Re: Laparoscopic Anatrophic Nephrolithotomy: Developments of the Technique in the Era of Minimally Invasive Surgery (From: Giedelman C,Arriaga J,Carmona O,et al. J Endourol 2012;26:444–450)

W e appreciate the authors of this article for showing the good feasibility of anatrophic nephrolithotomy by the laparoscopic method. We would like to highlight certain issues related to technical aspects of the described nephrolithotomy.

The authors performed nephrotomy in the initial two cases at the lateral border of the kidney and subsequently at about 1 to 2 cm medial to the lateral border of the kidney (presumed site of the Brodel line). One of eight (12.5%) patients had a major vascular complication (vascular fistula necessitating endovascular embolization) using their approach.

They have not tried/mentioned any method of precisely identifying the avascular line of Brodel. In the open method, this line is usually identified by selectively clamping either the anterior or posterior segmental artery. Although described at a 1 to 2 cm distance (as presumed by the authors and shown in Figure 3 in the article), often this may be an irregular line (not as a smooth curved/straight line) at a somewhat variable distance from the lateral border of the kidney (Fig. 1).

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FIG. 1.

Brodel avascular line defined after selective vascular clamping.

In addition to meticulous intraoperative hemostasis, precise identification and entry through this avascular plane may be important to minimize bleeding and prevent vascular complications like the one that was seen in the authors' series.