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PREVENTING STONE RECURRENCE
‘An Innovative Use of Rigid Cystoscope in Laparoscopic Pyelolithotomy’
The natural recurrence of urinary
stones is 10-15% at 1 year and 4-50% at 4 years11. The main
risks are large stones, multiple stones, cystine or calcium
phosphate stones, reduced renal clearance (e.g. hydronephrosis,
horse-shoe kidney) and residual stones. Residual stones although
they may be passed up to 3 years post-treatment, increase
recurrence rates by up to 300%12. Thus it is a logical therapeutic
imperative to render patients stone free.
It is crucial to appreciate two facts when it comes to understanding
current day surgical stone treatment when one aims to reduce
the incidence of stone recurrence!
| 1. |
Indications for Surgery
tend to predispose to stone/ fragment retention-This
occurs by virtue of the characteristic of the stone
burden – eg. stones for salvage therapy (post ESWL,
PCNL or URS stones, which are already fragmented heterogeneously
into numerous if not countless fragments) and complex
stone burden (multiple/ large stones, giant stag-horn).
This also occurs on account of outflow system characterisitics
(ectopic kidney, complex calyceal diverticulae, severe
infundibular stenosis, concomitant uretero-pelvic junction
obstruction) which predispose to fragment retention.
|
| 2. |
‘Laparoscope’
aided visualization of the pelvi-calyceal system ‘per
se’ is sub-optimal- It is thus incumbent that an
added modality of visualization be used to aid in the
optimal visualization of the pelvi-calyceal system with
a view to render the patient stone free. |
This can be accomplished by
a number of modalities.
| a. |
Flexible
Nephroscope/ Cystoscope
This would be the ideal as they provide a larger viewing
angle (250 degree), are manoueverable and prevent torque.
This however has to be weighed against a very high capital
cost, short therapeutic life and the fact that it is not
widely available. |
| b. |
Rigid Cystoscope
We introduce the innovative use of the Rigid Cystoscope
for visualisation of the pevi-calyceal system at laparoscopic
pyelolithotomy. The Rigid Cystoscope is placed co-axially
inside an indigenously designed sheath. This can be placed
through a 5mm port. Stones are grasped and extracted with
graspers introduced through accessory ports. Stone/ fragment
extraction is thus done under vision. This arrangement
has already been used successfully in the laparoscopic
exploration of the common bile duct and extraction of
CBD stones in the setting of choledocholithiasis. |
| |
Advantages
| 1.
|
Widely
available. |
| 2.
|
Cheaper. |
| 3.
|
Sturdier. |
Disadvantages
| 1.
|
Limited
viewing in comparison to a flexible scope. Maximum
viewing with a rigid cystoscope is 70 degrees. |
| 2.
|
Torque
can come into play when the stone is not easily
reachable. |
|
CONCLUSION
Recognising the fundamental role of residual stones/ fragments
in the formation of recurrent urinary stones we recommend
the routine use of an adjunctive modality to visualize the
pelvi-calyceal system at laparoscopy to detect and assist
in the extraction of kidney stones. This adjunctive modality
now can be made widely available. The dependable, sturdy Rigid
Cystoscope (ensheathed in an indigenously designed sheath)
is a cost-effective, useful alternative to the flexible viewing
scopes.
REFERENCES
| 1. |
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| 2. |
Buck AC, 1993;
The epidemiology, formation, composition and medical management
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| 3. |
Buck AC 1987;
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| 4. |
Assimos DG,
Boyce WH, Harrison LH, McCullogh DL, Kroovand RL, Sweat
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| 5. |
Bichler KH,
Lahme S, Strohmaier WL: Indications for open stone stone
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| 6. |
Kauk JH, Gill
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| 7. |
Gaur DD et
al; Retroperitoneal laparoscopic Pyelolithotomy; Journal
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| 8. |
Gaur et al;
Retroperitoneal laparoscopic Pyelolithotomy: How does
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| 9. |
The role
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| 10.
|
Bercowsky
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| 11.
|
Rassweiler
et al; 1992, ESWL, including imaging, Curr Opin Urol.
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| 12. |
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pp 2157-2182. |
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EVENT
CALENDAR
