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Litotrissia percutanea laparoscopica nel rene pelvico casi clinici

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Litotrissia percutanea laparoscopica nel rene pelvico: casi clinici con un approccio diverso

Litotrissia percutanea laparoscopica nel rene pelvico: casi clinici con un approccio diverso

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  • 1. Point of Technique Laparoscopically Assisted Percutaneous Pyelolithotomy in Pelvic Kidneys A Different Approach Pejman Shadpour, Robab Maghsoudi, Masoud Etemadian, Kaveh Mehravaran Keywords: laparoscopy, percutaneous nephrolithotomy, kidney calculi, kidney pelvis, nephrostomy, combined modality Urol J. 2010;7:194-8. therapy www.uj.unrc.ir INTRODUCTION nerves. Alternatively, laparoscopic Pelvic kidney stones pose a transperitoneal and retroperitoneal unique challenge to the urologists. pyelolithotomy in the pelvic Treatment options published kidney have been reported.(1,4) in the literature to date include This approach is time consuming extracorporeal shockwave and adequate skill is needed to lithotripsy (SWL), percutaneous suture the pelvis. In addition, nephrolithotomy (PCNL), intrarenal visibility during retrograde intrarenal surgery, laparoscopic surgery is severely laparoscopically assisted PCNL, limited. We describe our laparoscopic pyelolithotomy, and experience with an alternative open surgery. approach, laparoscopically assisted percutaneous pyelolithotomy, to Although ectopic location of treat these patients. the kidney can cause positioning problems during SWL, many CASE REPORT have suggested that calculi in these kidneys should be Three patients (two men and one approached with SWL initially woman) presented to our clinic if feasible.(1) However, when with dull abdominal pain. The reviewing the National Institutes initial workup revealed a pelvic of Health Consensus Conference kidney largely loaded with stones. recommendation for stones greater The mean age of the patients than 20 mm in size, PCNL was was 39.6 years (range, 24 to 54 favored as the initial treatment years). The patients’ mean weight option.(2) and body mass index were 81.7 kg (range, 60 to 93 kg) and 33 Laparoscopically assisted kg/m2 (range, 29 to 37 kg/m2), Hasheminejad Kidney Center, Iran University of Medical Sciences, percutaneous transperitoneal respectively. Tehran, Iran nephrolithotomy has been described to decrease the risk The mean stone size was 3 cm Corresponding Author: Pejman Shadpour, MD for the bowel injury.(3) There are (range, 2 to 4 cm). Two patients Hasheminejad Kidney Center, serious limitations to PCNL. The had a single stone and one had two Vanak Sq, Tehran, 19697, Iran Tel: +98 21 8864 4444 Amplatz sheath is inserted dorsally stones. These calculi were located Fax: + 98 21 8864 4447 near the iliac crest, which restricts in the pelvis, the middle calyx, or E-mail: pshad@iums.ac.ir free movement of the nephroscope infundibulum of the lower calyx. Received October 2009 Accepted February 2010 and may damage retroperitoneal Two pelvic kidneys were located194 Urology Journal Vol 7 No 3 Summer 2010
  • 2. Percutaneous Pyelolithotomy in Pelvic Kidneys—Shadpour et alon the left and one on the right side (Figures 1 abdominoplasty with tubal ligation. All hadand 2). previous failed SWL of the pelvic kidney stone. Intervening bowel and/or extremely thick fatIn addition to obvious obesity and shortstature, one patient had history of previousopen extraperitoneal pyelolithotomy of theaffected kidney and another one had undergoneFigure 1. Plain film and retrograde pyelography show right pelvic kidney stone in one patient.Figure 2. Pre-operative plain film and intravenous urographic image of one of the patients show left pelvic renal stones.Urology Journal Vol 7 No 3 Summer 2010 195
  • 3. Percutaneous Pyelolithotomy in Pelvic Kidneys—Shadpour et allayer precluded access to the kidney through and renal ultrasonography were also carried out atthe lumbodorsal approach in all three patients. weeks 2 and 12 postoperatively.Given these limitations, all patients consented toundergo laparoscopically assisted percutaneous RESULTSpyelolithotomy. Mean operative time was 71 minutes (range, 48 to 113 minutes). Estimated blood loss was 26TECHNIQUE mL (range, 8 to 50 mL). No patient receivedPre-operative laboratory examination was within blood transfusion during or after the procedure.the normal limits. Intravenous urography and All three patients were rendered stone-freenon contrast spiral computed tomography scan of based on final intra-operative nephroscopic andthe abdomen and the pelvis were performed pre- fluoroscopic inspection of the pyelocalycealoperatively for all three patients. system, which was confirmed by postoperative plain film and ultrasonography.On the day of surgery, after induction of generalanesthesia and placing a ureteral catheter by Patients were discharged from the hospital aftercystoscopy, patients were prepped and draped urine leakage discontinuation and documentationin supine position. Laparoscopy was performed of stone-free state. The postoperative periodusing two to three 5-mm ports in the midline. remained uneventful with no clinically detectableAfter exploration of the peritoneal cavity, leakage.the pelvic kidney was found and posteriorperitoneum was incised to swiftly expose the DISCUSSIONrenal pelvis by blunt dissection. The third trocar Although ectopic location of the kidney can causewas needed only where dissection of previous problems during SWL due to intervening boweladhesions became necessary. anteriorly and bones posteriorly, calculi in theseWith adequate visualization of the typically kidneys should be approached by this methodabnormal renal vasculature, the safest path to initially if at all possible.(1) In the case of SWLenter the congenitally anterior renal pelvis was failure, alternative modalities may be used.readily determined. An 18-gauge needle was Our patients were not appropriate candidatesinserted from the anterior abdominal wall into for classic prone dorsal PCNL because of theirthe renal pelvis. After full distention of the pelvis obesity, short stature, and intervening bowels.via the ureteral catheter, the tract was dilated Eshghi and colleagues described laparoscopicallyin single pass by an Amplatz clad cone dilator. assisted PCNL in 1985 to deal with the frequentA 24-F rigid nephroscope was used to perform problems encountered by retrorenal intestines.(3)pyeloscopy. The stones were either removed Holman and Toth reported good results and nointact or fragmented by Swiss Lithoclast Master major complications in 15 patients treated byLithotripter (EMS, Bern, Switzerland). A 14-F laparoscopically assisted PCNL.(5) El-Kappanyclosed tube drain was inserted through the and associates presented the combination oflowermost laparoscopic port. The renal pelvis laparoscopy and nephroscopy for treatment ofwas not repaired after removal of the scope, but ectopic pelvic kidney stones in 11 patients andthe ureteral catheter was left in place attached to a concluded that this combination is feasible, safe,14-F Foley catheter. and effective for treatment of such stones.(6) AronComplete blood count, blood urea nitrogen, and coworkers reported laparoscopically assistedcreatinine, and plain radiography were repeated percutaneous nephrolithotomy in a patient withthe day after surgery. Both catheters were history of previous open pyelolithotomy.(7) Inremoved 24 hours postoperatively and the drain PCNL, the tract traverses renal parenchyma, andwas removed on the second postoperative day. All obtaining a suboptimal non trans-papillary routepatients were discharged from hospital 48 hours is common. The latter plus exaggerated angulationafter the procedure. Kidney, ureter, bladder x-ray required to access middle and lower calyces in196 Urology Journal Vol 7 No 3 Summer 2010
  • 4. Percutaneous Pyelolithotomy in Pelvic Kidneys—Shadpour et almany pelvic kidneys can be associated with high laparoscopic dissection, for reasons mentionedprobability of bleeding from infundibular or above. Another well-known characteristicmore extensive parenchymal laceration. This of pelvic kidneys is the presence of vascularexplains the frequent occurrence of bleeding that variations, in which direct visualizationsometimes requires blood transfusion. afforded by laparoscopy can result in reduced associated risks. At the same time, percutaneousKramer and colleagues performed laparoscopic radially dilated access to the pelvis brings apyelolithotomy in three patients with a novel minimally invasive method for access tohorseshoe kidney. There were no minor or the kidney without requiring incision and/ormajor complications, and the estimated blood subsequent reclosure by suturing the urinaryloss was <50 mL. The pelvis was incised and tract, thereby, saving time without causing anyrequired suturing leading to mean operative time clinically significant leakage or risking vascularof 123 minutes (range, 74 to 150 minutes). They injury.concluded that laparoscopic pyelolithotomy canbe done safely, effectively, and efficiently with Also of note is the much more adequateproper patient selection and adherence to standard visualization of the pyelocalyceal interior inlaparoscopic surgical principles.(8) the submerged irrigant medium of the closed pyelocalyceal system through a nephroscope,Alternatively, laparoscopic retroperitoneal instead of the encumbered tangential air orpyelolithotomy was performed in a pelvic water view through a pyelotomy incision duringkidney by Harmon and associates.(1) Collins classic laparoscopic pyelolithotomy of a pelvicand coworkers reported the combination of kidney. It is also more efficient than puttinglaparoscopic pyelolithotomy and ultrasonic the nephroscope into a gaping wide gas filledlithotripsy.(9) Their patient underwent pyelotomy incision as described earlier.(8)uncomplicated laparoscopic pyelolithotomy. Thestone has been located into an entrapment sack. There is a case report by Figge which althoughThe open end of the Endocatch sack was brought claimed to represent percutaneous transperitonealthrough a trocar site and a nephroscope and nephrolithotomy, had actually involved aultrasonic lithotripter were deployed. The stone transpelvic route as described in our series. Thatwas fragmented and aspirated in the standard case report, however, did not include any attemptmanner, thereby, avoiding the need to extend at intracorporeal stone fragmentation, and didthe 12-mm trocar incision for stone extraction. not require exploration of the entire calycealThe patient was stone-free and discharged in the system.(10)morning of the first postoperative day without The fact that our patients had no postoperativeany complication.(9) leakage is particularly concerting. We believe thisIn this study, we presented an entirely different owes, at least in part, to deliberately leaving theapproach for percutaneous pyelolithotomy. We ureter without an indwelling stent once stone-used laparoscopic view to guide our nephroscope free state was ascertained postoperatively. Indirectly into the renal pelvis through a dilated addition to allowing unimpeded reflux to exertneedle puncture. By logical deduction based on high physiologic voiding pressures directly ontothe common feature of the anteriorly placed the pyelotomy site, a double J stent could oftenpelvis and posteriorly located renal parenchyma be blocked by clots and debris. Interestingly, thepeculiar to this patient group, it is easy to see only instance of prolonged urinary drainage inwhy accessing the renal parenchyma to perform a study by Holman and Toth was reported in alaparoscopically assisted PCNL is conceivably stented patient due to instrument malfunction.(5)more difficult than the method hereby described Unstented subjects in Kramer and colleagues’from the anatomical standpoint. report had uneventful recovery.(8) Similarly, totally tubeless PCNL is now widely perceived toOur patients were not amenable to the lessen urinary leakage significantly.dorsal approach to the renal cortex even withUrology Journal Vol 7 No 3 Summer 2010 197
  • 5. Percutaneous Pyelolithotomy in Pelvic Kidneys—Shadpour et alCONFLICT OF INTEREST 5. Holman E, Toth C. Laparoscopically assisted percutaneous transperitoneal nephrolithotomy in pelvicNone declared. dystopic kidneys: experience in 15 successful cases. J Laparoendosc Adv Surg Tech A. 1998;8:431-5.REFERENCES 6. El-Kappany HA, El-Nahas AR, Shoma AM, El- Tabey NA, Eraky I, El-Kenawy MR. Combination of 1. Harmon wJ, Kleer E, Segura Jw. Laparoscopic laparoscopy and nephroscopy for treatment of stones pyelolithotomy for calculus removal in a pelvic kidney. in pelvic ectopic kidneys. J Endourol. 2007;21:1131-6. J Urol. 1996;155:2019-20. 7. Aron M, Gupta NP, Goel R, Ansari MS. Laparoscopy- 2. Segura Jw, Preminger GM, Assimos DG, et al. assisted percutaneous nephrolithotomy (PCNL) Nephrolithiasis Clinical Guidelines Panel summary in previously operated ectopic pelvic kidney. Surg report on the management of staghorn calculi. The Laparosc Endosc Percutan Tech. 2005;15:41-3. American Urological Association Nephrolithiasis 8. Kramer BA, Hammond L, Schwartz BF. Laparoscopic Clinical Guidelines Panel. J Urol. 1994;151:1648-51. pyelolithotomy: indications and technique. J Endourol. 3. Eshghi AM, Roth JS, Smith AD. Percutaneous 2007;21:860-1. transperitoneal approach to a pelvic kidney for 9. Collins S, Marruffo F, Durak E, et al. Laparoscopic endourological removal of staghorn calculus. J Urol. pyelolithotomy with intraperitoneal ultrasonic 1985;134:525-7. lithotripsy: report of a novel minimally invasive 4. Meria P, Milcent S, Desgrandchamps F, Mongiat-Artus technique for intracorporeal stone ablation. Surg P, Duclos JM, Teillac P. Management of pelvic stones Laparosc Endosc Percutan Tech. 2006;16:435-6. larger than 20 mm: laparoscopic transperitoneal 10. Figge M. Percutaneous transperitoneal pyelolithotomy or percutaneous nephrolithotomy? Urol nephrolithotomy. Eur Urol. 1988;14:414-6. Int. 2005;75:322-6.198 Urology Journal Vol 7 No 3 Summer 2010