Bilateral Laparoscopic Transperitoneal Pyelolithomy: Dare You Do This?

Abstract

Introduction: The aim of this article is to describe our technique of bilateral laparoscopic pyelolithotomy (LP) in a 54-year-old patient with bilateral large stones of which one is a staghorn stone (SS).

Case Presentation: The patient's legs were extended and spaced from each other; the table was tilted to the right and to the left in a way to use only five trocars for both sides. The calculi were delivered intact at the end of the procedure. Operating time was 208 minutes. Blood loss was 250 mL. Hospital stay was 3 days. Double-J stents were removed 4 weeks later. The patient was stone free with a stable serum creatinine.

Conclusion: This case report is the first to describe a bilateral LP for large and SS. This procedure can minimize the postoperative morbidity and is associated with high stone-free rates. It is safe when done by expert surgeons, but further investigations are required to assess its reproducibility.

Introduction

With the huge advances in extracorporeal shockwave lithotripsy (SWL) and endourologic surgery (ureterorenoscopy [URS] and percutaneous nephrolithotomy [PCNL]), the indications for open or laparoscopic surgery for staghorn stones (SSs) have significantly decreased. PCNL is still the recommended first-line treatment for SS, solely or in combination with retrograde intrarenal surgery (RIRS). However, when failure of a reasonable number of PCNL is expected, or if multiple RIRS have been unsuccessful, open or laparoscopic surgery may be a valid treatment option. Few studies have reported laparoscopic SS removal, but no data in the literature describe bilateral laparoscopic nephrolithotomy since it has always been a consensus that we should not operate on both kidneys during the same procedure.

The aim of this article is to describe our surgical technique of bilateral laparoscopic pyelolithotomy (LP) in a 54-year-old patient with bilateral large stones.

Case Report

Case presentation

A 54-year-old Mediterranean patient with no known past medical or surgical history presented to the emergency room for general status alteration and vomiting. He was afebrile and had no urinary symptoms. Physical examination was unremarkable and laboratory tests revealed severe acute renal failure and hyperkalemia (serum creatinine = 14 mg/dL and K = 7 mg/dL). Urine analysis showed signs of urinary tract infection (25 red blood cells and 50 white blood cells per high-power microscopic field in urinary sediment on sterile collection). Kidney, ureter, and bladder radiograph (KUB) revealed bilateral large kidney stones, as well as CT scan that showed a right 6 × 4 cm large stone in an exophytic renal pelvis and a left 5 × 4.5 cm SS, with bilateral hydronephrosis (Fig. 1).

FIG. 1.

Kidney, ureter, and bladder radiograph (A) and CT scan (B) of the patient showing bilateral staghorn stones with bilateral hydronephrosis treated by nephrostomy tubes and Double-J stents (C).

After medical stabilization, the kidneys were drained by bilateral nephrostomy tubes. The patient was treated with intravenous antibiotics, and Double-J stents were inserted bilaterally 48 hours later (Fig. 1). The serum creatinine dropped to 3.5 mg/dL and a diuresis of 1500 mL was reported 2 days after bilateral Double-J stents insertion and nephrostomy tubes removal.

After discussing the case with the patient and explaining in details the risks and benefits of all treatment options, he refused absolutely to have multiple interventions and insisted on a treatment that allows him to be stone free in only one procedure. Therefore, an informed consent was obtained, and a laparoscopic transperitoneal bilateral pyelolithomy was scheduled 1 month later, after a complete course of antibiotics to treat the underlying infection.

Surgical technique

Under general anesthesia, in the supine position, a Foley catheter was inserted. The patient's legs were extended and spaced from each other; the table was tilted to the right and to the left so that only five trocars can be used for both sides of pyelolithotomy without moving the patient (Fig. 2). The patient's position and the trocar points were the main differences from the already described bilateral laparoscopic renal surgery in the literature. In contrast, we used this technique for the first time in LP.

FIG. 2.

The patient's position showing the laterally tilted table (A) and the five trocars scars 4 weeks after the surgery (B).

Pneumoperitoneum was achieved by insufflation of carbon dioxide using a VERESS needle through the umbilicus.

A 10-mm umbilical trocar was inserted into the peritoneal cavity to allow the entry of a 10-mm laparoscope. Two 5-mm access ports were positioned medially to the bilateral anterior iliac spine, another one was placed halfway between the umbilicus and the pubic symphysis and the last one 3 cm under the xiphoid process (Fig. 2).

For the left side, the surgical table was tilted 60° to the right to allow the bowel to drop away from the surgical field.

Toldt's fascia was dissected using electrocautery scissors and the retroperitoneum was accessed by reflecting the colon. The large stone in the renal pelvis was readily identified, and dissection of the renal pelvis was performed. Cautery and scissors were then used to create a pyelotomy large enough to remove the calculus (Fig. 3A). Although the stone was large and solitary, it needed to be pried from the inflamed urothelium by a diathermy hook to remove it from the renal pelvis. Then, it was delivered intact in an endobag to be removed at the end of the procedure (Fig. 3B). The proximal end of the inserted Double-J stent was identified and well anchored in the renal pelvis (Fig. 3C), which was irrigated with physiologic saline. The pyelotomy was closed by intracorporeal simple running sutures with 4-0 Vicryl (Fig. 3D) and Gerota's fascia was approximated.

FIG. 3.

Large pyelotomy showing the calculus (A) that was delivered intact in an endobag (B). The anchored proximal end of the inserted Double-J stent in the renal pelvis (C). The pyelotomy closure by intracorporeal simple running sutures with 4-0 Vicryl (D).

On the right side, the same procedure was done after tilting the surgical table to the left.

After the separate removal of the two stones through the umbilical incision, two Blake drains were placed through the lateral ports (one from each side). All port sites were closed with absorbable sutures.

Results

The whole operating time was 208 minutes. Blood loss was estimated as 250 mL. The left drain was removed on postoperative day 1; the right drain and the Foley catheter were removed on the second postoperative day. Hospital stay was 3 days. Double-J stents were removed at 4 weeks postoperatively. The patient was stone free with a serum creatinine level stabilized at 2.8 mg/dL 6 months after the surgery.

Discussion

In complex renal stones or stones with concomitant renal malformations, the use of SWL or endoscopic treatments requires multiple endourologic procedures to achieve stone-free status compared with single-session open or laparoscopic stone surgery.¹ Despite the multiple complications related to PCNL, this technique is widely done bilaterally²; therefore, a bilateral LP should also be considered taking into consideration every patient's history.

Since many years, laparoscopic surgery has been well accepted as efficient treatment for benign and malignant urologic conditions; it has several benefits over open surgery, including less morbidity and faster recovery periods.¹

LP, although more invasive than endourologic surgery, has yielded high stone-free rates.³ It provides the benefits of minimally invasive treatment and can be helpful in patients who require their stone to be removed in a single operative session, especially those who are poorly compliant (the case of our patient).^1,3

It is beneficial in patients who have a large single renal stone and who have renal anomalies such as ureteropelvic junction obstruction or ectopic kidney, caliceal diverticulum stones, horseshoe kidneys, and in pelvic kidney stones.³

However, few studies have reported laparoscopic stone removal that was usually reserved for special cases. In addition, all the reported procedures were unilateral.^1,3,4

The management of bilateral staghorn kidney stones has been classically based on multiple unilateral or bilateral PCNL, and no bilateral laparoscopic procedures have been described in the literature so far.¹ Therefore, the reported data could not be used to compare procedures with each other or with SWL or URS.

PCNL is known to have many complications, including hydrothorax, pneumothorax, pleural effusion, urinary fistula, ureteral obstruction, and urosepsis, which can sometimes lead to death.² Despite this, bilateral PCNL has been performed.² This fact encouraged us to do our one session bilateral LP knowing that the complications of this surgery can be minimal in centers with high expertise in laparoscopic surgery. Other arguments were the noncompliance of our patient and the highly reported rate of stone-free patients after LP in the literature.

Our patient did not experience any intraoperative or postoperative complications, and was discharged with minimal pain and discomfort. Importantly, he was stone free on control KUB and CT scan.

Conclusion

The aim of the surgical treatment of SS is to allow the patient to be stone free and to preserve his renal function. To our knowledge, this case report is the first to describe a bilateral LP for SS.

Bilateral LP can minimize the postoperative morbidity; it is an efficient procedure with associated high stone-free rates, using simple laparoscopic equipment without any significant increase in operative time, or morbidity. It enhances the economic benefits of the bilateral procedure and offers an achievable method of reducing hospital costs. Although it can be viewed as risky or unwise, we believe that it is safe when done by expert surgeons in selected patients, but PCNL remains the gold standard treatment and the only indication in our case was the patient's preference. Further investigation in a larger population size is certainly required to assess the reproducibility of this procedure to accept it as an alternative of PCNL in specialized centers.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Abbreviations Used

CT

computed tomography

KUB

kidney, ureter, and bladder radiograph

LP

laparoscopic pyelolithotomy

PCNL

percutaneous nephrolithotomy

RIRS

retrograde intrarenal surgery

SSs

staghorn stones

SWL

extracorporeal shockwave lithotripsy

URS

ureterorenoscopy

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Abdessater M, Kanbar A, El Khoury J, El Hachem C, Halabi R, Akl H, Boustany J, El Khoury R (2020) Bilateral laparoscopic transperitoneal pyelolithomy: dare you do this? Journal of Endourology Case Reports 6:2, 99–102, DOI: 10.1089/cren.2019.0126.