N. Simforoosh, MD Professor of Urology Shahid Labbafinejad Hospital, Urology Nephrolology Research Center, Shahid Beheshti University (M.C.)

Introduction: Laparoscopy has been used for removing

urinary stones from kidney and ureter in certain circumestances

A: Kidney Stones: Laparoscopic anatrophic

nephrolithotomy for staghorn is performed successfully (Simforoosh et al, 2008)

Laparoscopic pyelolithotomy is performed in normal (Kramer 2007) and congenitally abnormal kidneys (horseshoe, Mousavibahar 2008 cross ectopic kidney, Kamat 2004)

Lap. Nephrolitholotmy is used to remove stones from calcyeal diverticulum (Gress 2007)

The staghorn stone extracted by laparoscopy. (A). Abdominal view one month after surgery (B) Simforoosh et al.

Introduction: (continued)

B: ureteral stones Laparoscopy is being used recently more frequently for

special indications, to manage ureteral stones in lower, (10.5%) middle (16.3%) and specially upper ureter. (73%-simforoosh et al)

When inducated and done by experts, results are satisfactory.

Laparoscopic ureterolithotomy for Proximal ureteral stones:

Indications: - Large stones: larger than 1.5cm - Failure of ESWL or TUL - Impacted stone: (DJ nonnegotiable) - Dense stones: cystine and calcium phosphate stones

(hard to break) - Can be done both transperitoneal (Keeley) and

retroperitoneally (Gaur) - Available laparoscopic expertise is mandatory.

Technique: Position: Flank Access: modified open Trocars: 3 or rarely 4 Colon & deudenum in right and colon in left medialized. Stone in ureter located (rarely intra-op. ultrasound can be used)

Ureterotomy is done by cutting current or laser. Stone delivered and placed in bag & removed from trocar site. Experience will decrease operation time significantly (30-60min.)

Is it safe to do ureterotomy using cutting current? * In 40 patients during laparoscopic ureterolithotomy

ureterotomy was done using cutting current (coagulation current not used) and IVU was done post operatively in all of them. In all cases hydronephrosis was impoved and there was no stricture in any of them post opperatively during follow up period (average follow up: 10.5 months).

* Simforoosh N. et al. WCE 20th, 2002, Italy

Our experience*: I- Demographic & clinical parameters in 123 patients with laparoscopic

calculus removal

* Simforoosh N, et al. Laparoscopic Management of Ureteral Calculi: A Report of 123 Cases. Urol J. 2007 summer, 4(3): 138-41

UPPER URETER 90 (73.2)

Continued II- Results: Mean OR time (minutes) 143 ± 60.5 Oral intake (day) 22.39 ± 13.6 Mean hospital stay (day) 5.86 ± 3.51 Conversion (migration) 1 (0.8%) Reoperation (hematoma) 1 (0.8%) Urinoma 2 (DJ-conservative Tx) Stricture 4 (one repaired, 3 cured by DJ) Hydrocele 1 (0.8) Stone free (1st post op. day) 96.7%

A: Urography before laparoscopy: Upper ureteral stone causing

severe hydronephrosis

B: Urography after laparoscopy stone removal: hydronephrosis

was completely cured

ADVANTAGE OF USING LAPAROSCOPY IN MANAGEMENT OF PROXIMAL URETERAL STONES:

Intact stone removal Can be choice for large stones (> 2.5cm) Can be used successfully in impacted stones Successful in removing dense stones (cystine & cal.

Phost.) Can be used for failure of ESWL and TUL One shot removal No residual Effective in removing multiple and or large stones Appropriate alternative for stones candidate for open

surgery

THANK YOU