LAPAROSCOPIC PYELOLITHOTOMY: OPTIMIZING SURGICAL TECHNIQUE

LAPAROSCOPIC PYELOLITHOTOMY: OPTIMIZING SURGICAL TECHNIQUE

THE JOURNAL OF UROLOGY® 736 CONCLUSIONS: Robotic assisted laparoscopic reconstruction of the urinary tract is helpful for restoring urinary drainage...

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THE JOURNAL OF UROLOGY®

736

CONCLUSIONS: Robotic assisted laparoscopic reconstruction of the urinary tract is helpful for restoring urinary drainage in a minimally invasion fashion. Adherence to simple tips and tricks described in this video allows for reconstruction at any level from a renal calyx down to the bladder. Source of Funding: None

V2031 SIMULTANEOUS LAPAROSCOPIC TREATMENT FOR URETEROPELVIC JUNCTION OBSTRUCTION ACCOMPANIED BY NEPHROLITHIASIS Norihiko Tsuchiya*, Takamitsu Inoue, Takeshi Yuasa, Sohei Kanda, Teruaki Kumazawa, Shintaro Narita, Mitsuru Saito, Hiroshi Tsuruta, Shigeru Satoh, Tomonori Habuchi, Akita, Japan INTRODUCTION AND OBJECTIVE: Ureteropelvic junction (UPJ) obstruction is often accompanied by renal calculi. Currently, two endoscopic approaches are available for such cases: percutaneous nephrolithotomy with endopyelotomy and laparoscopic pyelolithotomy with pyeloplasty. We demonstrate the details of the latter technique in this presentation. METHODS: A 28-year-old female presented with left flank pain. Ultrasonography revealed left hydronephrosis and calculi in the lower calyx. CT scan showed a high insertion type of UPJ obstruction without crossing vessels. Renogram of the left kidney demonstrated a delayed excretion pattern with prolonged half-life time (25 min) after furosemide diuresis. The patient was placed in the right hemilateral position. Two 12mm and two 5-mm trocars were inserted, and the abdomen was insufflated with 10 mmHg of CO2. Two stay sutures were placed at the lowest point of the renal pelvis and the cephalad to UPJ for traction, and the renal pelvis was incised between the two sutures. First, all the renal stones were removed using stone forceps or a basket catheter under direct vision of a laparoscope or flexible cystoscope. Subsequently, standard dismembered pyeloplasty was performed over a double-J stent. RESULTS: The operating time was 322 min with minimal blood loss. The patient was discharged from the hospital 5 days after the surgery and had the stent removed 2 months later. The left flank pain was relieved, and furosemide renogram showed that the excretion halflife time of the left kidney decreased to 5 min. CONCLUSIONS: Thus, the concomitant laparoscopic pyelolithotomy with pyeloplasty achieves maximal stone clearance and ensures correction of UPJ with minimal morbidity. Source of Funding: None

V2032 LAPAROSCOPIC PYELOLITHOTOMY: OPTIMIZING SURGICAL TECHNIQUE José A. Salvadó*, Sergio Guzmán, Cristian Trucco, Santiago, Chile INTRODUCTION AND OBJECTIVE: The classical approach to renal stone disease includes shock wave lithotripsy or percutaneous lithotripsy and in some cases, a combination of both. The usefulness of laparoscopy in this issue remains debated. In this video we present our technique of laparoscopic pyelolithotomy assisted by flexible instrumentation in order to achieve maximal stone clearance in a selected group of patients. METHODS: From November 2006 till May 2008 our group performed 10 laparoscopic pyelolithotomy. Inclusion criteria were: large stone into the pelvis with several secondary calculi in peripheral calyces, concomitant ureteropelvic junction (UPJ) obstruction or patient with poorly functioning kidney. Evaluation with CT Scan, KUB radiograph and renal ultrasound was done before surgery. Image studies demonstrated in all patients some degree of hydronephrosis. Multiples stones in different poles in the same kidney was present in 4 cases, size ranging from 2 to 35 mm. Two patients has a previous open anatrophic nephrolitotomy. This series includes three women and six men and the mean age was 50 years (30-63) .

Vol. 181, No. 4, Supplement, Wednesday, April 29, 2009

RESULTS: Standard laparoscopic pyelolthotomy was performed in all cases using a flexible cystoscope introduced by the upper port. Free rate was 90 percent, determined by CT scan. Mean operative time was 195 minutes. Drain tube was retired on postoperative day 2. Foley catheter was retined for 1 week and double J stent for 1 month. Mean postoperative stay was 4 days(2-6). There was no intraoperative or postoperative complications. CONCLUSIONS: We believe that this technique can be considered in cases of a large stone burden in different locations into the kidney, concomitant UPJ obstruction and in patients with impaired renal function where they need to preserve parenchyma. Source of Funding: None

V2033 MANAGING “CROSSING” VESSELS IN PATIENTS WITH URETEROPELVIC JUNCTION OBSTRUCTION: THE DILEMMA CONTINUES? Rajesh K Ahlawat*, Gagan Gautam, Prasun Ghosh, Manav Suryavanshi, Rakesh Khera, Atul Thakre, New Delhi, India INTRODUCTION AND OBJECTIVE: The significance of a vessel associated with UPJ obstruction, and its management, has been debated. Transposition of such a vessel has been recommended for success. A vessel anatomically anterior to UPJ is “crossing” during transperitoneal (TP) approach, and has been posteriorly transposed. With retroperitoneal (RP) approach, a vessel will cross UPJ if anatomically posterior to it, and it has been placed anterior to UPJ with successful outcome. There are reports of success with superior transfixation of the crossing vessel, without intervening at UPJ. We review our data to look at significance of vascular transposition. METHODS: 21 cases had vessels associated to UPJ during 82 laparoscopic TP pyeloplasties. Two vessels crossed posterior, and 19 anterior to UPJ. The vascular band was released and pyeloplasty performed in all. A note was made of the sacrificed length of stenotic ureteric segment. It was ensured that pelvic V-flap falls to spatulated ureter without a twist, anterior or posterior to vessel. The vessel was transposed if it could not be mobilized superiorly well away from the neo-UPJ or if it added to ease of anastomosis by placing the vessel posteriorly. Success was defined as asymptomatic status and improved diuretic scan. RESULTS: Stenotic UPJ segment was >1 cm in 8, longest being 4.5 cm. Both posterior vessels were left in same anatomical location. One anterior vascular band contained only vein and was cut across before pyeloplasty. Posterior transposition was performed in 11 cases. Vessel was left anterior crossing in 7, all with baggy extra-renal pelvis. A long pelvic V-flap, in latter cases, brought neo-UPJ well away from the crossing vessel. Any attempt at bringing a long V-flap anterior to the crossing vessel, in fact, distorted the anatomy. Success was achieved in all 21 cases, irrespective of transposition of vessel. CONCLUSIONS: UPJ obstruction of varying length and anatomical configuration may be associated with crossing vessels. A crossing vessel needs to be released from UPJ, but its transposition may not be necessary in all cases. Transposition may add to ease of anastomosis since an untransposed vessel may come in the way while performing suturing. The outcome following a pyeloplasty in such cases is independent of the manner of vessel treatment. Source of Funding: None

V2034 LAPAROSCOPIC PYELOLITHOTOMY FOR MULTIPLE STONES IN A PREVIOUSLY OPERATED SOLITARY PELVIC KIDNEY Vincent G Bird*, John M Shields, Rosely De Los Santos, Miami, FL INTRODUCTION AND OBJECTIVE: Most large stone burdens are amenable to percutaneous surgery. However, renal ectopy and history of previous surgery may at times preclude safe use of a percutaneous approach. Herein we demonstate a laparoscopic approach for treatment of a large stone burden in a previously operated solitary pelvic kidney.