The laparoscopic approach to kidney stones associated with ureteropelvic junction obstruction : retrospective review of our series
Ureteropelvic junction obstruction is the most common congenital abnormality of the ureter, with an annual incidence of 5/100.000 population. The nephrolithiasis may be concomitant to ureteral junction obstruction in percentage from 20% to 70% (Husman, 1996). Metabolic causes and/or obstructive ones assume responsibility in equal way. The surgical treatment of UPJ obstruction associated with renal calculi is still controversial and has undergone significant changes in recent years. From open surgery to laparoscopic traditional surgery or robotics with the option percutaneous and ureteroscopy the range of therapeutic options has been significantly modified.
We reviewed our series of laparoscopic pyeloplasty associated with the simultaneous treatment of stones in the last 10 years.
Methods and results
On 275 cases in which it was performed laparoscopic pyeloplasty (May 2004/December 2013), the stone was present in 26 patients; in 17 cases (14 pelvic ranging in size from 2 cm to 6.5 cm and 3 calyceal) stones were removed at the same time, in 2 cases pelvic stones <1 cm were not removed because not achieved neither flexible nephroscope nor with other methods, in 7 cases calyceal stones have not been achieved. In 3 of these cases the stones was expelled spontaneously within three months. The methods used to remove the stones were: 1. Extraction with rigid forceps directly introduced into the trocar (grasping forceps or Joanna forceps) 2. Extraction with repeated washing of the pelvis and calyces 3. Extraction using a flexible nephroscope inserted through a small tight pelvic incision. Only in one case the procedure was simple, like a standard pyeloplasty; in all other cases, more or less intensive adhesions were found, with images of intense peri-nephritis. Of course, the operative times were longer, from 60-90 minutes necessary for a standard pyeloplasty to 120-180 minutes for more complex cases. For this reason, in 11 cases of lithiasis pelvic-calyceal and 8 of lithiasis calyceal lower multiple (excluded from this report) it was made a percutaneous approach first, and after several months it was realized the laparoscopic pyeloplasty (in these cases, during the dissection, significant adhesions were not found).
It is commonly thought that the urinary stasis and infection are the cause of kidney stones. Biochemical study in children has shown, however, that also the metabolic anomaly plays a role in explaining the high incidence of association of kidney stones to the uretero-pelvic junction obstruction. The reviews collected in the literature are always referred to a small number of patients. The largest series published using this approach in lithiasis associated with uretero-pelvic junction obstruction is from Ramakumar, where 19 patients underwent laparoscopic pyeloplasty with concomitant pyelolithotomy. He concluded that although laparoscopic pyeloplasty is a technically challenging procedure, concomitant pyelolithotomy can be performed safely. In our experience the contemporary treatment of stones in course of laparoscopic pyeloplasty appears easy and effective when the stone is single and large, can be problematic when it comes to multiple calyceal stones, where the use of a flexible nephroscope can improve the results. The ureteropelvic anastomosis is technically more difficult in all cases because the anastomotic flaps are thickened because of chronic inflammation induced by the stones. The preliminary percutaneous approach obtaining the complete clearance may be a valid alternative, but it involves the necessity of practicing two surgical procedures to the patient.
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PLoS ONE January 2013 Volume 8 Issue 1 e55026