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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
Laparoscopic and open stone surgeryTable 2.Comparison between laparoscopic and open ureterolithotomy (45, 71).Goel and H emal 2001 Skrepetis et al. 2001l ap. r et r o per i t . o pen l ap. t r an sper i t . o penNumber of patients 55 26 18 18Size of stones (mm) 21 (7-33) 24 (7-34) 19 (12-31) 17 (10-26)Duration of procedure (minutes) 108.8 (40-275) 98.8 (60-125) 130 (110-190) 85 (60-110)Postoperative hospital stay (days) 3.3 (2-14) 4.8 (3-8) 3.2 (2-5) 7.8 (7-11)Time to convalescence (days) 12.6 (7-21) 21.7 (14-28) 12 (8-26) 22 (16-34)Analgesics (mg Pethidin) 41,1 (25-75) 96,9 (50-150) n.a. n.a.Duration of analgesic (days) n.a. n.a. 1 (0-2) 4 (2-7)a steep learning curve in laparoscopic surgery for unexperiencedsurgeons leading to an initially high conversionrate (45).CONCLUSIONSToday most cases of stones in ureter or renal pelvis can bemanaged using endourological techniques (transureteralor percutaneous lithotripsy or shock wave lithotripsy).However, in some cases, the location, size or hardness ofthe calculi as well as an aberrant anatomy of the kidneymay require open or laparoscopic stone surgery. The modernlaparoscopic procedures are able to solve nearly allproblems which were domains of open stone surgery formerly.A retroperitoneal as well as a transperitoneal laparoscopicapproach may be useful depending on the locationof the stone. Therefore, laparoscopic centers should provideboth techniques. Compared to open surgery, theadvantages of laparoscopy are less pain, shorter convalescenceand better cosmetic results associated with a similargood functional outcome.REFERENCES1. Tiselius H-G, Ackermann D, Alken P, et al. EAU Guidelines onUrolithiasis. European Association of Urology 2008.2. Assimos DG, Boyce WH, Harrison LH, et al. The role for opensurgery since extracorporal shock wave lithotripsy. J Urol 1989;142:263-267.3. Segura JW. Current surgical approaches to nephrolithiasis.Endocrinol Metab Clin North Am 1990; 19:912-925.4. Kane MT, Cohen AS, Smith ER, et al. Commission on DieteticRegistration Dietetics Practice Audit. J Am Diet Assoc 1996; 1292-1301.5. Bichler KH, Lahme S, Strohmaier WL. Indications fo open stoneremoval of urinary calculi. Urol Int 1997; 59:102-108.6. Paik ML, Wainstein MA, Spirnak P, et al. Current indications foropen stone surgery in the treatment of renal and ureteral calculi. JUrol 1998, 159:374.7. Wickham JEA. The surgical treatment of renal lithiasis. In:Urinary Calculous Disease. Churchill Livingstone, Edinburgh, 1979;145-198.8. Wickham J. Current management of urinary calculi; Practitioner1989; 233:526-529.9. Buchholz NN, Hitchings A, Albanis S. The (soon forgotten) art ofopen stone surgery: to train or not to train? Ann R Coll Surg Engl2006; 88:214-217.10. Paik ML, Resnick MI. Is there a role for open stone surgery? UrolClin North Am 2000; 27:323-331.11. Alivizatos G, Skolarikos A. Is there still a role for open surgery inthe management of renal stones? Curr Opin Urol 2006; 16:106-111.12. Preminger GM, Assimos DG, Lingeman JEet al. Chapter 1: AUAguideline on management of staghorn calculi: diagnosis and treatmentrecommendations. J Urol 2005; 173:1991-2000.13. Wong C, Zimmerman RA. Laparoscopy-assisted transperitonealpercutaneous nephrolithotomy for renal caliceal diverticular calculi.J Endourol 2005; 19:608-613.14. Gil-Vernet J. New surgical concepts in removing renal calculi.Urol Int 1985; 20:255-288.15. Boyce WH, Elkins IB. Reconstructive renal surgery followinganatrophic nephrolithotomy: Follow-up of 100 consecutive cases. JUrol 1974; 111:307-312.16. Riedmiller H, Thüroff J, Alken P, Hohenfellner R. Doppler andB-mode ultrasound for avascular nephrotomy. J Urol 1983;130:224-227.17. Eisenberger F, Miller K, Rassweiler J. Open surgery. In: StoneTherapy in Urology. Georg Thieme Verlag, Stuttgart, New York,1991; 123-12418. Marberger M, Eisenberger F. Regional hypothermia of the kidney:surface or transarterial perfusion cooling? A functional study. JUrol 1980; 124:179-183.19. Eshghi AM, Roth JS, Smith AD. Percutaneous transperitonealapproach to a pelvic kidney for endourological removal of a staghorncalculus. J Urol 1985; 134:525.20. Figge M. Percutaneous transperitoneal nephrolithotomy. EurUrol 1988; 14:414.21. Harmon WJ, Kleer E, Segura JW. Laparoscopic pyelolithotomyfor calculus removal in a pelvic kidney; J Urol 1996; 155:2019.22. Chang TD, Dretler SP. Laparoscopic pyelolithotomy in anectopic kidney. J Urol 1996; 156:1753.23. Hoenig DM, Shalhav AL, Elbahnasy AM, et al. LaparoscopicArchivio Italiano di Urologia e Andrologia 2010; 82, 169
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Official Journal of the SIEUN, the
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ContentsHistological evaluation of
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R. Leonardi, R. Caltabiano, S. Lanz
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R. Leonardi, R. Caltabiano, S. Lanz
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F. Galasso, R. Giannella, P. Bruni,
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F. Galasso, R. Giannella, P. Bruni,
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ORIGINAL PAPERSurgery for renal cel
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S.D. Dyakov, G. Lucarelli, A.I. Hin
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S.D. Dyakov, G. Lucarelli, A.I. Hin
Page 21 and 22: M. Aza, S.S. Iqbal, M.V. Muhammad,
Page 23 and 24: Archivio Italiano di Urologia e And
Page 25 and 26: The Clavien classification system t
Page 27 and 28: PRESENTATIONPercutaneous nephrolith
Page 29 and 30: Percutaneous nephrolithotomy: An ex
Page 31 and 32: PCNL in ItalyTable 1.Number and hos
Page 33 and 34: PCNL in ItalyFigure 3.Comparison be
Page 35 and 36: The patient position for PNL: Does
Page 37 and 38: PCNL: Tips and tricks in targeting,
Page 39 and 40: Tubeless percutaneous nephrolithoto
Page 41 and 42: PRESENTATIONHigh burden and complex
Page 43 and 44: High burden and complex renal calcu
Page 45 and 46: PRESENTATIONEndoscopic combined int
Page 47 and 48: PRESENTATIONHigh burden stones: The
Page 49 and 50: PRESENTATIONStone treatment in chil
Page 51 and 52: Stone treatment in children: Where
Page 53 and 54: PRESENTATIONExtracorporeal shock wa
Page 55 and 56: PRESENTATIONPercutaneous nephrolith
Page 57 and 58: PRESENTATIONFlexible ureteroscopy f
Page 59 and 60: Flexible ureteroscopy for kidney st
Page 61 and 62: Indications, prediction of success
Page 69 and 70: Laparoscopic and open stone surgery
Page 71: Laparoscopic and open stone surgery
Page 75: Laparoscopic and open stone surgery
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