Laparoendoscopic pyelolithotomy and pyeloplasty in a pediatric patient

Abstract

Objective: To demonstrate a laparoendoscopic approach for the management of kidney stones in children. Our patient was an otherwise healthy 5 year-old boy who presented with left flank pain and gross hematuria for several months. His physical exam was benign. Renal function was within normal limits, whereas urinalysis revealed cystine crystals. Imaging showed 3 large radio-opaque calculi in the left kidney, each larger than 1 cm. On DMSA scan, the left kidney demonstrated globally decreased cortical activity. Methods: Once in the operating room, a left retrograde pyelogram was performed and a 5Fr × 18 cm ureteral stent placed. The patient was positioned into a semi flank position and three laparoscopic ports were inserted. The left renal pelvis and ureter were identified and a percutaneous 4.0 prolene hitch stitch was placed to suspend the renal pelvis. A pyelotomy was done and the ureteral stent was found to be dislodged into the proximal ureter, so the pelvis was dismembered. The ureter was spatulated for later reanastomosis. Through the open pelvis, one large renal pelvic stone was removed. A 15Fr rigid nephroscope was placed through the laparoscopic port to remove the remaining stones with a 2.2Fr Nitinol basket. The stones were bagged and removed though the 10 mm port site. The stent was advanced and the pelvis reapproximated with a double-armed 5.0 vicryl running simple stitch. Results: The total operative time was 4 h, with the laparoscopic component comprising approximately 3 h. The patient was discharged the next day. On follow-up, his symptoms had resolved. Conclusion: Our video demonstrates that laparoendoscopic surgery is a safe, efficient alternative and should be a management option offered to pediatric patients with large stone burdens. As it is associated with minimal post-operative morbidity, its utility may gain more widespread application with advances in laparoscopic equipment.