversion in cases of extensive adhesions If doubtful, ensure with ultrasound or fluoroscopy

Inability to localize stone

Use of intraoperative fluoroscopy or ultrasound

Peritoneal rent in

Place secondary ports under vision or digital guidance

retroperitoneoscopic approach

Retract the peritoneum with fan retractor Veress needle can be used for deflating abdomen Make rent bigger, so as to equalize pressure

Pyelolithotomy

Stone migration

Avoid excessive palpation of stone especially prior to pyelotomy Keep jaws of forceps open while attempting to grasp Use a flexible nephroscope to retrieve migrated stones Intraoperative fluoroscopy or ultrasound

Excessive perirenal adhesions

Confirmation of stone and pelvis by USG and gentle dissection

Adhesions, especially in

post ESWL patients

Nephrectomy

Excessive perirenal adhesions and pararenal adhesions

Renal dissection outside the Gerota's fascia Control hilar vessels first as for radical nephrectomy

Nephroureterectomy

Excessive perirenal adhesions

Renal dissection outside the Gerota's fascia Control hilar vessels first

Inability to dissect the

Place the patient in an oblique position rather than dead lateral and use

lower ureter due to adhesions

lower port near anterior superior iliac spine

Abbreviations: USG, Ultrasonography, ESWL, extracorporeal shock wave lithotripsy.

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