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M. Hruza, J. Rioja Zuazu, A. Serdar Goezen, J.J.M.C.H. de la Rosette, J.J. RassweilerTable 1.Comparison between open and endourological stone therapy (70).Open surgery Endourological(n = 61) therapy (n = 186)Stone-free at discharge 49 (8%) 58 (31%) p > 0.05Mean follow-up 42 months 36 monthsStone-free 44 (72%) 112 (60%) n.s.Asymptomatic remnants 2 (3%) 46 (25%) p > 0.05Symptomatic remnants 3 (5%) 15 (8%) n.s.Recurrence 12 (20%) 13 (7%) p > 0.05UTI at hospitalisation 35 (57%) 65 (35%)UTI in follow-up 18 (30%) 21 (11%)UTI after/before 0.51 0.32 p > 0.05UTI = Urinary tract infection.main benefits of the transperitoneal access. A higher rateof complications related to the bowel and complicationsdue to urine extravasation into the peritoneal space arethe most common disadvantages of this access. Theretroperitoneal access should be preferred for operationson the pyelon of the orthotopic kidney and on the proximalureter. Previous retroperitoneal surgery howeverprecludes a second operation via retroperitoneal accessbecause of adhesions limitating the possibility of developingthe retroperitoneal working space (63, 64).Reviewing the current literature, there is no agreement ifthe incision of the ureter to remove the calculus shouldbe made by using a diathermal hook or a cold laparoscopicknife. Nouira et al. reported a higher stricture rateafter using diathermia (60). Harewood et al. however useddiathermia in all their patients. The stricture rate in thisstudy was 0% (65).The question if the incision of the ureter should besutured after stone removal and if a Double-J stentshould be used is also debate. In 1994, Demerici et al.propagated suturing the ureter without stenting, howevertheir series was small (48). Kijvikai et al. presented thedata of 30 patients in 2006: they sutured the ureter usingsingle stitches without inserting a stent. A drain was usedto prevent the formation of urinomas. Only one of theirpatients underwent Double-J stenting after prolongedloss of urine via the drain (49). Hemal et al. reported in asimilar series that Double-J stenting for persistingextravasation of urine was necessary in two of their 31patients (47).The stricture rate after laparoscopic ureterolithotomy isabout three percent (66). Keeley et al. and Nouira et al.however presented a higher stricture rate due to a tootight suture of the ureter. Keeley et al. concluded that asuture of the ureter should not be recommended at allafter inserting a ureteral stent and a drain in theretroperitoneal space (37). Nouira et al. however favor anadapting, non-watertight suture of the ureter after insertionof the Double-J stent (60).Interestingly, the theory of Mitchson and Bird on the developmentof ureteral stenosis after laparoscopic ureterolithotomyis contrary: they blame a retroperitoneal fibrosis dueto an extravasation of urine into the retroperitoneal spaceand therefore postulate the need of a watertight suture ofthe ureter (67).Gaur et al. stated that in cases of a chronically infected oroedematous ureter the probability of an insufficiency ofthe suture leading to an extravasation of urine is elevated.Therefore, they suggest only to stent the ureter withoutany suture in these special cases (40).Especially in the United States the number of roboticassistedlaparoscopic procedures is increasing. In somecases, the laparoscopic pyelolithotomy was also performedusing this technique (68, 69). However, especiallyin these rare procedures, the value of roboticassistedsurgery in daily clinical practice can not berated at the moment.Results of laparoscopic and open stone surgeryIn 2000, Rassweiler et al. presented a comparison ofopen surgical versus endourological stone treatment(Table 1) (70): It was concluded that the rate of stonefreepatients after 36 and 42 months showed no significantdifference (72% vs 60%) although it had been significantlyhigher in the open group at the time of dischargefrom the hospital (80% vs 31%). Asymptomaticremnants were significantly more frequent in theendourological group (25% vs 3%). However, there wasno difference in the rate of symptomatic remnants. Therecurrence rate was significantly higher in the opengroup (20% vs 7%). There was a significant reduction ofurinary tract infections after endourological therapy.Few data have been published on the topic of laparoscopicpyelolithotomy and ureterolithotomy. Evenmajor laparoscopic centers are not able to present highnumbers of patients who underwent these infrequentprocedures. Beside a number of case reports on thissubject there are only few studies with sufficient collectivesof patients. One publication reporting the data of101 patients after laparoscopic pyelolithotomy can befound (40). Only two further reports including morethan 30 patients have been published (45, 49). Thereare no randomised studies comparingthe open and laparoscopic approach.Only two non-randomised comparativestudies can be found, they aresummarized in Table 2. Skrepetis et al.compared the results of 18 patientsafter laparoscopic stone surgery to aformer series of 18 patients after opensurgery: In the laparoscopic group,less analgesic medication wasrequired, hospital stay and time toconvalescence were shorter. However,operative times were significantlylonger. There were no significant differencesin stone free rates and complicationrates (71). Goel and Hemalcompared 55 patients after laparoscopictreatment to 26 after open surgery.Their results were similar tothose of Skrepetis and his group.Additionally they stated that there was68Archivio Italiano di Urologia e Andrologia 2010; 82, 1