Editorial Comment for Gonzalez et al.

T he authors have nicely described not only how to perform laparoscopic caliceal diverticulectomy, but also when to do it. This latter point cannot be overemphasized. Patient selection is indeed paramount to successful outcomes. The treatment algorithm referred to herein is comparable to others in the literature. ¹ The laparoscopic approach is preferred for symptomatic caliceal diverticuli with thin overlying renal parenchyma, large stone burden (>2 cm), or anterior lesions not amenable to ureteroscopy (obliterated infundibulum, most lower calices). Anterior lesions with thick overlying renal parenchyma may need additional maneuvers akin to laparoscopic partial nephrectomy, such as hilar control and parenchymal suturing. Percutaneous access remains a practical option for deep posterior lesions. Previous failed endourologic procedures are no longer contraindications to a laparoscopic approach.

Laparoscopic localization of the diverticulum can be difficult, particularly for small or deep lesions. Intraoperative laparoscopic ultrasound is a key adjunct that should be available for these cases. Furthermore, a laparoscopic cyst aspiration needle is useful to help identify the diverticulum under ultrasonographic guidance. Lastly, retrograde injection of methylene blue through a ureteral catheter may help demonstrate the lesion as well as identify any communication with the collecting system.

The infundibular neck has been managed primarily with fulguration, particularly when there is a pinpoint connection. Nevertheless, suture ligation should not be forsaken, because this recapitulates the open technique and has been our preferred method for a patent infundibulum in a large lesion. Laparoscopic free-hand suturing has become more commonplace as the worldwide experience with advanced laparoscopic procedures continues to expand. Furthermore, robot-assisted laparoscopic surgery has surpassed its dynamic growth phase for radical prostatectomy in the United States, and renal surgery is rapidly following suit. As such, many urologists may have more experience with robot-assisted surgery than with either retroperitoneal laparoscopic access or laparoscopic suturing. Thus, transperitoneal robot-assisted caliceal diverticulectomy may become a reasonable approach to the laparoscopic management of these lesions.