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M. Hruza, J. Rioja Zuazu, A. Serdar Goezen, J.J.M.C.H. de la Rosette, J.J. RassweilerFigure 1.The renal pelvis of a horse shoe kidney is open forlaparoscopic removal of a stone.Figure 2.After a longitudinal incision of the ureterthe ureteral calculus is visible.Figure 3.A grasper is used to remove the stonefrom the ureter.large stone, intracorporal ultrasound (50), a combinationof laparoscopy and percutaneous nephroscopy(26) or the insertion of a flexible scope through one ofthe ports (25) can be helpful. An organ bag can help tobring out large or multiple stones. After stone removal,the renal pelvis is closed using a running intracorporalsuture. If no Double-J stent was placed preoperatively,it should be inserted before suturing. We normally usean additional drain in the retroperitoneal space to preventthe formation of an urinoma.c) Transperitoneal removal of stones in a diverticulum of therenal pelvis: In the majority of cases, there is only a thinlayer of tissue to be inserted using electrocauterisation tofree the stone (51). In some cases there is difficulty tolocalise the diverticulum because it does not bulge outover the contour of the kidney. Therefore, preoperativeimaging is recommended in all cases. Sometimes, intracorporaluntrasound can be useful, too (50). Afterremoval of the stone and the diverticulum, the gap maybe filled with fatty tissue or Gerota’s fascia (28, 51).Synthetic glue can also be considered for closure (29).d) Transperitoneal pyelolithotomy in kidneys with anatomicalabnormalities: In cases of ectopic or malrotated kidneysor in kidneys with irregular form, modificationsin the way of access and in the position of the trocarscan be necessary. These procedures should only bedone by experienced laparoscopists. Preoperatively,accurate imaging and planning are mandatory.– The prevalence of horseshoe kidneys is about 0.25%.Frequently the are associated with complications asobstruction, infection of stone formation (52, 53).Because both pelvises point ventrally they can besufficiently reached using a transperitoneal access(54) (Figure 1).– The prevalence of pelvic kidneys is lower (0.02-0.03%). On the left side they are more frequentthan on the right (55, 56). The laparoscopic accessto a pelvic kidney is transperitoneal (23-27, 57). Atthe beginning, a transureteral balloon catheter isplaced into the renal pelvis to make its laparoscopicidentification easier. After filling the renal pelviswith contrast media, X-rays can be used for orientation(23, 24).In cases of pelvic kidneys as well as horseshoe kidneys,the technique of laparoscopic assisted percutaneousnephrolithotripsy is described. The percutaneouspuncture of the renal pelvis with a needle isdone under laparoscopic guidance to prevent injuriesto other structures in difficult anatomical circumstances.Laparoscopic instruments can be used toguide the needle into its aim1 (9, 58, 59).e) Transperitoneal laparoscopic ureterolithotomy: After openingthe peritoneum, the ureter is exposed. Importantanatomical landmarks are the psoas muscle and thegonadal veins. Large stones are clearly identifiable inmost cases, for smaller stones imaging can be used asdescribed for stones in the renal pelvis. After identificationof the calculus, the ureter is temporarily occludedproximally and distally of the stone to prevent shifting.Most authors prefer a longitudinal incision of the ureterfor stone removal (Figures 2 and 3). The closure of theureter should be done using an intracorporal suture66Archivio Italiano di Urologia e Andrologia 2010; 82, 1