Nephroscopy with carbon dioxide in combination with laparoscopy in the treatment of urinary stones | Actas Urológicas Españolas (English Edition)

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García-Seguí, M. Gascón-Mir" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "García-Seguí" "email" => array:1 [ 0 => "agarciasegui@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Gascón-Mir" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Urología, Hospital General Mateu Orfila, Mahón, Menorca, Islas Baleares, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nefroscopia con uso de dióxido de carbono en combinación con laparoscopia para el manejo de la litiasis urinaria" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 746 "Ancho" => 952 "Tamanyo" => 195674 ] ] "descripcion" => array:1 [ "en" => "Using a nitinol basket, the calculi were progressively removed." ] ] ] "textoCompleto" => "IntroductionIn current clinical practice, laparoscopic surgery is rarely used to treat urinary stones, because most of the calculi are eliminated successfully using endourological techniques or by shock waves.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a>The combination of laparoscopic procedures with endourological techniques has been described, and it offers significant benefits for the management of complex lithiasis with anatomical abnormalities. The removal of the stones during laparoscopic pyelolithotomy can be performed with laparoscopic atraumatic forceps; however, it can be difficult and traumatic to reach some calyceal stones with rigid instruments. Inserting a flexible nephroscope guided by laparoscopic assistance allows for a systematic inspection of all renal cavities and the stones can be removed in their entirety.<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a>Flexible nephroscopy combined with laparoscopy may have some disadvantages because of irrigation with saline solution. The problem occurs because the renal pelvis is open, as the fluid may leak into the peritoneal cavity. Furthermore, the interphase between the liquid and gas from the pneumoperitoneum can alter intrarenal vision. Mason and Hoenig described the technique of flexible nephroscopy using CO2 in combination with laparoscopy in the treatment of urinary stones in order to avoid irrigation with saline solution.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>We present our experience on the feasibility and effectiveness of nephroscopy with use of CO2 in combination with laparoscopy for the management of the urolithiasis.Patients and methodsA total of 5 patients with urolithiasis underwent laparoscopic surgery in combination with nephroscopy using CO2. Of these, three had multiple pyelic lithiasis together with stenosis of the UPJ with indication for surgical treatment. They underwent laparoscopic pyelolithotomy, flexible nephroscopy with use of CO2 and Anderson–Hynnes laparoscopic pyeloplasty. The fourth case is a patient with calyceal stones in a pelvic kidney who underwent laparoscopic pyelolithotomy and flexible nephroscopy with CO2. The last case is a patient with a large calculus impacted in at the level of the proximal ureter, which during laparoscopic ureterolithotomy shifted to the renal pelvis and required CO2 ureteronephroscopy. In all the patients, informed consent was obtained for the surgical procedures suggested. All the patients underwent preoperative imaging studies (intravenous urography and/or computerized axial tomography).The indications for laparoscopic surgery for urinary tract stone disease are well established and are as follows: when both calculi with anatomical abnormalities coexist (ectopic kidney, horseshoe kidney, renal malrotation, etc., or in situations with anatomical changes following a surgical procedure such as renal transplantation); symptomatic stones in diverticula of the renal pelvis that cannot be managed by endoscopic techniques; very hard, impacted, and large calculi (>15mm) mainly in children; when both nephrolithiasis with another renal disease that requires laparoscopic surgery, such as laparoscopic pyeloplasty in the stenosis of the UPJ, coexist; and when there is an economic or social need to remove the stones in a single surgical intervention.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Surgical techniqueThe patient is placed in lateral decubitus position. Transperitoneal approach with placement of three trocars was used. A laparoscopic tower using a 30° laparoscope, and another endourological tower with flexible cystoscope were available in the operating room to perform laparoscopic surgery and nephroscopy simultaneously. The first 10-mm trocar was inserted at the level of the umbilicus, through a transumbilical incision with open technique. The other two ports were placed on the anterior axillary line, maintaining the proper triangulation with the umbilical trocar (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The first 4 patients underwent the same procedure of laparoscopic pyelolithotomy. Once the renal pelvis and the proximal ureter were dissected, a pyelic incision was performed. The calculi visible through the opening in the renal pelvis were removed using an atraumatic laparoscopic piece, and they were deposited in a laparoscopic extraction bag. We proceeded to perform nephroscopy, for which we introduced the flexible cystoscope through the 10-mm trocar, and under laparoscopic assistance it was directed towards the interior of the renal pelvis inserting it through the pyelic incision (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). On the irrigation line of the endoscope, the CO2 hose which was used previously for the pneumoperitoneum was connected (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Through there, the gas was insufflated, and with an atraumatic laparoscopic forceps, the pyelotomy edges were confronted to prevent gas leakage and manage to distend the renal cavities (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Flexible nephroscopy was performed ‘without liquid’ running a systematic inspection of the calyces (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Using a nitinol basket, the calculi were progressively removed and deposited in a laparoscopic extraction bag (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). Upon completion of litoextraction we proceeded to reconstruction according to the corresponding procedure.<elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia>In all the cases of stenosis of the UPJ, we performed Anderson–Hynnes laparoscopic pyeloplasty, and in the case of the pelvic kidney, closure of the renal pelvis with intracorporeal suturing was performed. In the latter case, laparoscopic ureterolithotomy was prescribed, and then the cystoscope was introduced through the incision of the ureter and advanced in a retrograde manner to reach the renal cavities. The calculus is located in the renal pelvis and extracted with laparoscopic forceps. Finally, ureteral closure is performed with intracorporeal suture. In all patients, double J ureteral catheter was inserted anterogradely, and a Jackson–Pratt drain was left exteriorized through one of the holes of the trocars.ResultsAll the cases were successfully completed laparoscopically without conversion. The average age of the patients was 45 years (38–62), and 4 were male. The average operative time of the nephroscopy was 22.4minutes (15–48minutes). The intraoperative bleeding was invaluable. The average hospital stay was 3.2 days (3–5). There were no complications. One of the patients with stenosis of the UPJ had a great amount of kidney stones; therefore, the nephroscopy was the longest (48minutes), managing to remove a total of 18 calculi. Despite this, it was the only case in our series that showed residual stones and it required additional ureteroscopy.DiscussionPercutaneous, retrograde, or through shock wave techniques are the main approaches to the treatment of urinary stones for their good results and low morbidity. Laparoscopic surgery is a complement for those cases that may have a lower success rate and an increased risk of morbidities, like when both anatomical abnormalities or very bulky calculi coexist.<a class="elsevierStyleCrossRefs" href="#bib0005">1–5,7,8</a>Many authors have reported that the endourological and laparoscopic procedures can be combined successfully in a single intervention to improve the rates of residual stones and resolve synchronous anomalies.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Fariña Pérez et al.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> described a case of lithiasis in a pelvic kidney treated with laparoscopic pyelolithotomy combined with flexible nephroscopy. These authors conclude that the use of the endoscope allowed them to perform a more limited pyelic incision to remove the calculus, which meant less surgical time and lower risk of fistula. El-Kappany et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> described the benefits of the combination of laparoscopy with nephroscopy for patients with ectopic kidney, both to assist in the performance of percutaneous nephrolithotomy and to carry out nephroscopy through pyelotomy. Ramakumar et al.,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> and Whelan and Wiesenthal,<a class="elsevierStyleCrossRef" href="#bib0025">5</a> point the fact that the optimal treatment for patients with stenosis of the UPJ, in conjunction with renal lithiasis, is laparoscopic pyeloplasty combined with flexible nephroscopy, which includes simultaneous radiological assistance through fluoroscopy.The performance of the laparoscopic pyelolithotomy in combination with conventional nephroscopy implies that much of the saline solution for irrigation leaks into the peritoneal cavity. This liquid which accumulates in varying amounts can be difficult to extract from the bowel loops and cause some problems.<a class="elsevierStyleCrossRefs" href="#bib0015">3,6,10</a> Nadu et al.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> observed that during the laparoscopic procedure, the saline solution accumulated in the abdominal cavity occupies the space of pneumoperitoneum, and it may affect the quality of the vision and work space. It has also been observed that the small stones can be dragged by the irrigation fluid outside the renal pelvis<a class="elsevierStyleCrossRef" href="#bib0045">9</a> and lost in the abdominal cavity.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Although the relevance of this issue has not been sufficiently treated in the literature, it is clear that the search for these missing calculi in the abdomen is difficult and time consuming. However, the complications of loss of calculi in the abdomen after laparoscopic cholecystectomy are well described, including intra-abdominal abscesses, fistulas, and prolonged fever.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>Additionally, in our opinion, we consider that the saline solution that leaks from the renal pelvis, where the potentially infected calculi are present, can spread foci of infection. Schatloff et al. point that this fluid accumulated in the abdomen complicates the postoperative period, because it predisposes the ileus and it generates doubts about a false sensation of anastomotic leakage during the first few days after the surgery, for showing an output increased by the drain.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>Mason and Hoenig<a class="elsevierStyleCrossRef" href="#bib0030">6</a> were the first authors to describe the usefulness of nephroscopy with use of CO2 in combination with laparoscopy. The technique was applied in a patient with pelvic kidney who had 4 caliceal stones of 10 and 12mm, treated with laparoscopic pyelolithotomy combined with the mentioned innovative nephroscopy. They reported that the intrarenal vision obtained with CO2 insufflation is excellent, because the distension of the renal cavities is particularly good, which facilitates the systematic and thorough inspection of the calyces, adding avoidance of the use of irrigation. In our series, we had the same perception and our results were satisfactory.Schatloff et al.,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> also described an excellent view when they performed nephroscopy with use of CO2 in combination with laparoscopic pyeloplasty in a patient with multiple kidney stones and stenosis of the UPJ. These authors point that the calculi located in the calyces, which do not drain naturally into the renal pelvis because of the patient's side position, were difficult to inspect clearly, due to the air–water interface that is created in the calyces that do not drain the urine that they produce. They suggest a maneuver to overcome this deficiency, consisting in suspending the gas insufflation and administering a minimum irrigation with a 50-ml syringe in small amounts of solution applied in short ‘pulses’. In one of our patients, we had to apply this maneuver and we checked its effectiveness.At present, most patients with urinary lithiasis who are treated with laparoscopic surgery are due to the need for concomitant laparoscopic pyeloplasty due to UPJ stenosis. Our series confirms this postulate. The limitations of our research are due to the fact that this is a retrospective study, and the number of patients is limited, due to the low current indication for the laparoscopic treatment of urolithiasis. An obvious disadvantage of nephroscopy with use of CO2 is the inability to implement technologies for stone fragmentation or laser vaporization.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> In our last patient with ureteral lithiasis, it was intended to exclusively perform laparoscopic ureterolithotomy; however, the displacement of the calculus to the renal pelvis forced us to perform the ureteronephroscopy. The latter procedure could have been avoided if we had performed a maneuver of proximal and distal occlusion on the ureter to prevent dislocation of the stone.<a class="elsevierStyleCrossRefs" href="#bib0005">1,8</a> However, we could solve the problem without complications using the resource of the nephroscopy with use of CO2 that we had used previously. The effectiveness obtained with the technique of insufflating gas to perform endourological procedures changes the paradigm that all urological endoscopies are performed with irrigation fluid, and it raises the idea of its potential usefulness in other endoscopic cases of the upper or lower urinary tract, where the vision is affected by active bleeding or turbidity of the internal environment.ConclusionFlexible nephroscopy with use of CO2 in combination with laparoscopy is a feasible and effective procedure for the treatment of urinary stones in selected cases with anatomical abnormalities, complex calculi, or those susceptible to a concomitant laparoscopic treatment. This technique is definitely an excellent resource to reduce the rate of residual stones during laparoscopic pyelolithotomy, which avoids the complications of accumulation of irrigation fluid during nephroscopy.Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres100629" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Material and method" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec87793" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres100628" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivos" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec87794" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-07-08" "fechaAceptado" => "2011-07-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec87793" "palabras" => array:5 [ 0 => "Kidney" 1 => "Laparoscopy" 2 => "Nephroscopy" 3 => "Calculi" 4 => "Pyelolithotomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec87794" "palabras" => array:5 [ 0 => "Riñón" 1 => "Laparoscopia" 2 => "Nefroscopia" 3 => "Cálculos" 4 => "Pielolitotomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectiveLaparoscopy in combination with nephroscopy is rarely used for the treatment of complex urinary stones or anatomical abnormalities with difficult access to stones. During the nephroscopy, in an opened renal pelvis, large amount of fluid leaks and collects in the peritoneal cavity and can be a drawback. In these cases, the nephroscopy with use of carbon dioxide (CO2) can be an alternative. We present our experience in with this technique. Material and methodWe performed surgeries using the 3-port transperitoneal technique. Five patients with urolithiasis were included. Three patients had concomitant ureteropelvic junction (UPJ) stenosis, one with stones in ectopic kidney, and the third had a large stone impacted in the proximal ureter. Patients were treated by pyelolithotomy or ureterolithotomy combined with flexible nephroscopy using CO2 and dismembered pyeloplasty was performed in appropriate cases. A flexible cystoscope was passed through a port and guided laparascopically through the opening in the renal pelvis. The gas cannula was connected to the irrigation channel of the endoscope to insufflate CO2 and calculi were extracted with a nitinol basket. ResultsMedian age was 45 years (24–58). Mean operative time of nephroscopy was 22.4minutes (range 15–48). Mean intra-operative blood loss was inestimable. There were no complications or conversion. Residual lithiasis requiring ureteroscopy was present in one patient. ConclusionsFlexible nephroscopy using CO2 in combination with laparoscopy is a feasible and effective technique for the treatment of urinary stones in selected cases to avoid accumulation of fluid in the peritoneal cavity." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivosLa laparoscopia en combinación con nefroscopia se ha usado en raras ocasiones para el tratamiento de litiasis urinarias complejas o con anomalías anatómicas que presentan cálculos de difícil acceso. Con la pelvis renal abierta, la fuga del líquido de irrigación hacia cavidad peritoneal puede ser inconveniente. La nefroscopia empleando dióxido de carbono (CO2) es una alternativa en estos casos. Nuestro objetivo es presentar nuestra experiencia con dicha técnica. Material y métodosEmpleamos abordaje transperitoneal con tres trócares. Cinco pacientes con litiasis urinaria fueron incluidos. Tres casos presentaban estenosis de la unión pielo-ureteral, un caso tenía riñón pélvico y un último caso tenía un cálculo grande impactado en el uréter proximal. Se les realizó pielolitotomía o ureterolitotomía laparoscópica en combinación con nefroscopia flexible empleando CO2 y pieloplastia laparoscópica en los casos correspondientes. Se insertó un cistoscopio flexible a través de un trócar y se dirigió hasta las cavidades renales. La manguera del gas se conectó al canal de irrigación del endoscopio para insuflar el CO2 y se realizó la extracción de los cálculos con cesta. ResultadosLa edad promedio de los pacientes fue 45 años (24-58). El tiempo operatorio pro-medio de la nefroscopia fue 22,4 minutos (15-48) y el sangrado intraoperatorio fue inestimable. No se presentaron complicaciones ni conversión. Un paciente presentó litiasis renal residual que precisó ureteroscopia. ConclusionesLa nefroscopia flexible empleando CO2 en combinación de laparoscopia es fac-tible y efectiva para el tratamiento de la litiasis urinaria en casos seleccionados, ya que evita la acumulación de líquido en la cavidad peritoneal." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: García-Seguí A, Gascón-Mir M. Nefroscopia con uso de dióxido de carbono en combinación con laparoscopia para el manejo de la litiasis urinaria. 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Skill and talent

Nephroscopy with carbon dioxide in combination with laparoscopy in the treatment of urinary stones

Nefroscopia con uso de dióxido de carbono en combinación con laparoscopia para el manejo de la litiasis urinaria

A. García-Seguí

Corresponding author

agarciasegui@gmail.com

Corresponding author.

, M. Gascón-Mir

Servicio de Urología, Hospital General Mateu Orfila, Mahón, Menorca, Islas Baleares, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In current clinical practice&#44; laparoscopic surgery is rarely used to treat urinary stones&#44; because most of the calculi are eliminated successfully using endourological techniques or by shock waves&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The combination of laparoscopic procedures with endourological techniques has been described&#44; and it offers significant benefits for the management of complex lithiasis with anatomical abnormalities&#46; The removal of the stones during laparoscopic pyelolithotomy can be performed with laparoscopic atraumatic forceps&#59; however&#44; it can be difficult and traumatic to reach some calyceal stones with rigid instruments&#46; Inserting a flexible nephroscope guided by laparoscopic assistance allows for a systematic inspection of all renal cavities and the stones can be removed in their entirety&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Flexible nephroscopy combined with laparoscopy may have some disadvantages because of irrigation with saline solution&#46; The problem occurs because the renal pelvis is open&#44; as the fluid may leak into the peritoneal cavity&#46; Furthermore&#44; the interphase between the liquid and gas from the pneumoperitoneum can alter intrarenal vision&#46; Mason and Hoenig described the technique of flexible nephroscopy using CO<span class="elsevierStyleInf">2</span> in combination with laparoscopy in the treatment of urinary stones in order to avoid irrigation with saline solution&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We present our experience on the feasibility and effectiveness of nephroscopy with use of CO<span class="elsevierStyleInf">2</span> in combination with laparoscopy for the management of the urolithiasis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A total of 5 patients with urolithiasis underwent laparoscopic surgery in combination with nephroscopy using CO<span class="elsevierStyleInf">2</span>&#46; Of these&#44; three had multiple pyelic lithiasis together with stenosis of the UPJ with indication for surgical treatment&#46; They underwent laparoscopic pyelolithotomy&#44; flexible nephroscopy with use of CO<span class="elsevierStyleInf">2</span> and Anderson&#8211;Hynnes laparoscopic pyeloplasty&#46; The fourth case is a patient with calyceal stones in a pelvic kidney who underwent laparoscopic pyelolithotomy and flexible nephroscopy with CO<span class="elsevierStyleInf">2</span>&#46; The last case is a patient with a large calculus impacted in at the level of the proximal ureter&#44; which during laparoscopic ureterolithotomy shifted to the renal pelvis and required CO<span class="elsevierStyleInf">2</span> ureteronephroscopy&#46; In all the patients&#44; informed consent was obtained for the surgical procedures suggested&#46; All the patients underwent preoperative imaging studies &#40;intravenous urography and&#47;or computerized axial tomography&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The indications for laparoscopic surgery for urinary tract stone disease are well established and are as follows&#58; when both calculi with anatomical abnormalities coexist &#40;ectopic kidney&#44; horseshoe kidney&#44; renal malrotation&#44; etc&#46;&#44; or in situations with anatomical changes following a surgical procedure such as renal transplantation&#41;&#59; symptomatic stones in diverticula of the renal pelvis that cannot be managed by endoscopic techniques&#59; very hard&#44; impacted&#44; and large calculi &#40;&#62;15<span class="elsevierStyleHsp" style=""></span>mm&#41; mainly in children&#59; when both nephrolithiasis with another renal disease that requires laparoscopic surgery&#44; such as laparoscopic pyeloplasty in the stenosis of the UPJ&#44; coexist&#59; and when there is an economic or social need to remove the stones in a single surgical intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Surgical technique</span><p id="par0035" class="elsevierStylePara elsevierViewall">The patient is placed in lateral decubitus position&#46; Transperitoneal approach with placement of three trocars was used&#46; A laparoscopic tower using a 30&#176; laparoscope&#44; and another endourological tower with flexible cystoscope were available in the operating room to perform laparoscopic surgery and nephroscopy simultaneously&#46; The first 10-mm trocar was inserted at the level of the umbilicus&#44; through a transumbilical incision with open technique&#46; The other two ports were placed on the anterior axillary line&#44; maintaining the proper triangulation with the umbilical trocar &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The first 4 patients underwent the same procedure of laparoscopic pyelolithotomy&#46; Once the renal pelvis and the proximal ureter were dissected&#44; a pyelic incision was performed&#46; The calculi visible through the opening in the renal pelvis were removed using an atraumatic laparoscopic piece&#44; and they were deposited in a laparoscopic extraction bag&#46; We proceeded to perform nephroscopy&#44; for which we introduced the flexible cystoscope through the 10-mm trocar&#44; and under laparoscopic assistance it was directed towards the interior of the renal pelvis inserting it through the pyelic incision &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; On the irrigation line of the endoscope&#44; the CO<span class="elsevierStyleInf">2</span> hose which was used previously for the pneumoperitoneum was connected &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Through there&#44; the gas was insufflated&#44; and with an atraumatic laparoscopic forceps&#44; the pyelotomy edges were confronted to prevent gas leakage and manage to distend the renal cavities &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Flexible nephroscopy was performed &#8216;without liquid&#8217; running a systematic inspection of the calyces &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Using a nitinol basket&#44; the calculi were progressively removed and deposited in a laparoscopic extraction bag &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; Upon completion of litoextraction we proceeded to reconstruction according to the corresponding procedure&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In all the cases of stenosis of the UPJ&#44; we performed Anderson&#8211;Hynnes laparoscopic pyeloplasty&#44; and in the case of the pelvic kidney&#44; closure of the renal pelvis with intracorporeal suturing was performed&#46; In the latter case&#44; laparoscopic ureterolithotomy was prescribed&#44; and then the cystoscope was introduced through the incision of the ureter and advanced in a retrograde manner to reach the renal cavities&#46; The calculus is located in the renal pelvis and extracted with laparoscopic forceps&#46; Finally&#44; ureteral closure is performed with intracorporeal suture&#46; In all patients&#44; double J ureteral catheter was inserted anterogradely&#44; and a Jackson&#8211;Pratt drain was left exteriorized through one of the holes of the trocars&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">All the cases were successfully completed laparoscopically without conversion&#46; The average age of the patients was 45 years &#40;38&#8211;62&#41;&#44; and 4 were male&#46; The average operative time of the nephroscopy was 22&#46;4<span class="elsevierStyleHsp" style=""></span>minutes &#40;15&#8211;48<span class="elsevierStyleHsp" style=""></span>minutes&#41;&#46; The intraoperative bleeding was invaluable&#46; The average hospital stay was 3&#46;2 days &#40;3&#8211;5&#41;&#46; There were no complications&#46; One of the patients with stenosis of the UPJ had a great amount of kidney stones&#59; therefore&#44; the nephroscopy was the longest &#40;48<span class="elsevierStyleHsp" style=""></span>minutes&#41;&#44; managing to remove a total of 18 calculi&#46; Despite this&#44; it was the only case in our series that showed residual stones and it required additional ureteroscopy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Percutaneous&#44; retrograde&#44; or through shock wave techniques are the main approaches to the treatment of urinary stones for their good results and low morbidity&#46; Laparoscopic surgery is a complement for those cases that may have a lower success rate and an increased risk of morbidities&#44; like when both anatomical abnormalities or very bulky calculi coexist&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5&#44;7&#44;8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Many authors have reported that the endourological and laparoscopic procedures can be combined successfully in a single intervention to improve the rates of residual stones and resolve synchronous anomalies&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Fari&#241;a P&#233;rez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> described a case of lithiasis in a pelvic kidney treated with laparoscopic pyelolithotomy combined with flexible nephroscopy&#46; These authors conclude that the use of the endoscope allowed them to perform a more limited pyelic incision to remove the calculus&#44; which meant less surgical time and lower risk of fistula&#46; El-Kappany et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> described the benefits of the combination of laparoscopy with nephroscopy for patients with ectopic kidney&#44; both to assist in the performance of percutaneous nephrolithotomy and to carry out nephroscopy through pyelotomy&#46; Ramakumar et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and Whelan and Wiesenthal&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> point the fact that the optimal treatment for patients with stenosis of the UPJ&#44; in conjunction with renal lithiasis&#44; is laparoscopic pyeloplasty combined with flexible nephroscopy&#44; which includes simultaneous radiological assistance through fluoroscopy&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The performance of the laparoscopic pyelolithotomy in combination with conventional nephroscopy implies that much of the saline solution for irrigation leaks into the peritoneal cavity&#46; This liquid which accumulates in varying amounts can be difficult to extract from the bowel loops and cause some problems&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6&#44;10</span></a> Nadu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> observed that during the laparoscopic procedure&#44; the saline solution accumulated in the abdominal cavity occupies the space of pneumoperitoneum&#44; and it may affect the quality of the vision and work space&#46; It has also been observed that the small stones can be dragged by the irrigation fluid outside the renal pelvis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and lost in the abdominal cavity&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Although the relevance of this issue has not been sufficiently treated in the literature&#44; it is clear that the search for these missing calculi in the abdomen is difficult and time consuming&#46; However&#44; the complications of loss of calculi in the abdomen after laparoscopic cholecystectomy are well described&#44; including intra-abdominal abscesses&#44; fistulas&#44; and prolonged fever&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Additionally&#44; in our opinion&#44; we consider that the saline solution that leaks from the renal pelvis&#44; where the potentially infected calculi are present&#44; can spread foci of infection&#46; Schatloff et al&#46; point that this fluid accumulated in the abdomen complicates the postoperative period&#44; because it predisposes the ileus and it generates doubts about a false sensation of anastomotic leakage during the first few days after the surgery&#44; for showing an output increased by the drain&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Mason and Hoenig<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> were the first authors to describe the usefulness of nephroscopy with use of CO<span class="elsevierStyleInf">2</span> in combination with laparoscopy&#46; The technique was applied in a patient with pelvic kidney who had 4 caliceal stones of 10 and 12<span class="elsevierStyleHsp" style=""></span>mm&#44; treated with laparoscopic pyelolithotomy combined with the mentioned innovative nephroscopy&#46; They reported that the intrarenal vision obtained with CO<span class="elsevierStyleInf">2</span> insufflation is excellent&#44; because the distension of the renal cavities is particularly good&#44; which facilitates the systematic and thorough inspection of the calyces&#44; adding avoidance of the use of irrigation&#46; In our series&#44; we had the same perception and our results were satisfactory&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Schatloff et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> also described an excellent view when they performed nephroscopy with use of CO<span class="elsevierStyleInf">2</span> in combination with laparoscopic pyeloplasty in a patient with multiple kidney stones and stenosis of the UPJ&#46; These authors point that the calculi located in the calyces&#44; which do not drain naturally into the renal pelvis because of the patient&#39;s side position&#44; were difficult to inspect clearly&#44; due to the air&#8211;water interface that is created in the calyces that do not drain the urine that they produce&#46; They suggest a maneuver to overcome this deficiency&#44; consisting in suspending the gas insufflation and administering a minimum irrigation with a 50-ml syringe in small amounts of solution applied in short &#8216;pulses&#8217;&#46; In one of our patients&#44; we had to apply this maneuver and we checked its effectiveness&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">At present&#44; most patients with urinary lithiasis who are treated with laparoscopic surgery are due to the need for concomitant laparoscopic pyeloplasty due to UPJ stenosis&#46; Our series confirms this postulate&#46; The limitations of our research are due to the fact that this is a retrospective study&#44; and the number of patients is limited&#44; due to the low current indication for the laparoscopic treatment of urolithiasis&#46; An obvious disadvantage of nephroscopy with use of CO<span class="elsevierStyleInf">2</span> is the inability to implement technologies for stone fragmentation or laser vaporization&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In our last patient with ureteral lithiasis&#44; it was intended to exclusively perform laparoscopic ureterolithotomy&#59; however&#44; the displacement of the calculus to the renal pelvis forced us to perform the ureteronephroscopy&#46; The latter procedure could have been avoided if we had performed a maneuver of proximal and distal occlusion on the ureter to prevent dislocation of the stone&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;8</span></a> However&#44; we could solve the problem without complications using the resource of the nephroscopy with use of CO<span class="elsevierStyleInf">2</span> that we had used previously&#46; The effectiveness obtained with the technique of insufflating gas to perform endourological procedures changes the paradigm that all urological endoscopies are performed with irrigation fluid&#44; and it raises the idea of its potential usefulness in other endoscopic cases of the upper or lower urinary tract&#44; where the vision is affected by active bleeding or turbidity of the internal environment&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Flexible nephroscopy with use of CO<span class="elsevierStyleInf">2</span> in combination with laparoscopy is a feasible and effective procedure for the treatment of urinary stones in selected cases with anatomical abnormalities&#44; complex calculi&#44; or those susceptible to a concomitant laparoscopic treatment&#46; This technique is definitely an excellent resource to reduce the rate of residual stones during laparoscopic pyelolithotomy&#44; which avoids the complications of accumulation of irrigation fluid during nephroscopy&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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            0 => "Resumen"
            1 => "Objetivos"
            2 => "Material y m&#233;todos"
            3 => "Resultados"
            4 => "Conclusiones"
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          "identificador" => "xpalclavsec87794"
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          "titulo" => "Introduction"
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          "titulo" => "Patients and methods"
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          "titulo" => "Results"
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          "titulo" => "Conclusion"
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          "titulo" => "Conflict of interest"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-07-08"
    "fechaAceptado" => "2011-07-19"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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            0 => "Kidney"
            1 => "Laparoscopy"
            2 => "Nephroscopy"
            3 => "Calculi"
            4 => "Pyelolithotomy"
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      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:5 [
            0 => "Ri&#241;&#243;n"
            1 => "Laparoscopia"
            2 => "Nefroscopia"
            3 => "C&#225;lculos"
            4 => "Pielolitotom&#237;a"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Laparoscopy in combination with nephroscopy is rarely used for the treatment of complex urinary stones or anatomical abnormalities with difficult access to stones&#46; During the nephroscopy&#44; in an opened renal pelvis&#44; large amount of fluid leaks and collects in the peritoneal cavity and can be a drawback&#46; In these cases&#44; the nephroscopy with use of carbon dioxide &#40;CO<span class="elsevierStyleInf">2</span>&#41; can be an alternative&#46; We present our experience in with this technique&#46;</p> <span class="elsevierStyleSectionTitle">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed surgeries using the 3-port transperitoneal technique&#46; Five patients with urolithiasis were included&#46; Three patients had concomitant ureteropelvic junction &#40;UPJ&#41; stenosis&#44; one with stones in ectopic kidney&#44; and the third had a large stone impacted in the proximal ureter&#46; Patients were treated by pyelolithotomy or ureterolithotomy combined with flexible nephroscopy using CO<span class="elsevierStyleInf">2</span> and dismembered pyeloplasty was performed in appropriate cases&#46; A flexible cystoscope was passed through a port and guided laparascopically through the opening in the renal pelvis&#46; The gas cannula was connected to the irrigation channel of the endoscope to insufflate CO<span class="elsevierStyleInf">2</span> and calculi were extracted with a nitinol basket&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Median age was 45 years &#40;24&#8211;58&#41;&#46; Mean operative time of nephroscopy was 22&#46;4<span class="elsevierStyleHsp" style=""></span>minutes &#40;range 15&#8211;48&#41;&#46; Mean intra-operative blood loss was inestimable&#46; There were no complications or conversion&#46; Residual lithiasis requiring ureteroscopy was present in one patient&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Flexible nephroscopy using CO<span class="elsevierStyleInf">2</span> in combination with laparoscopy is a feasible and effective technique for the treatment of urinary stones in selected cases to avoid accumulation of fluid in the peritoneal cavity&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La laparoscopia en combinaci&#243;n con nefroscopia se ha usado en raras ocasiones para el tratamiento de litiasis urinarias complejas o con anomal&#237;as anat&#243;micas que presentan c&#225;lculos de dif&#237;cil acceso&#46; Con la pelvis renal abierta&#44; la fuga del l&#237;quido de irrigaci&#243;n hacia cavidad peritoneal puede ser inconveniente&#46; La nefroscopia empleando di&#243;xido de carbono &#40;CO<span class="elsevierStyleInf">2</span>&#41; es una alternativa en estos casos&#46; Nuestro objetivo es presentar nuestra experiencia con dicha t&#233;cnica&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Empleamos abordaje transperitoneal con tres tr&#243;cares&#46; Cinco pacientes con litiasis urinaria fueron incluidos&#46; Tres casos presentaban estenosis de la uni&#243;n pielo-ureteral&#44; un caso ten&#237;a ri&#241;&#243;n p&#233;lvico y un &#250;ltimo caso ten&#237;a un c&#225;lculo grande impactado en el ur&#233;ter proximal&#46; Se les realiz&#243; pielolitotom&#237;a o ureterolitotom&#237;a laparosc&#243;pica en combinaci&#243;n con nefroscopia flexible empleando CO<span class="elsevierStyleInf">2</span> y pieloplastia laparosc&#243;pica en los casos correspondientes&#46; Se insert&#243; un cistoscopio flexible a trav&#233;s de un tr&#243;car y se dirigi&#243; hasta las cavidades renales&#46; La manguera del gas se conect&#243; al canal de irrigaci&#243;n del endoscopio para insuflar el CO<span class="elsevierStyleInf">2</span> y se realiz&#243; la extracci&#243;n de los c&#225;lculos con cesta&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La edad promedio de los pacientes fue 45 a&#241;os &#40;24-58&#41;&#46; El tiempo operatorio pro-medio de la nefroscopia fue 22&#44;4 minutos &#40;15-48&#41; y el sangrado intraoperatorio fue inestimable&#46; No se presentaron complicaciones ni conversi&#243;n&#46; Un paciente present&#243; litiasis renal residual que precis&#243; ureteroscopia&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La nefroscopia flexible empleando CO<span class="elsevierStyleInf">2</span> en combinaci&#243;n de laparoscopia es fac-tible y efectiva para el tratamiento de la litiasis urinaria en casos seleccionados&#44; ya que evita la acumulaci&#243;n de l&#237;quido en la cavidad peritoneal&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Garc&#237;a-Segu&#237; A&#44; Gasc&#243;n-Mir M&#46; Nefroscopia con uso de di&#243;xido de carbono en combinaci&#243;n con laparoscopia para el manejo de la litiasis urinaria&#46; Actas Urol Esp&#46; 2012&#59;36&#58;186&#8211;90&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The flexible cystoscope is inserted through a trocar and the CO<span class="elsevierStyleInf">2</span> hose was connected on the irrigation line of the endoscope&#46;</p>"
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      "titulo" => "References"
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Article information

ISSN: 21735786
Original language: English

DOI:10.1016/j.acuroe.2012.05.007

The statistics are updated each day

Year/Month	Html	Pdf	Total

2023 March	1	0	1
2018 March	1	0	1
2018 February	50	1	51
2018 January	46	1	47
2017 December	61	0	61
2017 November	45	2	47
2017 October	35	1	36
2017 September	33	3	36
2017 August	26	3	29
2017 July	31	2	33
2017 June	44	2	46
2017 May	42	1	43
2017 April	29	12	41
2017 March	28	22	50
2017 February	61	1	62
2017 January	24	0	24
2016 December	45	5	50
2016 November	45	4	49
2016 October	52	7	59
2016 September	54	7	61
2016 August	35	8	43
2016 July	18	2	20
2016 June	41	5	46
2016 May	48	19	67
2016 April	39	9	48
2016 March	54	14	68
2016 February	52	19	71
2016 January	48	15	63
2015 December	47	19	66
2015 November	48	14	62
2015 October	33	16	49
2015 September	32	9	41
2015 August	58	2	60
2015 July	74	7	81
2015 June	31	2	33
2015 May	53	8	61
2015 April	54	10	64
2015 March	32	4	36
2015 February	13	3	16
2015 January	30	6	36
2014 December	18	5	23
2014 November	24	2	26
2014 October	42	5	47
2014 September	35	3	38
2014 August	33	6	39
2014 July	23	6	29
2014 June	20	2	22
2014 May	16	2	18
2014 April	15	5	20
2014 March	32	9	41
2014 January	8	1	9
2013 December	11	1	12
2013 November	19	1	20
2013 October	20	4	24
2013 September	6	3	9

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