To Stent Not to Stent and How to Stent

J-stenting is not required in a routine case of pyelolithotomy. In patients where preoperatively J-stenting has been done, we do not change the stent and proceed with the status quo situation.

In patients without a J-stent wherein J-stenting is deemed necessary, this can be accomplished in an antegrade fashion. We have used the following different techniques for antegrade stenting during pyeloplasty, ureterolithotomy, or pyelolithotomy: (i) Alken's needle insertion through one of the ports: The needle is directed toward the site of pyelotomy and a straight guidewire is steered through it into the bladder and a 4.8 French stent is passed over this guidewire into the bladder; (ii) percutaneous placement of a 14 French intravenous cannula and insertion of a guide wire which is passed into the bladder followed by the double J-stent; (iii) direct passage of a guidewire through the port and its manipulation into the bladder (sometimes the placement of an extra port may be necessary); and (iv) insertion of a premounted stent over a guidewire and held with a 5 mm Hem-O-Lok clip, which is unlocked once the stent has reached into the bladder, allowing safe removal of the guidewire.

TABLE2 ■ Steps of Pyelolithotomy

Patient selection

Preoperative preparation and patient positioning Technique Transperitoneal access Retroperitoneal access (creation of retroperitoneal space) Placement of ports Common steps Approach

Identification of the upper ureter Dissection of the renal pelvis (intrarenal or extrarenal) Incision of renal pelvis Retrieval of the stone from the renal pelvis To stent or not to stent Closure of pyelotomy Removal of stone from the body Exit and closure of the ports Postoperative management

If the stone gets migrated proximally into a calyx or if there are preexisting stones in the calyces, a flexible nephroscope, cystoscope, or ureteroscope may be inserted through a laparoscopic trocar to remove these calculi under direct vision.

Occasionally, stone removal with rigid laparoscopic instruments becomes difficult. If such a situation, a flexible nephroscope, cystoscope, or ureteroscope can be used to retrieve caliceal stones.

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