Clinical Nephrology, DOI 10.5414/CN108392
LETTER TO THE EDITOR
Letter ©2014 Dustri-Verlag Dr. K. Feistle ISSN 0301-0430 DOI 10.5414/CN108392 e-pub: October 8, 2014
A novel laparoscopic ureterolithotomy with renal stone removal using a rigid nephroscope and ultrasonic lithotripter through a laparoscopic port in a patient with giant ureteral and renal stones Yu Seob Shin, Jae Hyung You, and Myung Ki Kim Department of Urology, Chonbuk National University Medical School and Research Institute of Clinical Medicine of Chonbuk National UniversityBiomedical Research Institute of Chonbuk National University Hospital, Jeonju, South Korea
Sir, – Ureteral stones larger than 5 cm in size and/or weighing more than 50 g are referred to as giant ureteral stones . Urinary tract anomalies play an important role in the pathogenesis of giant ureteral stones. The anomalies are usually noticed by symptoms in childhood. However, in cases in which the symptoms are not severe and the child’s parents remain unaware of the abnormality, long-term urinary obstruction and chronic infection may result in stone formation or acute aggravation of infection . In the present case, we report a giant ureteral stone in an incomplete duplication of the ureter with a staghorn renal stone, which were simultaneously removed. A 52-year-old healthy woman was referred to the hospital due to left flank pain. Urinalysis revealed microscopic hematuria and pyuria. Her serum creatinine was 0.62 mg/dL and there were no other laboratory studies with significant abnormalities. A plain abdominal radiograph showed a giant upper ureteral stone, 8.6 × 1.8 cm in size, with a 1.1 × 0.5 cm sized lower ureteral stone and staghorn renal stone on the ipsilateral side (Figure 1). Computed tomography scan of the abdomen showed an incomplete duplication of the ureter, consisting of two ureteral
Figure 1. A plain abdominal radiograph showed a giant upper ureteral stone, 8.6 × 1.8 cm in size, with 1.1 × 0.5 cm sized lower ureteral stone and staghorn renal stone on the ipsilateral side.
limbs proximally that fuse distally to become a single channel draining to the bladder. We first removed the lower ureteral stone by ureteroscopy to resolve urinary tract obstruction. We proposed a transperitoneal laparoscopic approach. The patient underwent surgery in the full lateral decubitus position. Four trocars were placed; specifically, a camera port was placed at the umbilicus and one 11-mm port was placed at the level of the umbilicus on the lateral border of the rectus muscle, which can help a rigid nephroscope get better penetration. One 5-mm port was placed in the midline below the umbilicus, and a 2-mm port was placed at the superior border of the rectus muscle. The colon was reflected medially, and the retroperitoneum was exposed. The stone was identified as a bulge; the ureter was incised using a laparoscopic knife on the lowermost portion of the stone and the stones were removed (Figure 2). An Amplatz sheath was placed at the incised site of the ureter through the 11-mm port. A rigid nephroscope was advanced to the collecting system through the Amplatz sheath and staghorn renal stone was removed by ultrasonic lithotripter and stone forceps. We did not find any evidence of stone spillage after successful stone removal. Ureterotomy closure was performed by intracorporeal interrupted sutures. The operation time was 115 minutes
Clinical Nephrology, Vol. 82 – No. 5/2014 – Letter to the editor
Figure 2. a: Stone was removed from the ureter during transperitoneal laparoscopic ureterolithotomy. b: The removed stone showed a giant lower ureteral stone, 8.6 × 1.8 cm in size, with another renal stone.
and blood loss was 20 mL. The patient was discharged 7 days postoperatively with no complications. Stone analysis was consistent with calcium apatite composition. A plain abdominal radiograph performed postoperatively revealed resolution of stones. In this case, we performed laparoscopic ureterolithotomy with renal stone removal using a rigid nephroscope and ultrasonic lithotripter through the ureteral incision site. Thus, we could avoid additional surgery such as percutaneous nephrolithotomy for staghorn renal stone. It seems that laparoscopic ureterolithotomy with renal stone removal using a rigid nephroscope and ultrasonic lithotripter through the ureter incision site can play an important role in the surgical management of large ureteral stones with ipsilateral staghorn renal stones. In this case, a giant upper ureteral stone with a staghorn renal stone was located at the upper moiety of the duplicated system. The renal stone could be removed by a percutaneous approach with some technical difficulties, and was too large to attempt retrograde intrarenal surgery. Dilatation of ureter is enough to access the Amplatz sheath and the ureter incision site via the laparoscopic port. We decided to remove the renal stones with a rigid nephroscope and ultrasonic lithotripter through a laparoscopic port. Amplatz sheath access was on the ureter incision site, and we were able togently advance a rigid nephroscope to the collecting system. We carefully monitored the laparoscopic view in order to avoid injury to the ureter, UPJ, and renal vasculature. In this novel operation, the ideal access to the Amplatz sheath on the incision site of the ureter through laparoscopic port, in order to advance rigid renoscope to the
collecting system, was technically challenging. If the incision site is not close enough to the collecting system, the rigid nephroscope might be unable to approach the collecting system. In addition, an 11-mm laparoscopic port was inserted with considering the angle that would help the rigid nephroscope get better penetration. In special cases such as this one, our novel method might be appropriate. However, in general cases of upper ureteral stone with renal stone, our novel method might not be. Of course, in patients with a small renal stone, a flexible scope with a laser instrument could be useful and safe.
Conflict of interest None declared.
References  
Sabnis RB, Desai RM, Bradoo AM, Punekar SV, Bapat SD. Giant ureteral stone. J Urol. 1992; 148: 861-862. PubMed Izumi K, Kono M, Kato H, Tsukahara K, Namiki M. Ectopic ureter accompanied by giant ureteral stone and pyonephrosis. Int J Urol. 2007; 14: 856858. CrossRef PubMed Correspondence to Myung Ki Kim, Department of Urology, Chonbuk National University Medical School, Geonjeero 20, Deokjin-gu, Jeonju, 561-712, Korea [email protected]