Abstract
Introduction:
Laparoscopic pyeloplasty (LP) is a well-accepted minimally invasive approach for the management of pelviureteric junction obstruction (UPJO). 1 In patients presenting with UPJO and multiple calculi, calculi located in renal pelvis can be cleared following pyelotomy during LP. However, multiple caliceal calculi are difficult to extract by pyelotomy alone. Usage of intracorporeal flexible ureteroscopy (IFURS) for clearance of caliceal calculi during laparoscopic pyelolithotomy for large staghorn calculus has been previously described. 2 We present a video demonstration of LP and IFURS for simultaneous addressal of UPJO and multiple caliceal calculi.
Materials and Methods:
Preoperative assessment included present history, clinical and biochemical profiles, and imaging (radiography [XR], ultrasound [USG], computed tomography urogram [CTU], diuretic renogram [DR], and retrograde pyelogram [RGP]). Patients with significant UPJO and multiple caliceal calculi comprised the study cohort. All procedures were conducted through transperitoneal access. After dismemberment of pathological segment and pyelotomy, FURS with access sheath was inserted through a 5-mm working port and directed into the pelvicaliceal system under direct supervision. Flexible ureteroscopy was then carried out, all calices inspected, and caliceal calculi were retrieved using entrapment basket. The retrieved calculi were immediately transferred to the intraperitoneal retrieval bag. Pyeloplasty was then completed, pelviureteric approximation with interrupted sutures and pelvic edge approximation in continuous manner. Ureteral stent was placed in an antegrade manner. Operative and postoperative parameters were noted. Stent removal was undertaken at 6 weeks. Follow-up assessment included USG and XR for calculi clearance. Drainage was assessed by RGP and DR at 6 months postoperatively.
Results:
Between July 2012 and January 2013, five similar procedures were conducted. The mean age was 32.2 years (range, 8–55 years). The mean number of caliceal calculi was 18.8 (range, 5–59). Pathology involved the left side in four and the right side in one. One unit was malrotated. The mean preoperative glomerular filtration rate (GFR) was 30.2 mL/minute (range, 22.2–34.8 mL/minute). The mean operative duration was 280 minutes (range, 240–330 minutes). The mean blood loss was 75 mL (range, 50–100 mL). No major intraoperative or postoperative events were noted. The mean hospital stay was 3.8 days (range, 3–5 days). Complete clearance of calculi at pyeloplasty was possible in four patients (80%). One patient required additional flexible ureteroscopy during stent removal. Till last follow-up, all patients were symptom free. The mean 6-month postoperative GFR was 42.2 mL/minute (range, 40.4–44.6 mL/minute) (p < 0.001).
Conclusion:
Intracorporeal usage of FURS during LP enables simultaneous addressal of multiple caliceal calculi and UPJO, preserving the goals of minimally invasive access. The procedure is well tolerated and renders satisfactory outcome.
No competing financial interests exist.
Runtime of video: 7 mins 51 secs
