Percutaneous ureterolithotomy

Percutaneous Nephrolithotomy: Challenges for a Novice Urologist

PCNL is the treatment of choice for large renal stones. It is a procedure of expertise. It may look simpler when done by an experienced urologist; however, for a beginner, learning each and every step is very important. He should be well-versed about the difficulties faced at every step and know how to tackle them. This article focuses mainly on the intricacies faced by a trainee during the procedure and how to troubleshoot them. Failure at any stage can lead to bleeding complications or incomplete removal of stones.

Percutaneous nephrolithotomy: technique

Percutaneous nephrolithotomy (PCNL) is considered to be the first line of treatment for large renal stones. Though PCNL comes with higher morbidity, its efficacy is unbeaten by other minimally invasive modalities. However, potential complications, such as bleeding, occur. Improved skills and modifications of the procedure may reduce the probability of adverse outcomes. This article discusses the current trends and standards in PCNL technique with special focus on all important steps as positioning, access, instruments, dilation, disintegration, and exit, including outcomes, complication management, and training modalities.

Laparoscopic retroperitoneal extirpative and reconstructive renal surgery

Retroperitoneal laparoscopy for renal surgery is a viable and versatile alternative to transperitoneal access. Location of the kidneys in the retroperitoneum makes it an attractive approach. The development of both approaches paralleled during the last two decades; however, retroperitoneal laparoscopy witnessed a steep learning curve because of the constraint of working space, lack of obvious landmarks, and appropriate instrumentations. This approach has several advantages and is currently being used for extirpative and reconstructive procedures for various renal pathologic conditions. After creation of retroperitoneal space, the techniques can be tailored to the desired indication for successful culmination. The learning curve can be shortened by adequate training; subsequently, with experience, this can be used proficiently.

Retroperitoneal renal laparoscopy

The retroperitoneal laparoscopic approach to the kidney offers a minimally invasive access that mimics the open surgical techniques of renal surgery. It allows renal surgery without violation of the peritoneal cavity with its attendant complications such as bowel injury and ileus. Over the last two decades, all renal surgery has been shown to be feasible through this technique. This includes complicated procedures such as a donor nephrectomy and radical nephroureterectomy for upper tract transitional cell cancers. We began performing retroperitoneoscopic renal surgery in the early 1990s and have developed a number of modifications to existing techniques so as to make this surgery easy and cost effective. In this review, we discuss the evolution of retroperitoneoscopic renal surgery, the indications, techniques and outcome of all types of retroperitoneoscopic renal surgery.

Fluoroscopy-Assisted Retroperitoneal Laparoscopic Renal Surgery in Children

PURPOSE

To investigate the use of C-arm fluoroscopy for locating small dysplastic renal lesions during retroperitoneal laparoscopic nephrectomy in children.

PATIENTS AND METHODS

From March 2003 to March 2005, two boys and four girls with a mean age of 5 years underwent retroperitoneal laparoscopic nephrectomy under C-arm fluoroscopic guidance. The indications for laparoscopic renal surgery were ectopic ureter with dysplastic kidney (N = 3), hypertensive nephropathy (N = 1), and dysplastic kidney secondary to reflux nephropathy (N = 2).

RESULTS

All operations were completed with no necessity for conversion to open surgery. Small dysplastic kidneys were easily located using C-arm fluoroscopy, and retroperitoneal laparoscopic nephrectomy was then performed. One patient required open contralateral reimplantation after laparoscopic nephrectomy because of high-grade vesicoureteral reflux. The mean operative time was 139 minutes (range 71-210 minutes). Blood loss was minimal, and no transfusion was required. There were no intraoperative or postoperative complications other than a peritoneal injury in one patient, which caused no subsequent major problem. The mean postoperative hospital stay was 3.8 days, and all children returned to normal activity within 3 to 6 days.

CONCLUSIONS

This is the first report to our knowledge of retroperitoneal laparoscopic renal surgery under C-arm fluoroscopic guidance. This approach allowed quick and easy location of small ectopic kidneys prior to retroperitoneal laparoscopic nephrectomy and was found to be very useful for the treatment of small dysplastic renal lesions in children.

Retroperitoneoscopic ureterolithotomy for impacted ureteral stone

Retroperitoneoscopic ureterolithotomy was successfully performed in two patients with impacted upper ureteral stone. The retroperitoneal space was extended using a balloon dissector and four ports were established into the retroperitoneal space according to Gaur's procedure (1993). The impacted ureteral stone was removed after the ureter was incised using a hook electrode. An indwelling splint or stent was placed in the ureter. The incised ureter was not sutured and an indwelling drain was placed in the retroperitoneal space. Urine leakage ceased within 3 days postoperatively. With regard to complications, the first patient developed wound infection caused by methicillin-resistant Staphylococcus aureus and the second patient had abscess formation in the psoas muscle. Retroperitoneoscopic ureterolithotomy should be useful as an alternative treatment for impacted ureteral stones because it involves minimal postoperative pain.

Percutaneous ureterolithotomy: direct method for removal of impacted ureteral stones

PURPOSE

We report 52 percutaneous urterolithotomies in 51 patients having large, impacted middle ureteral stones. Direct percutaneous stone removal can be performed as successfully as in cases of renal stones treated with percutaneous nephrolithotomy.

METHODS

The operation is performed under local anesthesia; therefore, the procedure is quicker and simpler than the laparoscopic or retroperitoneoscopic intervention. All patients became stone free. In two patients (4%), ultrasound disintegration was necessary; in the remaining cases, there was no need for any fragmentation: the stone was removed intact. A retroperitoneal drain was always left at the end of the procedure. With the exception of two cases, the ureter was always stented without closure of the ureteral incision.

RESULTS

Fever (> or = 38 degrees C) was observed in 15 patients (29%) for 2 days. Retroperitoneal hematoma 5 cm in diameter was seen in one patient. One patient had urine leakage through the retroperitoneal drain in the postoperative period for 18 days. Also, one patient came back 3 days after discharge with urine leakage through the percutaneous retroperitoneal tract.

CONCLUSION

Direct percutaneous ureterolithotomy is an effective way to remove impacted middle ureteral stones but is advisable only for endourologists with considerable experience.

Retroperitoneal laparoscopic management of urolithiasis

Laparoscopic retroperitoneal pyelolithomy (Lap PL) and ureterolithotomy (Lap UL) were performed in 20 and 24 patients, respectively. The average operating time was 61.4 minutes for Lap UL and 80.2 minutes for Lap PL. The conversion rate for Lap PL was 4 (20%) patients, and none of the Lap ULs required conversion. There were no major postoperative complications, except prolonged tube drainage in 2 patients, and the average hospital stay was 3.6 days.

Minimal access ureterolithotomy

A new minimally invasive ureterolithotomy is herein described which utilizes a 3 cm long skin incision. Surgery is performed with the aid of a newly developed bivalve retractor endoscope (Jakoscope) which provides excellent illumination with built-in double fiberoptic light cables and high intensity light source. The new surgical technique can be utilized in the rare cases of ureteral stone when other standard modalities may not work or when the patient demands definitive rapid treatment, and cannot be followed postoperatively.

Initial experience with retroperitoneoscopic nephroureterectomy: use of a double-balloon technique

OBJECTIVES

To report the initial experience with retroperitoneoscopic nephroureterectomy for symptomatic, end-stage vesicoureteral reflux.

METHODS

Two patients underwent a nephroureterectomy by a four-port retroperitoneal laparoscopic approach. In 1 patient, a double-balloon technique was used to dissect the pelvic extraperitoneal space and gain access to the juxtavesical ureter. In the second patient, the distal ureter was mobilized with routine laparoscopic dissection techniques.

RESULTS

Operative time was 6 and 5.5 hours, respectively, and mean hospital stay was 4 days. Mean patient follow-up is 17.5 months.

CONCLUSIONS

The technique of retroperitoneoscopic nephroureterectomy is in evolution; until now, a major concern has been the inadequate access to the distal ureter through a completely retroperitoneoscopic approach. Described herein is a double-balloon technique that significantly facilitates dissection of the juxtavesical ureter during a retroperitoneal laparoscopic nephroureterectomy.

Retro-peritoneoscopy: anatomical rationale for direct retroperitoneal access

Although the upper urinary tract resides at an extraperitoneal location, the traditional laparoscopic approach to these organs has been transperitoneal. Several investigators have advocated using a direct approach to the retroperitoneum to minimize risks associated with transperitoneal surgery. We performed autopsy and radiographic studies in an effort to define the location of the retroperitoneum relative to surface anatomy. These investigations indicate that the peritoneal reflection was consistently anterior to the posterior axillary line. Moreover, when a patient was placed in the lateral position, the anteroposterior extent of the potential retroperitoneal space increased 2-fold. Based on these studies, a technique for direct retro-peritoneoscopy was initiated and successfully performed in 21 of 23 patients. Direct access to the retroperitoneum can be performed in a reliable and safe manner.

Advances in laparoscopic urology, Part I. History and development of procedures

Many of the recent applications of laparoscopy to urologic surgery have demonstrated the feasibility of these techniques to complete the intended diagnostic or therapeutic objectives and provide the patient with a more comfortable and shorter recuperative period. Ongoing laboratory and clinical research continues to expand the field of laparoscopic urologic surgery in terms of therapeutic and reconstructive techniques. The second part of this review will explore the more innovative applications of laparoscopic urology and the impact this may have on the practice and art of urology.

Retroperitoneoscopy: the Washington University Medical School experience

OBJECTIVE

To describe our initial experience with balloon dilatation of the retroperitoneum.

METHODS

In 12 patients undergoing laparoscopic renal surgery, the retroperitoneum was dilated using the technique of balloon dilatation. This technique is described and the operative procedure performed in each patient is outlined. The postoperative recovery data and complications are also presented.

RESULTS

This procedure provided excellent exposure of the anatomic structures within the retroperitoneal space and simplified the surgical dissection by staying out of the abdominal cavity.

CONCLUSIONS

Access to the retroperitoneal space is easily and quickly performed utilizing the technique of balloon dilation and may minimize the risk of injury to peritoneal organs.

Retroperitoneal laparoscopic ureterolithotomy for multiple upper mid ureteral calculi

A 30-year-old man presented with upper mid ureteral calculi and gross hydroureteronephrosis. The 4 large and 2 small calculi were removed successfully using Gaur's technique of retroperitoneal laparoscopy.

Special considerations in the technique of laparoscopic ureterolithotomy

Laparoscopic ureterolithotomy was performed in 2 men, accompanied in 1 by unroofing of a complex renal cyst. This new technique is indicated as an alternative to open lithotomy when more conventional minimally invasive measures have failed and in patients in whom laparoscopy is being performed for another indication. Modifications in technique are necessary depending on the location of the stone. Laparoscopic ureterolithotomy should not be performed unless a guide wire or catheter can be placed past the stone preoperatively. The technique is described in detail.

Retroperitoneal endoscopic ureterolithotomy: our experience in 12 patients

Retroperitoneal endoscopic ureterolithotomy was successful in 9 of 12 patients who had calculi impacted in the upper and mid ureter with gross hydronephrosis and recurrent infection. This procedure was made possible by the technique of balloon retroperitoneoscopy recently described by the author.

Retroperitoneal laparoscopic nephrectomy: laboratory and clinical experience

Laparoscopic nephrectomy using an entirely retroperitoneal approach was performed in six anesthetized female pigs. In each animal, the kidney was localized using fluoroscopy, following which the retroperitoneum was insufflated with CO2. Subsequently, a retroperitoneal laparoscopic nephrectomy was performed in a 48-year-old man with a chronically obstructed, nonfunctioning kidney. Although the retroperitoneal approach provides excellent exposure for the dissection of the renal hilum, anatomic factors in the human limit port placement and organ entrapment and increase the risk for development of a pneumothorax.

Laparoscopic urology: past, present, and future

Laparoscopy has begun to have a significant impact on the management of urologic problems. Although initially limited to diagnostic pediatric problems, it has more recently been used to resolve myriad adult urologic conditions. Indeed, during the past year laparoscopic urology has moved well beyond the diagnosis of the undescended testicle and has been successfully used for pelvic lymphadenectomy, varicocelectomy, ureterolysis, drainage of a pelvic lymphocele, bladder suspension, and nephrectomy. Future applications of laparoscopy in urology may well include nephroureterectomy, cystectomy, and creation of an ileal conduit.

Retroperitoneoscopy: foreign body retrieval

Retroperitoneoscopy is a rarely indicated procedure for the urological surgeon. However, it can be a useful means to approach some types of ureteral pathology and foreign bodies. We describe a case in which a severed surgical drain was removed from deep within the retroperitoneum by using a percutaneous retroperitoneal approach.

Percutaneous ureterostomy

Percutaneous ureterostomy was performed bilaterally in 1 patient and unilaterally in another when easier methods of total diversion failed. This advanced endourological technique is most applicable in a thin patient with tortuous ureters.