Laparoscopic and robot-assisted surgery in the management of urinary lithiasis

Abstract

Objectives: To review the current role of laparoscopy and robot-assisted laparoscopy for managing urinary lithiasis.

Results: The contemporary indications for laparoscopic stone management are: anatomical variations in location or shape of the kidney (pelvic kidney, horseshoe kidney and malrotated kidney); coexisting pathologies, e.g. pelvi-ureteric junction obstruction; and stones in a renal unit with lower ureteric obstruction. The laparoscopic approach allows the simultaneous management of both the pathologies. Symptomatic stones in diverticula not amenable to endourological intervention can be treated with laparoscopy. Large impacted pelvic and ureteric calculi with a functioning renal unit are an indication for laparoscopic ureterolithotomy or pyelolithotomy. This review of current reports suggests that in a selected group of patients with complex stone disease the laparoscopic approach offers good success rates with minimal complications. There are few reports of robotic procedures in stone disease but existing data suggest that it is feasible.

Conclusion: Laparoscopic surgery is effective for complex renal stones and offers excellent stone clearance rates with minimal morbidity. Laparoscopic surgery is complementary in managing these stones. Robot-assisted laparoscopic technique of urinary tract stone management is in its early stage of implementation and randomised trials that compare robot assisted outcomes with other minimally invasive techniques are needed.

Keywords: CE, contrast-enhanced; LAN, laparoscopic anatrophic nephrolithotomy; LP(P), laparoscopic pyelolithotomy (with pyeloplasty); LU, laparoscopic ureterolithotomy; Laparoscopic surgery; PCNL, percutaneous nephrolithotomy; Review; Robotics; Stones; US, ultrasonography.

Figure 1

LAN: (a) A Satinsky is applied en bloc to the renal hilum; (b) intraoperative US helps to delineate the stones; (c) stones collected in the bag; (d) the defect is closed with surgical and Hem-o-Lok clips.

Figure 2

LP: (a and b) appropriate imaging in the form of IVU and CT help to ascertain the anatomy of the pelvicalyceal system and the vascular anatomy. (c) The incision is made over the pelvis and the stone removed.

Figure 3

LU: (a) IVU showing an impacted upper ureteric calculus. (b) The ureter is dissected and the incision made over the stone. (c) The stone is extracted with stone-holding forceps.

Figure 4

Laparoscopic lower-pole nephrectomy: (a) intraoperative US; (b) securing the hilum; (c) incising the lower pole and stone removal; (d) closure of the lower-pole defect.