The evolution of the treatment of urinary stone disease

The surgical management of urinary stone disease has developed over recent years; treatment options include ESWL, percutaneous nephrolithotomy and ureterorenoscopy (rigid or flexible). The 2013 edition [1] of the European Association of Urology Guidelines on Urolithiasis indicates that laparoscopic kidney stone surgery should be considered in the following cases: complex stone burden, failed previous ESWL and/or endourological procedures, anatomical abnormalities, morbid obesity, and nephrectomy in case of non–functioning kidney. The ureteropelvic junction (UPJ) obstruction is an anatomical abnormality defined by a blockage of urine flow from the kidney to the proximal ureter. We consider that in the case of UPJ obstruction with concomitant kidney stone, the laparoscopic pyeloplasty should be the treatment of choice. This type of treatment offers the necessary guarantees for the treatment of the UPJ obstrucion and allows us to combine endoscopic instruments to treat the associated secondary lithiasis with a stone free rate of 100% and a success of UPJ obstruction resolution near 95% [2]. No comparative studies have been done in this field, but it seems that laparoscopic pyeloplasty procedures have better outcomes in UPJ obstruction with concomitant lithiasis. Anterograde endopyelotomy with concomitant percutaneous stone removal has been performed with a success rate of 64% to 85% in different series [3] and ureteroscopic endopyelotomy or endoureterotomy with a ureteral balloon device has also been used with a success rate of 78% [3].

The choice between retroperitoneoscopic or transperitoneal approach in laparoscopic pyeloplasty is a never–ending debate. Equivalent success rates have been quoted in the literature for both approaches [4] but as Dr. Marcin Słojewski said in his editorial comment [5] surgeon preferences and experience remains the main determinant of choice. In our department, we are starting to treat selected cases of kidney stone disease by retroperitoneoscopic approach; the results in the first cases are promising and we hope to have enough experience in a few years to show our findings.