The role of laparoscopic surgery for renal calculi management

Abstract

To date, most cases of renal calculi have been managed with extracorporeal shockwave lithotripsy and endoscopic procedures. However, for complex renal stone conditions, these minimally invasive procedures may require multiple operative sessions. Open surgery is usually reserved as a salvage procedure, although it is invasive in nature. Laparoscopic treatment is well accepted in renal surgery. For stone disease, it can duplicate open surgical techniques such as pyelolithotomy, pyeloplasty, anatrophic nephrolithotomy, caliceal diverticulectomy and nephrectomy. Although the laparoscopic techniques for stone treatment are quite challenging, it is both feasible and safe. Laparoscopic treatment is a viable option for large renal stone treatment with an excellent stone-free rate, especially when patients require their stones to be treated within a single session. However, it is more invasive in nature than endourology procedures and so should be reserved as the last resort option for renal stone management in the modern endourology era.

Introduction

Currently, most cases of renal calculi have been managed with extracorporeal shockwave lithotripsy (SWL) and endoscopic procedures such as percutaneous nephrolithotomy (PNL) or ureteroscopy. Thus, open procedures for the treatment of renal calculi have become obsolete [Paik et al. 1998; Bichler et al. 1997; Assimos et al. 1989]. However, for complex renal stones or stones with concomitant renal malformations, the use of SWL or endoscopic treatments may require multiple endourological procedures to achieve stone-free status compared with single-session open stone surgery.

Laparoscopic surgery provides several benefits over open surgery including less morbidity and faster recovery periods. It has been well accepted as a standard treatment for benign and malignant urological conditions. However, the number of studies regarding the role of laparoscopic management of renal stones is quite limited.

This article reviews the current role including indication, surgical modalities and outcomes of laparoscopic surgery for renal stone disease.

Laparoscopic pyelolithotomy with/without pyeloplasty

Laparoscopic pyelolithotomy (LP) was first described more than 20 years ago [Salvado et al. 2009]. It is usually used to remove stones during laparoscopic pyeloplasty. The question concerned is whether this procedure is still necessary for renal stone management in this modern endourological treatment era. Although most of renal calculi have been treated with SWL or ureteroscopy, the stone-free rates vary widely ranging between 45% and 99% depending on stone burden, location and composition. In addition, patients with large stone burden may require multiple endoscopic procedures or multiple access sites for PNL. These can increase the risk of complications and the recovery period of the procedure, and so these patients are not suitable for minimally invasive treatment.

Indication

LP is not a common procedure, however, it provides the benefits of minimally invasive treatment. It can be helpful in patients who require their stone to be removed in a single operative session, and is especially useful for poorly compliant patients. It can also be beneficial in patients who have a large single renal stone or renal anomalies such as ureteropelvic junction (UPJ) obstruction or ectopic kidney. PNL may not be suitable in the treatment of large stones in pelvic ectopic kidney, and it may require laparoscopic assistance to avoid visceral organ injury. In the case of stones in an ectopic kidney with laterally or anteriorly directed pelvis, the surgeon can easily perform LP to achieve stone clearance within a single operative session without the need for sophisticated endoscopic equipment. LP can minimize the postoperative morbidity by primarily closing the opening of the pelvocaliceal system [Gupta et al. 2007; Kamat and Khandelwal, 2004]. Kramer and colleagues have demonstrated the indications, safety and efficacy of LP in their five cases of single renal calculus [Kramer et al. 2007]. These were three of renal calculi including one in horseshoe kidney, one for a pelvic kidney and one for a large renal–pelvic calculus. The mean size of stone was 2280 mm² (range 540–8200 mm²). All cases were completed with laparoscopy. Stein and coworkers have demonstrated their experience of performing LP at the time of laparoscopic pyeloplasty in the patients who have UPJ obstruction [Stein et al. 2008]. They found that this is an efficient procedure with associated high stone-free rates (80%), using simple laparoscopic equipment without any significant increase in operative time or morbidity [Stein et al. 2008].

However, LP may not be indicated in complex staghorn calculi. It may not be possible to completely remove complex stones through one pyelotomy incision [Badani et al. 2006]. The procedure is easier in patients with extrarenal pelvis, while it is difficult for intrarenal pelvis type [Badani et al. 2006]. Goel and Hemal reviewed their experience with retroperitonal LP and they found that LP was not generally indicated in those with orthotopically located kidneys [Goel and Hemal, 2003]. There was increased operative times, longer hospital stay, and poorer cosmetic results compared with patients who underwent PNL. This was also demonstrated and confirmed by others [Meria et al. 2005].

Operative techniques

LP can be performed using the same technique as in several standard laparoscopic renal procedures. In general, three to four port placements are used. The stone can be directly removed through the pyelotomy incision. The pyelotomy incision is usually closed with laparoscopic freehand suturing. Most of the time, the ureteric stent is usually placed for 4–6 weeks.

The stone in the calyx can be removed by using a flexible nephroscope. The nephroscope can be introduced through one of the laparoscopic ports and passed through the pyelotomy incision. The stone can be visualized and retrieved by the stone baskets [Salvado et al. 2009]. The disadvantage of this technique is the leakage of irrigation fluid into peritoneal cavity and this can cause bowel ileus after surgery. In addition, the interface of fluid and the carbon dioxide used for pneumoperitoneum can alter the visualization. Mason and Hoenig have demonstrated the use of carbon-dioxide-based nephroscopy to overcome of this problem [Mason and Hoenig, 2008]. They connected the carbon dioxide line to the irrigation port of a flexible nephroscope, which has been initially connected to the laparoscopic port, and then performed pyeloscopy with excellent visualization.

However, the most debatable technical issue is the access route, whether the transperitoneal or retroperitoneal approach provides better results.

Recently, Al-Hunayan and colleagues have described the study comparing the results between transperitoneal laparoscopic pyelolithotomy (TLP) and retroperitoneal laparoscopic pyelolithotomy (RLP) in the treatment of large renal pelvic stones [Al-Hunayan et al. 2009]. They found that RLP provides a shorter operative time (93.2 min versus 112.1 min, p = 0.01), shorter resumption time for oral intake (1.2 days versus 1.9 days, p < 0.01), and shorter hospital stay (3.8 days versus 5.2 days, p < 0.01) as compared with RLP. The other outcomes including stone-free rate were similar. This is because, by using RLP, the surgeon can access the renal pelvis directly and can perform the surgery by replicating the open surgical technique without the need to manipulate the bowel. Therefore, it results in a decrease in injury to the bowel and postoperative ileus. If urine leakage should occur after the operation, it will be contained within the retroperitoneal space. This results in faster recovery of bowel function. However, the majority of surgeons are usually familiar with the transperitoneal route, because it provides a larger working space and better view of anatomical landmarks for performing the surgery. Nambirajan and colleagues reported a prospective randomized study, comparing the two accesses in laparoscopic radical nephrectomy [Nambirajan et al. 2004]. They found that there is no difference between both accesses regarding the morbidity or technical difficulty of the procedure. Concerning the risk of infection from infected urine during TPL, Badani and colleagues concluded that the transperitoneal approach is as well tolerated as the retroperitoneal approach in terms of perioperative infection [Badani et al. 2006]. Therefore, surgeon experience and preference may be the most important factors in this regard.

Outcomes and complications

Several studies have demonstrated the efficacy and safety of LP for large renal stones. The stone-free rates ranged between 88.9% and 100% [Salvado et al. 2009; Badani et al. 2006; Nambirajan et al. 2005].

Most of the patients received the benefits of minimally invasive treatment such as less pain, shorter hospital stay and faster recovery compared with open surgery. The complication of LP usually relates to the pyelotomy closure and the stone removal. Meria and colleagues reported that urinary leakage after the procedure developed in 2 of 16 patients [Meria et al. 2005]. Nambirajan and colleagues also reported the prolonged urinary leakage in their series because of the difficulty of closure of the friable pelvis [Nambirajan et al. 2005]. The stent was placed and the leakage was stopped after 30 days with this conservative treatment. Al-Hunayan and colleagues reported peritonitis in one case which was due to the stone slipping into the peritoneal cavity [Al-Hunayan et al. 2009]. This patient required open laparotomy to remove the stone and drain the abscess formation. The other minor complications were also reported, such as prolonged ileus and urinary tract infection after surgery [Meria et al. 2005].

Laparoscopic treatment of the stone in caliceal diverticulum

A caliceal diverticulum is usually asymptomatic; however, it is prone to urinary stasis. It may present with symptoms when infection or a stone develops. The key for the treatment of a stone in diverticulum is to completely remove the stone together with obliteration of the diverticulum. In the past, open surgery played a major role in the management of symptomatic caliceal diverticular calculi. In the last decade, this open procedure has been replaced by SWL, PNL or ureteroscopy. However, these endoscopic treatments have some technical limitations. Thus, laparoscopic treatment has become an interestingly minimally invasive alternative option to overcome the limitations of endoscopic management.

Indications

Large stones within the caliceal diverticulum overlying with thin renal parenchyma is the ideal situation for laparoscopy. This is because it may be difficult to stabilize the guide wire within the diverticulum cavity using a PNL technique. The manipulation is also difficult if the large stone within the cavity is of equal size because of the limited working space. In addition, there will be less bleeding from the parenchyma cutting when using laparoscopy if the parenchyma is thin. An anterior calyx lesion is also an indication for using laparoscopic treatment. It is quite difficult to get access from a posterior access point with the PNL procedure. The laparoscopic approach may not be suitable in the case of failed PNL or a deep diverticulum overlying with thick renal parenchyma. The perirenal adhesions close to the area of surgical interest may make localization of the diverticulum difficult.

Operative techniques

Laparoscopic treatment of stones in the diverticulum can be performed through three or four laparoscopic ports as in the standard laparoscopic renal procedure. It can be performed through both transperitoneal and retroperitonal approaches [Miller et al. 2002]. The key steps are retrograde ureteral access and the requirement of intraoperative laparoscopic ultrasound. The ureteric catheter is necessary for retrograde injection of dye to identify the diverticulum which is usually easily visualized by the blue discoloration. However, it is not always successful and intraoperative laparoscopic ultrasound is required to identify the stone. Use of endoscopic light guidance may be helpful and the diverticulum can be visualized by the brightness of the light. Once the diverticulum is identified, the nephrotomy incision can be made using laparoscopic scissors or a laparoscopic electrocautery hook. The stone should be gently extracted and immediately entrapped within the endoscopic bag to prevent stone loss and spreading of infection. After removal of the stone, the diverticular neck can be fulgurated using laparoscopic freehand suturing.

Outcomes and complications

Several authors have demonstrated the success of the laparoscopic approach to a caliceal diverticular with the stone-free rates ranging between 92% and 100% [Nambirajan et al. 2005; Wong and Zimmerman, 2005; Miller et al. 2002; Ramakumar and Segura, 2000]. These results were comparable with those using PNL approaches [Shalhav et al. 1998]. The diverticulum was obliterated in between 92% and 100% of cases with very high percentage of patients becoming symptom free. The complication was insignificant. The appropriate patient selection and the requirement of necessary intraoperative instrumentations are important keys to achieving excellent operative outcomes.

Laparoscopic anatrophic nephrolithotomy

The treatment of staghorn calculi remains challenging. The goal of the treatment is to achieve complete removal of the stone. SWL, PNL or a combination have limited efficacy for their management. The stone-free status may require several sessions of the procedure and might result in considerable morbidity and treatment cost. Therefore, several authors reserve open surgery as the preferred option for managing large staghorn calculi, especially if the patients want their stone removed within a single operative procedure. However, open stone surgery is invasive in nature. There are few data regarding the role of the alternative minimally invasive treatment option such as laparoscopy for the management of staghorn stones.

Indication

Laparoscopic anatrophic nephrolithotomy (LANL) should be reserved for large staghorn stones in the patients who want their stone removed within a single operative session. It may not be suitable for staghorn stones with the combination of multiple small pieces of stones which may result in the difficulty of stone removal during the operation. In addition, it may be unsuitable in patients who have anatomical caliceal abnormality. This condition requires caliceal reconstruction which needs a longer warm ischemic time. At present, there is no perfect method to performing renal hypothermia which may result in compromising renal function after surgery.

Operative techniques

Kaouk and colleagues reported the feasibility of LANL in a porcine study [Kaouk et al. 2003]. However, so far there have only been three small series with total of eight cases of LANL in humans reported in the world literature [Kijvikai, 2009; Simforoosh et al. 2008; Deger et al. 2004]. The major technical limitation of the procedure is how to perform renal hypothermia during the operation with a reliable method. Simforoosh and colleagues reported using the technique of LANL for large staghorn stones (mean stone size of 53 mm) in five cases, using a laparoscopic bulldog clamp (Aesculap, Tuttlingen, Germany) to control the renal hilum [Simforoosh et al. 2008]. After control of the renal hilum, they made an incision on the Brodel line including the collecting system. Then, the stone was removed and the segmental vessels were repaired with an absorbable suture. The renal parenchyma and collecting system were approximated together with each other using the buttress one row of a polyglactin suture and Hem-o-lok for the purpose of reducing ischemic time. The entire procedure was performed under warm ischemia. They found that the mean warm ischemic time was 32 (29–35) min. The intravenous pyelogram after surgery showed a functional corresponding renal unit together with an improvement of obstruction in all cases.

Deger and colleagues demonstrated the first human LANL using a nasogastric bag filled with ice slush placed posterior to the kidney to achieve surface renal hypothermia during their operation [Deger et al. 2004]. The cold ischemic time was 45 min and the stone was removed completely. The renal function was 18% initially, improving to 28% 6 weeks after the surgery.

Recently, Kijvikai has also reported using the LANL technique in two cases of complete staghorn stones [Kijvikai, 2009]. These procedures were performed under renal hypothermia. This technique of renal cooling was duplicated from their previous report of the simple technique used in performing renal hypothermia during pure laparoscopic partial nephrectomy [Kijvikai et al. 2010]. The mean cold ischemic time was 55 min, and the patients had a good renal function after surgery compared with the preoperative level.

Outcomes and complications

In all series [Kijvikai, 2009; Simforoosh et al. 2008; Deger et al. 2004], most of the patients had a stone-free status after surgery. However, there were three out of eight cases which reported 6 mm, 8 mm and 10 mm residual stones after surgery. Fortunately, these stones could be treated with SWL thereafter. The operative time ranged between 120 and 280 min among the reported cases. Interestingly, there were no complications in any cases. The patients still had several significant benefits of minimally invasive treatment by laparoscopy. However, these small series are only preliminary results. The longer follow up and the larger number of patients are required to confirm the advantage of this procedure. A comparative study with PNL is also needed.

Laparoscopic simple nephrectomy and partial nephrectomy

Patients who present with large stones in the kidney without any evidence of function or stone-bearing hydrocalix, nephrectomy or partial nephrectomy are indicated as a viable treatment option.

Operative techniques and outcomes

Nephrectomy in this condition is usually associated with perinephric infection and inflammation which may lead to severe fibrosis and dense adhesion. Therefore, the procedure is usually challenging. Kijvikai and colleagues have demonstrated the feasibility and safety of hand-assisted laparoscopic nephrectomy in a patient with renal calculus who developed nephrocutaneous fistula and failed previous open flank exploration [Kijvikai et al. 2006]. Open surgery was not successful, because the surgeons had to deal with severe inflammation and adhesion before controlling the pedicles by using a flank approach. This approach resulted in significant bleeding and the operation was abundant. In this most challenging condition, laparoscopic surgery can be performed with a transperitoneal approach and by using hand assistance. Using the transperitoneal approach, the surgeon can initially control the renal hilum before dissection of the rest. The concern regarding the spreading of infection into the peritoneal cavity was minimized by using a surgical swab passing through the hand port device to cover the fistula discharge. In this reported case, there were no complications and the patient had received more benefit from laparoscopic treatment over the open surgery. However, in some reports with the same situations, the severe complications might occur such as colonic perforation and external iliac artery injury [Nambirajan et al. 2005; Hemal et al. 2001].

Conclusions

Laparoscopic surgery is a minimally invasive viable option for the treatment of large renal calculi or calculi associated with renal anomaly. It can duplicate open surgical techniques such as pyeloplasty, pyelolithotomy, caliceal diverticulectomy, nephrolithotomy and nephrectomy, even in the most challenging condition. It can also be an alternative procedure to endoscopic stone managements such as SWL, PNL and ureteroscopy, especially in patients who want to complete their stone removal within a single operative session. At present, laparoscopic treatment continues to expand its role, and it can be the salvage procedure in cases of failed endoscopic treatment. However, it is more invasive in nature than endoscopic procedures. Therefore, it should be reserved as the last resort option for renal calculi management in the modern endourology era. Open surgery for renal calculi treatment may become obsolete and could be resigned to the history of urological surgery in the near future.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest statement

None declared.