Outcomes

Multiple studies have described both transperitoneal and retroperitoneal LPL for large renal pelvis stones ranging from 1.6 to 4 cm with high SFR (range 71–100%) (Table 104.2) [7–13]. Complication rates have been reported to range from 0% to 27% with open conversion rate up to 20%. Although earlier cases reported prolonged urinary leakage likely from pyelotomies that were not closed, later cases with intracorporeal suturing of the pyelotomy resulted in decrease in urinary leakage [8].

Initial comparison studies of both transperitoneal and retroperitoneal LPL to PCNL for a large renal pelvis stones have reported comparable SFRs (88% vs. 82%), estimated blood loss (EBL) (173 ml vs. 141 ml), complication rates (12% vs. 18%), and length of stay (LOS) (3.8 days vs. 3 days), respectively [14, 15]. The mean operative time, however, was significantly longer for LPL (142 minutes vs. 72 minutes). These results were later confirmed by a larger, randomized study [16]. In this series, no significant differences were seen on the intra‐ and postoperative parameters such as EBL, pain control, rate of blood transfusion, LOS, or SFR at three months (100% vs. 96%, respectively). The only difference was the mean operative time, which was significantly longer for the LPL group (130.6 minutes vs. 108.5 minutes, respectively).

The advancements in laparoscopic techniques, however, translated into more favorable outcomes with LPL in the more recent studies. Tefekli et al. reported a lower EBL and postoperative decrease in hemoglobin with LPL compared to the match‐paired patients treated with PCNL [13]. Although not statistically significant, higher SFR (100% vs. 88.4%, respectively) was also seen with LPL. Recent randomized study and meta‐analysis confirmed these results where shorter mean operative time and LOS was associated with PCNL whereas lower transfusion rates were seen with LPL [20, 22]. When compared to ESWL, LPL was also shown to have higher SFR, lower levels of postoperative pain, and a faster recuperation [23]. Some series also reported higher single‐session SFR with LPL compared to ESWL and PCNL, especially with a larger stone burden [24]. Despite these more favorable contemporary series, the current combined evidences still suggest that LPL, although feasible, is only indicated under special considerations [12].

Special consideration: renal pelvic stones with a concomitant UPJ obstruction

Renal pelvic stones with a concomitant UPJ obstruction is one of the most common situations where LPL is considered over other means of therapy. Approximately 20% of patients with UPJ obstruction harbor stone disease [25]. An extended pyelotomy, which can later be incorporated into the final pyeloplasty incision, is used to extract the pelvic stones with rigid graspers under direct laparoscopic vision [26]. A flexible endoscope (cystoscope preferred over ureteroscope) passed through one of the laparoscopic ports, then through the pyelotomy, and into the renal collecting system can then be used to inspect and clear the calyces of remaining stones. In many series, SFRs of 75–90% can be achieved with up to 90% of patients showing no evidence of obstruction on follow‐up diuretic renal scan [26, 27]. In a comparative study by Stein et al., concomitant LPL, compared to the laparoscopic pyeloplasty alone, was also shown to be both effective and safe with high SFR of 80% and comparable success rates of UPJ obstruction (93% vs. 100%, respectively) without a significant increase in morbidity or operative time (174 minutes vs. 170 minutes, respectively) [25]. Other intra‐ and postoperative parameters such as EBL, number of ports, and LOS were also similar between the two groups.

The application of robotics, especially with concurrent reconstruction, have also been reported, with advantages in improved maneuverability and visualization. Studies have reported additional mean operative time of 61.7 minutes for concomitant stone extraction without added complications or LOS during robot‐assisted pyeloplasty (RAP) [21, 28]. One of the main concerns for any robotic application, however, is its added cost. These cost increases are mainly from the equipment depreciation, maintenance, and replacements, as well as longer operative time. Studies have shown that RAP may cost 1.7–2.7 times more than laparoscopic pyeloplasty [29, 30]. Its cost, however, can be mitigated by its shorter mean operative time (140 minutes for RAP vs. 235 minutes for laparoscopic pyeloplasty in one series) as well as lessened depreciation impact of the equipment in high‐volume centers [30].

Procedure

A preoperative evaluation with computed tomography (CT) should provide sufficient data regarding stone size, location of stone, and pertinent anatomy. A CT with contrast and delayed imaging may be of benefit when vascular abnormalities or other anatomic aberrancies exist (e.g. malrotated kidney). If a CT is not available, an intravenous pyelogram (IVP) can be considered.

Both transperitoneal and retroperitoneal approaches are feasible for LPL. The author’s preference is the transperitoneal approach. After positioning the patient in the modified contralateral decubitus position with all pressure points well padded and the patient appropriately secured to the bed, the patient’s abdomen and genitalia are prepped and draped in the usual sterile manner. A Foley catheter is then placed. Pneumoperitoneum is achieved with the surgeon’s preferred method. A Veress needle or Hasson technique is utilized to establish pneumoperitoneum at either umbilical or left upper quadrant (Palmer’s point) areas. Once pneumoperitoneum is established with 15 mmHg of CO₂ pressure, three ports are placed in a triangular configuration, with a 12 mm port at the umbilicus, a 12 mm port in the ipsilateral lower quadrant and a subxiphoid 5 mm port (may be upsized to a 12 mm port) (Figure 104.1). An additional 5 mm incision with or without port under the xyphoid process can be utilized for a self‐locking grasper for liver retraction during the right‐sided procedure if necessary. For an obese patient, the ports are displaced laterally and cephalad.

Once ports are placed, the table is rotated toward the contralateral direction such that the camera port is flat to the horizon. Using a 30° down scope, the abdominal contents are inspected and the white line of Toldt is incised to allow for medial reflection of the colon. The ureter is then identified over the psoas muscle (running parallel to the gonadal vessels) and traced up to the renal pelvis. Stones in renal pelvis are generally easily identified due to their bulge. If the identification is difficult due to surrounding inflammation and/or adhesions, more thorough dissection to expose the renal pelvis may be necessary. Care must be taken to avoid inadvertent injury to the ureter or renal pelvis in case of tissue friability which is often present. Laparoscopic ultrasound or on‐table fluoroscopy can be utilized to locate the stone in the pelvis or any fragments in the calyces.

A pre‐positioned ureteral catheter may facilitate identification of the ureter and renal pelvis. This can also serve to test for watertight closure of pelvis and to place a ureteral stent in a retrograde manner toward the end of the case. Placement of ureteral catheter should be performed at the beginning of the case, either before the laparoscopic portion or, alternatively, during, with a flexible cystoscope by the assistant surgeon while the patient is in the modified flank position and undergoing the laparoscopic portion of the case. Alternatively a ureteral stent can be passed in the antegrade fashion before closure of the pyelotomy.

Pyelotomy should be made and extended with laparoscopic scissors in a longitudinal fashion using a curvilinear incision (Figure 104.2a). The surgeon must plan the size and direction of the pyelotomy based on the size and location of the stone, the renal pelvis anatomy, and whether or not it will be incorporated into a pyeloplasty. A flexible cystoscope, and if necessary a flexible ureteroscope, may be passed through one of the 12 mm ports into the pyelotomy to inspect the renal pelvis and all calyces for stone (Figure 104.3). Stone basket extraction may be performed when necessary. Pressure irrigation to 300 mmHg with normal saline is used to create a turbulent flow inside the pelvis for adequate hydrodistention for exploration. The mucosal adhesions to the stones can be dissected off using a right‐angle dissector [31]. An endoscopic retrieval bag may be used to minimize the risk of intra‐abdominal stone loss and to facilitate the extraction of multiple and/or small stones (Figure 104.2b). A double pigtail ureteral stent is left in place; either placed over a wire inserted through the previously placed ureteral catheter or introduced over a wire in the antegrade direction through the pyelotomy (Figure 104.2c). The pyelotomy is then closed with a 3‐0 absorbable suture (e.g. polyglactin) (Figure 104.2d). A closed suction drain is placed in proximity to the pyelotomy. The abdominal fascia on the 12 mm port sites are closed with figure‐of‐eight 2‐0 polyglactin sutures, and the skin is closed either with running subcuticular closure or staples.

In the retroperitoneal LPL, the patient is placed in the full‐flank position and secured to the bed with all pressure points well padded. A 2 cm incision is made below the tip of the 12th rib on the posterior axillary line. The retroperitoneal space is then bluntly dilated with the index finger. A 12 mm balloon trocar system is then used to further develop the retroperitoneal cavity. Pneumoretroperitoneum is created with insufflation pressure of 15 mmHg. Under direct visualization, the working trocars (12 mm and 5 mm) are placed four fingerbreadths away from the camera port directly above (12 mm port) and below (5 mm port) it. In an obese or tall patient, the trocar placements should be displaced superiorly for optimal working environment. A fourth trocar can be placed after further reflection of the peritoneum anteriorly if needed. The renal pelvis should be visualized first in the hilum. The rest of the procedure is carried out similar to the transperitoneal LPL.

The retroperitoneal approach has several theoretical advantages over the transperitoneal approach. It is thought to have decreased risks of visceral injury from the trocar placement as well as from manipulation during the procedure. Less irritation of the intestine and peritoneum from urine in the retroperitoneal space is another theoretical advantage. The transperitoneal approach, however, provides more familiar anatomy to most surgeons with larger working space. Balloon dissection to create the retroperitoneal space is also not necessary in this approach. As discussed above, both approaches are considered safe and effective during LPL, and it is the surgeon’s preference and comfort level that should dictate the method of choice.

Outcomes

LAN is a minimally invasive alternative to OAN. In 2003, Kaouk et al. were the first to describe LAN in a porcine model [36]. This study, which utilized the techniques of OAN with a mean warm ischemia time of 30 minutes, showed the feasibility of laparoscopic application for a large staghorn stones. This was quickly followed by Deger et al. describing the first LAN in patients with complete staghorn stone via transperitoneal approach [37]. Cold ischemia with ice slush was used, with mean ischemia time of 45 minutes. The collecting system was closed with an absorbable running suture. No complications were reported, and the patient’s follow‐up IVP and renal scan showed resolution of obstruction and improvement in renal function, respectively. Since then, more contemporary series utilizing warm ischemia have reported similar efficacy and safety of both transperitoneal and retroperitoneal LAN in treating staghorn stones [38–40]

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