|Year : 2019 | Volume
| Issue : 1 | Page : 4-8
Does laparoscopy has a place in managing urinary stones in the era of mini- and micro-PCNL
Mohammed Mahdi Babakri, Kaled A Saed, Faiz Bin Break, Mohammed Lahdan
Department of Surgery, Faculty of Medicine and Health Sciences, Aden University, Aden, Yemen
|Date of Submission||09-Oct-2017|
|Date of Acceptance||11-Oct-2017|
|Date of Web Publication||26-Sep-2019|
Dr. Mohammed Mahdi Babakri
Faculty of Medicine, Aden University, Khormaksar, Aden
Source of Support: None, Conflict of Interest: None
Introduction: Surgical management of urinary stones has witnessed major development in the last few decades. After the successful introduction of Shock wave lithotripsy (SWL), the urologist's armamentarium for treating stones became versatile by adoption of rapidly evolving technologies that increasingly replaced the traditional open surgery.There are special situations when SWL and endourology is not the optimal choice and open surgery was the only option at a time, here comes the role of laparoscopy to replace the open surgery for dealing with these cases where endourology has major limitations. Hereby we will highlight the current international trend in laparoscopic surgery for urolithiasis and demonstrate our limited experience in laparoscopic stone surgery in ten patients in Aden, Yemen.
Patient and Method: From March 2011 to September 2017. Ten consecutive patients' ages 4-60 years (mean 38 years) with renal and ureteral stones underwent laparoscopic removal of their stones. The indications for laparoscopy were; unavailability of pediatric PNL setup in two children, failed of SWL in one, renal stones with concomitant PUJO in one, and large impacted ureter stones in the rest of patients.
Result: Stone largest diameter ranged from 25 to 45 mm (mean 28 mm), operative time ranged from one to 4 hours (mean 2.3 hours) and hospital stay ranged from four to seven days (mean 5 days). The procedure completed successfully an all, but one patient in whom conversion to open ureterolithotomy performed, because of difficulty to access the large impacted intramural stone, no major intra or post-operative complications, no blood transfusion needed. One patient develop prolonged urine leakage for 10 days managed conservatively. Follow up after three, six and 12 months with plain abdominal x-ray (KUB) ultrasonography (US) and Urography (IVU) when indicated showed no residual stones and no newly developed hydronephrosis.
Conclusion: Laparoscopic surgery is safe and effective in management of large renal and ureter stones in patients who are not suitable candidate for endourology.
Keywords: Laparoscopic surgery, pyelolithotomy, retroperitoneoscopy, uretrolithotomy
|How to cite this article:|
Babakri MM, Saed KA, Break FB, Lahdan M. Does laparoscopy has a place in managing urinary stones in the era of mini- and micro-PCNL. Saudi J Laparosc 2019;4:4-8
|How to cite this URL:|
Babakri MM, Saed KA, Break FB, Lahdan M. Does laparoscopy has a place in managing urinary stones in the era of mini- and micro-PCNL. Saudi J Laparosc [serial online] 2019 [cited 2019 Oct 13];4:4-8. Available from: http://www.saudijl.org/text.asp?2019/4/1/4/267861
| Introduction|| |
Surgical management of urinary stones has witnessed a major development in the past few decades. After the successful introduction of shock-wave lithotripsy (SWL) by Chaussy and Schmit in 1980, the urologist's armamentarium for treating stones became versatile by adoption of rapidly evolving technologies that increasingly replaced the traditional open surgery.
The introduction of laparoscopic surgery in urology practice has lagged behind other specialties for a while; recently, there is a trend toward increasingly using laparoscopic surgery in treating various benign and malignant urological diseases.
SWL and endourology have been established as the main techniques in treating urinary stones.
However, there are special situations when SWL and endourology are not the optimal choice and open surgery was the only option at a period of time, and here comes the role of laparoscopy to replace the open surgery for dealing with these cases where endourology has major limitations.,
To present our local experience in laparoscopic stone surgery and to highlight the current trend in laparoscopic management of urinary stones, we retrospectively reviewed the clinical records of all patients treated by laparoscopic surgery for urinary stones at our center. Furthermore, international literatures were reviewed for studies and articles concerning the laparoscopic management of urinary stones using Medline database and major international urology journal archives.
| Patients and Method|| |
The clinical records of all patients treated by laparoscopy for renal and ureteral stones up to September 2017 were reviewed, and all patients' pre-, intra-, and postoperative data were collected and analyzed manually; range and mean values were mainly used for this purpose [Table 1].
The indications for laparoscopy were unavailability of pediatric percutaneous nephrolithotomy (PNL) setup in two children, failed of SWL in one patient, and large impacted ureter stones in the rest of patients.
| Results|| |
For renal and upper ureter stones, the patient was placed in slandered flank position; for mid- and lower-ureter stones, the patient was placed in supine position with elevation of the ipsilateral side; and head-down position to help bowl to fall down away from the surgical field.
For transperitoneal laparoscopy (TL), three ports were used: one 12-mm umbilical trocar for camera and two 5-mm trocars for instruments; the fourth 5-mm trocar was used in some cases to help retracting the kidney [Figure 1] and [Figures 2].
|Figure 1: Patient's position and port configuration for transperitoneal laparoscopic pyelolithotomy|
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|Figure 2: Patient's position and port configuration for transperitoneal laparoscopic ureterolithotomy for mid- and lower-ureter stones|
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For retroperitoneoscopy, a 2-cm incision was made below the tip of the 12th rib and hand dissection was made to create a space for a balloon made of the middle finger of No. 8 gloves [Figure 3].
|Figure 3: Balloon made of No. 8 glove's finger used for creation of retroperitoneal space|
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A 10-mm trocar was inserted for the camera by open method at the initial incision and another two 5-mm trocars at the anterior axillary lines, one on the same level as the primary trocar and another just above the iliac crest [Figure 4].
|Figure 4: Patient's position and port configuration for retroperitoneal laparoscopic pyelolithotomy|
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From March 2011 to September 2017, ten consecutive patients (nine males and one female), aged 4–60 years (mean: 36 years), with renal and ureteral stones underwent laparoscopic removal of their stones at our urology center in Aden [Table 1].
The largest diameter of the stone ranged from 25 to 45 mm (mean: 28 mm), operative time ranged from 1 to 4 h (mean: 2.3 h), and hospital stay ranged from 4 to 7 days (mean: 5 days). All patients were stented by retrograde cystoscopy at the beginning of the procedure, if not already stented. The approach was transperitoneal in seven and retroperitoneal in three patients.
The procedure was completed successfully in all patient except one in whom conversion to open ureterolithotomy performed, because of difficulty to access the large impacted intramural stone, no major intra- or post-operative complications, no blood transfusion needed. One patient developed prolonged urine leakage for 10 days which was managed conservatively.
Follow-up after 3, 6, and 12 months with plain abdominal X-ray (KUB) ultrasonography and intravenous urography when indicated showed no residual stones and no newly developed hydronephrosis [Table 1].
| Discussion|| |
Gaur described the first successful retroperitoneoscopic laparoscopic pyelolithotomy (RLP) in 1994. The advantage of laparoscopy for large renal stone removal over PNL is the complete visual control of the structures of interest, thus minimizing the possibility of major bleeding or colon injury. The possibility of treating other associated pathologies such as ureteropelvic junction obstruction is another advantage of laparoscopic pyelolithotomy (LP).
Zhao et al. performed a meta-analysis on studies comparing PNL and LP on 996 patients and found that LP has more stone-free rate and less complications, especially bleeding; however, PNL has shorter operative time. The same results were obtained by Wang et al. in another meta-analysis published in 2013 in the Journal of Urology. Haggag et al. reported similar results in a nonrandomized comparative study and they reported shorter hospital stay for LP; the small number of patients and nonrandomized nature of the study were the major limitations of their study.
Using RLP versus PNL, Li et al. found no significant differences in the mean postoperative hospital stay (4.5 2.3 vs. 4.3 1.3 days), rate of blood transfusion (0% vs. 1.1%), conversion rate (0% vs. 3.4%), and rate of total postoperative complication (P > 0.05). The procedural duration and mean drop in hemoglobin levels were significantly lower in the RLP.
Al-Hunayan et al. found no difference in estimated blood loss, stone-free rate, or hospital stay, and the operative time was longer in RLP.
Although this is an initial experience, our study, which is the first in the whole country, showed similar result in operative time, hospital stay, complications, and stone-free rates to other internationally reported series. Blood transfusion is not needed in all of our cases in comparison to more than 20% of 60 patients treated by PNL in our center in the same period (unpublished data).
Ureterorenoscopy (URS) has been established as the modality of choice for treating ureteral stones with high success rate and minimal complications; however, there are situations when URS is less optimal to deal with; for example, large stone burden [Figure 5] and [Figure 6] or stone associated with stricture not amenable to endoscopic management.
|Figure 5: Intravenous urography showing large right lower ureter stone surprisingly causing no obstruction|
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|Figure 6: The same stone in figure during extraction using a bag made of No. 6 gloves|
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In comparison to URS, laparoscopic ureterolithotomy (LU) achieves high stone-free rate;, the operative time tends to be longer in LU.
The ureter can be approached via transperitoneal or retroperitoneal route.,, Transperitoneal access has the advantages of wide space and familiar anatomy, but there is greater risk of bowel injury and colon mobilization is sometimes needed. Qadri et al. reported high success of retroperitoneal LU in 123 cases with low morbidity; the mean operative time was 88 min.
Our study showed a male-to-female ratio of 9:1, which is higher than internationally reported ratios, although no conclusion could be drawn because of the small number of our series.
Laparoscopic surgery for urinary stones is safe and highly successful with low morbidity, and the main disadvantages of laparoscopy are the long learning curve and longer operative time in comparison to endourology.
| Conclusion|| |
Laparoscopic management of urolithiasis has its place in certain cases where SWL and endourology are not the optimal choice; it is safe and highly effective in experienced hands at the cost of highly steep learning curve.
The small number of cases and retrospective nature are the major limitations of our study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]