Surgical Techniques in Urology

Concomitant Treatment of UreteropelvicJunction Obstruction and Renal Calculi WithRobotic Laparoscopic Surgery and RigidNephroscopyJi Zheng, Junan Yan, Zhansong Zhou, Zhiwen Chen, Xin Li, Jinhong Pan, and Weibing Li

INTRODUCTION The treatment of ureteropelvic junction obstruction (UPJO) and concomitant calculus poses

Ji Zheng and Junan Yan contribuFinancial Disclosure: The authoFrom the Urological Surgery R

Medical University, Chongqing,Reprint requests: Jinhong Pan

Urological Surgery Research InsUniversity, Gao Tanyan Rd 30hotmail.com; liweibing63@yahoo.Submitted: April 2, 2013, acc

ª 2014 Elsevier Inc.All Rights Reserved

a technically challenging situation. We present our experience with using rigid nephroscopy forrenal calculi removal during robot-assisted pyeloplasy (RAP) for UPJO.

TECHNICALCONSIDERATIONS

From December 2010 to November 2012, 25 patients with UPJO had RAP at our institution; 9 ofthose had concurrent renal calculi, which were simultaneously treated with rigid nephroscopy.

For stone extraction, a rigid ureteroscope was passed through an assistant trocar under laparo-scopic vision directly into a previously created pyelotomy. The stones were extracted using a rigidgrasper or stone basket through the rigid ureteroscope. For the removal of the stones within theupper and lower calyces, the rigid ureteroscope was introduced into the incised renal pelvisthrough robotic trocars if the “assistant trocar” route failed.Complete stone clearance was achieved in 8 of 9 patients. Residual calculi in 1 patient wereremoved with a single session of extracorporeal shock wave lithotripsy. At the mean follow-up of10.2 months, no patients had obstruction or recurrent stones. The mean operative time was 187.1minutes, which was 40.9 minutes longer than the mean operative time in patients without renalcalculi. There was no significant difference in blood loss, hospital stay, complications, and successrates between patients with and without renal calculi.

CONCLUSION Our data suggest that the use of a concomitant rigid nephroscope and RAP is a safe and feasible

option for the treatment of UPJO complicated with renal calculi. UROLOGY 83: 237e242, 2014.� 2014 Elsevier Inc.

reteropelvic junction obstruction (UPJO) is acommon obstructive pathology of the upper

Uurinary tract, and stasis because of the obstruc-

tion can result in renal calculus formation.1,2 The inci-dence of renal calculi associated with UPJO has beenreported to be approximately 20%,3 and a therapeuticdilemma still exists regarding what constitutes the idealtreatment for patients with UPJO.

The surgical treatment of UPJO and concomitantcalculus has evolved significantly from open surgery tominimally invasive treatments. Several reported mini-mally invasive treatment options include percutaneousnephrolithotomy (PNL) with endopyelotomy,4 laparo-scopic pyeloplasty (LP),5-8,18 and robot-assisted

ted equally.rs declare that they have no relevant financial interests.esearch Institute, Southwest Hospital, Third MilitaryChina, M.D., Ph.D., and Weibing Li, M.D., Ph.D.,titute, Southwest Hospital, Third Military Medical, Chongqing 400038, China. E-mail: panjh765@com.cnepted (with revisions): August 1, 2013

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pyeloplasty (RAP)2,9,11 with the use of flexible andrigid scopes to retrieve the stones from the calyces.

RAP is increasingly popular for managing UPJO andscores over pure laparoscopy because the former proce-dure allows the use of a magnified 3 dimensional andstable vision system, precise tremor-free movements, andbetter maneuverability.2,9-11 According to Atug et al9 andNayyar et al,11 concurrent stone extraction and UPJOrepair can be successfully and safely performed with RAPand a concomitant flexible nephroscopy.

In the context of the technical demands and someother limitations of flexible nephroscopy, we present ourexperience with concomitant treatment of UPJO andrenal calculi using robotic LP and rigid nephroscopy.

METHODS

PatientsFrom December 2010 to November 2012, 25 patients withUPJO had RAP at our institution; 9 of those had concurrentrenal calculi, which were simultaneously treated with rigidnephroscopy at RAP. The patients’ medical records werereviewed retrospectively. Our study has been performed in

0090-4295/14/$36.00 237ttp://dx.doi.org/10.1016/j.urology.2013.08.008

Figure 1. Computed tomography urography (CTU) showing ureteropelvic junction obstruction and concurrent renal calculi. (A)Representative ureteropelvic junction obstruction (arrow) and renal calculus (arrowhead) revealed by CTU. (B) CTU showingrenal calculi in renal pelvis and upper calyces.

Figure 2. Schematic diagram of trocar template for left robot-assisted pyeloplasy and nephrolithotomy by rigid nephroscopy.(A) Trocar template for left robot-assisted pyeloplasy; a, robotic camera trocar; b and c, robotic arms trocar; d, assistanttrocar. (B and C), a rigid ureteroscope (black arrows) is introduced into the incised renal pelvis. Renal stones (white arrows) inlower calyces (B) and upper calyces (C) are removed by a rigid grasper (white arrowheads) through the ureteroscope. (Colorversion available online.)

accordance with the ethical standards laid down in the 1964Declaration of Helsinki and its later amendments. We haveobtained an ethics statement from our ethics committeeaccording to the legislation of our ethics committee. For allpatients, intravenous urography (IVU), emission computedtomography, computed tomography urography (Fig. 1), and/ormagnetic resonance urography were completed preoperatively toconfirm the diagnosis of UPJO, the unilateral renal function,and the number, size, and location of the stones.

There were 6 men and 3 women in patients with renalcalculi, with a mean age of 27.7 (13-43) years (Table 1). Stoneswere located on the left side in 7 patients and on the right sidein 2 patients. The stone size ranged from 3 to 21 mm. Therewere 2 patients with bilateral stones and UPJO. After surgery,the patients underwent IVU, diuretic renogram, and/or unen-hanced computed tomography (CT) to evaluate their drainagepattern and to assess any residual stones. All patients receivedIVU and diuretic renogram follow-up at 3, 6, 12 months, andyearly thereafter to confirm the success of the procedure. Successwas defined as an improvement of drainage.

Operative TechniqueAfter the induction of general anesthesia, the patients wereplaced in a 45� lateral decubitus position. Four trocars, including

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1 assistant trocar, were positioned as previously described.1

Briefly, 3 trocars (two 10-mm robotic trocars and one 12-mmtrocar) were placed in a triangulated configuration. A 12-mmassistant port was placed infraumbilically or subxiphoidally toretrieve sutures, aid in retraction, and provide suction (Fig. 2).After pneumoperitoneum was achieved with carbon dioxide

using a Veress needle, a da Vinci (Intuitive Surgical, CA) robotwas then docked. The renal pelvis and ureteropelvic junctionwere exposed using standard robotic laparoscopic techniques.9,12

The renal pelvis was partially incised, thus allowing access forrigid nephroscopy and stone removal. The initial incision wasnot too large to prevent avulsion of the ureteropelvic junctionbut still allowed better nephroscopic vision during neph-rolithotomy. For the treatment of the stones within the renalpelvis and middle calyces (Fig. 1), a 9.8F rigid ureteroscope(Karl Storz Endoscopy-America, Inc., Culver City, CA), witha camera, light source, and continuous irrigation system, waspassed through the assistant trocar under laparoscopic visiondirectly into the previously created pyelotomy (Fig. 3C). Thestones were extracted using a rigid grasper or stone basketthrough a rigid ureteroscope (Fig. 3D-F), and 1 robotic arm wastemporarily undocked to provide suction if necessary. For theremoval of the stones within the upper and lower calyces, therigid ureteroscope was introduced into the incised renal pelvis

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Table 1. Patient demographics and perioperative data

Variables

Values

UPJO þ Renal Stone UPJO P Value

Number of patients 9 16 eMale:female 6:3 11:5 eMean age, y (range) 27.7 (13-43) 25.8 (14-50) eRight:left 7:2 5:11 eMean number of stones (range) 2.8 (2-7) e eMean stone size, mm (range) 9.5 (3-21) e eMean operative time, min (range) 187.1 (105-362) 146.2 (90-380) eMean estimated blood loss, mL (range) 50.4 (20-100) 46.8 (10-120) .752Mean hospital stay, d (range) 6.1 (3-15) 5.8 (3-13) .828Open conversion None None eComplications* 2 3 .835Procedural stone clearance rate 8 (88.9%) e eAncillary procedures 1 e eStone free rate after ancillary procedures 9 (100%) e eMean follow-up, mo (range) 10.2 (2-25) 10.6 (1-30) eSuccess rate (improvement in drainage) 9 (100%) 16 (100%) e

UPJO, ureteropelvic junction obstruction.* Postoperative transient urinary leakage (Clavien Grade IIIa).

through robotic trocars (Fig. 2B, C; Fig. 3A, B) if the “assistanttrocar” route failed. The opened renal pelvis could be partlyclosed by holding the cut ends with the help of robotic arms tokeep the system distended for better visualization.

For larger stones that could not be removed by rigid instru-ments, pneumatic lithotripsy, Electrical Medical System (EMS;Swiss LithoClast Master), or a holmium laser was used to frag-ment the calculi. Smaller stone debris in the calyces was flushedout using the ureteroscope irrigation fluid and removed from therenal pelvis or retroperitoneum using the suction system. Aftera stone was removed from the renal pelvis, it was placed into thecut end of a latex glove finger and then removed through the12-mm assistant port at the end of the procedure. Then, ultra-sound tests were performed to confirm the clearance of thestones.

After the calculi were removed, the operation continued asa standard LP. All patients had dismembered Anderson-Hynespyeloplasty, and the repair was performed using 4-0 Vicrylinterrupted free-hand sutures. A tube drain was placed in allpatients through robotic-port C. The Foley catheter and drainwere typically removed on postoperative day 2-3. The ureteralstent was removed after 8 postoperative weeks.

Statistical AnalysisData analysis was performed with the SPSS (version 13.0)software (SPSS, Inc., Chicago, IL). Numerical variables werecompared using Student t test. To compare categorical variables,the Fisher exact test was used.

RESULTSAs shown in Table 1, the mean (range) age of the9 patients with concomitant stones was 27.7 (13-43)years. The median number of stones removed was 2.8(2-7), and the mean stone size was 9.5 (3-21) mm. Theaverage operative time was 187.1 (105-362) minutes,which was 40.9 minutes longer than the mean operativetime in patients who did not have concomitant stoneremoval. Residual calculi were noted in 1 patient on thepostoperative IVU and unenhanced CT test, resulting in

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a procedural stone-free rate of 88.9% (8 of 9 patients).The patient underwent a single session of extracorporealshock wave lithotripsy. All patients were rendered stonefree, giving a 100% stone-free rate at the mean follow-upof 10.2 (2-25) months after the ancillary procedures.The stent was removed after 8 weeks in all patients. Afollow-up IVU and diuretic renogram confirmed theabsence of obstruction in all patients, which resulted ina success rate, measured as an improvement in drainage,in 9 of 9 (100%).

There was no significant difference in blood loss,hospital stay, open conversion, and success rates betweenpatients with and without renal calculi. Postoperativeretroperitoneal urinary leakage was noted in 2 of 9 (22%)patients with renal calculi and 3 of 16 (19%) patientswithout calculi; no difference in urinary leakage rates wasreported between the 2 groups. Their ureteral stents wereadjusted or replaced through the ureteral orifice by ure-teroscopy, and the urinary leakage disappeared 1 day later.No patients required blood transfusion. There were nointraoperative complications and other postoperativecomplications.

COMMENTThe incidence of renal calculi complicating UPJO isapproximately 20%,3 and this condition presents a treat-ment challenge and controversy for the surgeon. Openpyeloplasty and pyelolithotomy, with a success rate of90%, are traditionally considered the gold standardprocedures for the treatment of UPJO and concomitantcalculi.13 However, the open surgery has several draw-backs, including pain because of a flank incision, pro-longed recovery, and the risk of hernia formation.

To minimize morbidity and the drawbacks of opensurgery, several minimally invasive techniques have beendeveloped as alternatives. Antegrade endopyelotomywith concomitant nephrolithotomy, a minimally invasive

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Figure 3. Nephrolithotomy by rigid nephroscopy through robotic and assistant trocar. (A-C) The incised renal pelvis (arrow-head) was revealed by a robotic arm to facilitate the placement of the rigid ureteroscope (arrow) through a robotic (A and B) orassistant trocar (C). (D) Renal calculus (arrow) extracted by a grasper (arrowhead) through the rigid ureteroscope. (E and F)Ureteroscopic view of renal calculus (E) and calculus clamping (F). (Color version available online.)

technique first established in 1991, avoids the drawbacksassociated with open surgery but demonstrates somewhatlower success rates than open pyeloplasty.14-17 Agarwalet al4 reported that concomitant PNL and LP are feasibleand safe for patients with UPJO complicated by multiplecalculi. However, PNL with endopyelotomy usuallyrequires 2 procedures with a longer operation time and isassociated with a higher incidence of bleeding, urosepsis,and colonic or pleural injury.4,22

Since its introduction in 1993,18 LP has beenincreasingly used in the treatment of UPJO and hassuccess rates of 96%-98% and minimal morbidity.19-21

Subsequently, the performance of LP and concomitantstone removal are reported to be feasible and safe.5-9

Ramakumar et al8 performed LP concomitant with pye-loplasty in 20 patients, their stone-free rate was 80%(16 of 20), and 18 of the 20 patients (90%) presented noevidence of obstruction and/or improved hydronephrosis.After performing LP and pyelolithotomy using a flexible

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endoscope, Ball et al6 reported an 85.7% stone-free rate(6 of 7 patients). According to Inagaki et al,20 21 patients(22 renal units) had simultaneous LP and lithotomy; allpatients were treated successfully and retained an intactureteropelvic junction (UPJ), and 20 renal units (90.9%)were stone free. Srivastava et al5 reported that 20 patients(20 renal units) who underwent transperitoneal LP andconcomitant pyelolithotomy were rendered stone free atthe 6-month follow-up. Diuretic renography at follow-uprevealed improved drainage in 18 of 20 (90%) patients.In a recent report by Stein et al,7 15 (10.6%) patientsunderwent concomitant ipsilateral pyelolithotomy at LP.Laparoscopic graspers alone were used in 11 (73.3%)patients, flexible nephroscopy was used in 2 (13.3%)patients, and laparoscopic irrigation was used in 2(13.3%) patients for renal stone removal; the overallstone-free rate after LP was 80%.

The robotic-assisted laparoscopic technique is now fastgaining popularity and might become the new standard

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of care in the near future for managing UPJO, especiallyin the presence of crossing vessels.23,24 RAP withconcomitant pyelolithotomy was recently reported byAtug et al.9 The researchers used 1 robotic cephaladworking arm to allow the passage of a flexible nephro-scope into the pelvicalyceal system to extract the stones.Their stone-free rate was 100%, but their operative timewas 61 minutes longer for patients undergoing pyeloli-thotomy. Nayyar et al2 reported that stone clearancecould be achieved in 8 of 10 patients with UPJO andconcomitant calyceal stones at robotic pyeloplasty. Inaddition, Nayyar et al11 presented a report on thesuccessful management of ectopic pelvic kidneys withureteropelvic junction obstruction and secondary renalstones using a robotic technique.

To our knowledge, the simultaneous treatment ofUPJO and nephrolithiasis with the da Vinci roboticsystem and rigid nephroscopy has not been previouslyreported. In the context of the technical demands andseveral other limitations of flexible nephroscope, wereport our experience with the use of rigid nephroscopyduring robotic LP for nephrolithiasis removal. In thepresent study, and similar to a previous report,9 our rigidnephrolithotomy did not significantly affect the estimatedblood loss, duration of hospital stay, open conversion,complications, or success rates at RAP. The proceduralstone-free rate was 8 per 9 (88.9%), which is slightlylower than the rate associated with flexible neph-rolithotomy at RAP.9 Residual calculi were noted in1 patient by postoperative IVU and unenhanced CTtests. However, at the mean follow-up of 10.2 months,after the ancillary procedures (extracorporeal shock wavelithotripsy), a 100% stone-free rate was achieved. Themean operative time was 40.9 minutes longer in patientswith renal calculi in our study. Our time for neph-rolithiasis removal by rigid nephroscopy was 20.9minutes, which was slightly shorter than the 40 minutesreported by Atug et al.9 Considering the different stonesizes and stone numbers between our study and that ofAtug et al, it is difficult to conclude that rigid nephro-scopy is superior to flexible nephroscopy for neph-rolithiasis removal at RAP.

Although our experience suggests that RAP withconcomitant pyelolithotomy by rigid nephroscope isfeasible and effective, there are several concerns to beaddressed. First, at the time of RAP, the efficiency andsafety of rigid nephroscopy in the treatment ofcomplicated renal stones require further verification. Asstone size is not a limiting factor for PNL, it has beenreported that calculi >20 mm or branched staghorncalculi are most likely amenable to PNL as a treatmentoption.4,22 Second, additional training for surgeons andthe cost of installation and maintenance of a roboticsystem also remain a concern, especially in developingcountries such as ours. Third, for secondary renal calculithat cannot be reached by rigid ureteroscopy, a combi-nation of rigid and flexible nephroscopy might help toreduce operative time and increase procedure stone-free

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rates. Fourth, secondary UPJO and the associated renalcalculi might also be treated with robotic laparoscopicsurgery and rigid nephroscopy, which requires furtherstudy.

CONCLUSIONOur data suggest that the use of concomitant rigidnephroscopy and RAP is a safe and feasible option for thetreatment of UPJO complicated with renal calculi.However, the efficiency and safety of rigid nephroscopy inthe treatment of complicated renal stones concomitantwith RAP require further verification.

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