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LAPAROSCOPIC PYELOLITHOTOMY
“I
will not cut even for the stone, but leave such procedures
to
practitioners of that craft” -
Hippocrates
The
last century has seen a radical change in the management of
renal calculi. First bladder calculi are less common and there
has been a marked increase in the incidence (UK- 600-1000%)
of renal calculi2. Secondly and probably of more importance,
is the fact that most (up to 95%) renal calculi today are
managed by less invasive therapies (namely Extra Corporeal
Short Wave Lithotripsy – ESWL, Per Cutaneous Nephrolithotomy
– PCNL and Uretero Renoscopy- URS). Only 2-4% 4,5 of
renal calculi are managed by conventional open surgery, in
the present day scenario. This fortunate turn of events has
been good for patients who no longer have to dread an operative
procedure for ‘stones’. Adding to this advantage
of less invasive therapies, comes the advent of laparoscopic
(read ‘retroperitoneoscopic’) removal of renal calculi
which tomorrow might replace conventional open surgery for
almost all patients for whom open surgery was indicated. Knowing
that nephrolithiasis is a commonly prevalent disease (life
time risk – 3-15% [West]3), especially in Northern India,
the number of patients coming for surgical management continues
to be significant despite accounting for the fact that most
small calculi would pass spontaneously. Thus we believe it
is incumbent on the surgeon who was traditionally comfortable
with his ‘open’ skills to re-orient himself to this
added advantage of laparoscopic removal of renal calculi.
This, in most cases, would mean a ‘Retroperitoneal (Laparoscopic)
Pyelolithotomy or Ureterolithotomy’. Laparoscopic Anatrophic
Nephro-lithotomy has been successfully accomplished in an
animal model6. The following document provides a basic background
to this issue.
Doing
us proud again Dr. D.D. Gaur in 1994 reported the first retroperitoneal
laparoscopic pyelolithotomy7. Since then, this procedure has
come a long way!
| 1. |
Today this
procedure is standardized, safe and reproducible. |
| 2. |
It has also
been found to be effective and efficient without an associated
increase in the complication rate! |
| 3. |
Furthermore
laparoscopic Pyelolithotomy is feasible when combined
with pyeloplasty. Here again the results are comparable
to those of open surgery and the advantages of open surgery are
maintained in this approach along with decreased post-operative
morbidity! |
Indications
Today Laparoscopic pyelilothotomy is indicated where open
surgery was indicated. Namely:-
| • |
Complex (eg.
Staghorn calculus) and large (multiple calculi) stone
burden, which are not fit for ESWL,
PCNL or URS. |
| • |
Where less
invasive (ESWL, PCNL or URS) have failed. |
| • |
Where concomitant
outflow obstruction exists. |
| • |
Symptomatic
calculi in complex calyceal diverticulae |
| • |
Ectopic kidneys. |
Contraindications
Probably the only contraindication for laparoscopic management
(nephrectomy) of renal calculi is in the setting of xanthogranulomatous
pyelonephritis where this approach is plagued by renal scarring
and operative time is longer and morbidity greater10.
Issues
that need to be addressed
| 1.
|
Expertise
Certainly this procedure and approach has a significant
learning curve. As in any procedure fundamental concepts
need to be appreciated first! We hope to address this
issue successfully in a preliminary fashion in our upcoming
‘Workshop’. |
| 2. |
Economy
With the widespread availability of laparoscopic equipment
for gall bladder stone disease, employing this readily
available infrastructure for renal stone disease is attractive!!
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| 3. |
Renal sparing nature
Proponents of surgery have claimed the putative nephron-sparing
and renal function saving advantages of surgery over
PCNL8 and ESWL respectively.
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In
the May 11th (Sunday), 3rd
LIVE WORKSHOP & CME – “FOCUS ON URINARY STONES”,
we will be dealing in depth with the laparoscopic interventions
for urinary stones. We hope this article served as an appetizer
for your clinical intellect.
|
Event
Calender 
