Author's Response to Mandal et al.

To the Editor:

W e greatly value the editorial comments. Given the complexity of the management of staghorn renal stones, several modifications have been proposed and practiced after the original description of open anatrophic nephrolithotomy (AN) by Smith and Boyce. ¹

While repairing of the collecting system after stone removal is a classic procedure (and I do believe that reconstruction of opened infundibulae may hasten the process of reepithelialization and probably may reduce the chance of restenosis), concurrent closure of the renal parenchyma and collecting system in a single layer has been shown to be quite effective with minimal complications and is in favor of reducing ischemia time (video clip). ^{2 –4} The latter approach has also been successful during laparoscopic partial nephrectomy. ⁵

Similarly, the methods of identifying the avascular plane on the posterior surface of the kidney as well as the site of nephrotomy are debatable. As Mandal and associates nicely commented, the site of nephrotomy is about 2 cm posterior to the white Brodel line in standard technique. ¹ Consistent with many investigators, ^2,6,7 however, we believe that placing the nephrotomy over the avascular Brodel line would be helpful to limit the bleeding, preserving the renal parenchyma, and direct exposure over the posterior calices and the stone. We also used anatomic landmarks for delineating the site of nephrotomy rather than inducing another parenchymal ischemia for this purpose (video clip). ^2,6

Many lessons learned from laparoscopic partial nephrectomy are applicable in laparoscopic AN. With regard to the complexity of staghorn stones, however, important issues such as outlining the appropriate site and the length of the nephrotomy incision as well as the duration of warm ischemia time may be ad hoc. Values of open AN and percutaneous nephrolithotomy for complete staghorn renal stones have withstood the test of time. We definitely need comparative trials to clearly show the benefits and challenges of laparoscopic AN in terms of stone-free rate, complications, preservation of renal function, and hospital costs.