title: Transperitoneal laparoscopic pyelolithotomy after failed percutaneous access in the pediatric patient.
abstract: OBJECTIVE
  We present our experience with transperitoneal laparoscopic pyelolithotomy in pediatric patients in whom percutaneous renal access failed and the stone burden warranted open intervention.
  
  
  METHODS
  A transperitoneal laparoscopic approach was used for pyelolithotomy in 8 patients 3 months to 10 years old (mean age 4 years). Percutaneous access failed secondary to a nondilated system and/or an occluding lower pole calculus. Inclusion criteria were failed percutaneous access secondary to a nondilated system and/or stone occlusion of the lower pole system and failed shock wave lithotripsy or a stone burden of greater than 2.5 cm2. A posterior pelviotomy was made. Stones in the renal pelvis were removed with rigid graspers under direct laparoscopic vision. A flexible cystoscope was introduced through a port if caliceal stones were present. The renal pelvis was reconstructed. A watertight anastomosis was verified.
  
  
  RESULTS
  Average operative time was 1.6 hours (range 0.8 to 2.3). Mean hospital stay was 2.15 days (range 2 to 3). A range of 1 to 3 stones (median of 1) were removed and the mean stone burden was 2.9 cm2. No intraoperative complications were noted. Stone analysis revealed 3 patients with calcium oxalate stones, 1 with a calcium phosphate stone and 4 with cysteine stones. There was 1 patient with stone recurrence at a mean followup of 12 months (range 3 to 20). Thus, the overall long-term stone-free rate was 87.5%.
  
  
  CONCLUSIONS
  Transperitoneal laparoscopic pyelolithotomy is feasible when percutaneous access fails and open pyelolithotomy is considered due to a large stone burden.
authors.affiliation: Seattle Children's Hospital, University of Washington, 98105-0371, USA. patcasale@seattlechildrens.org
authors.forename: Pasquale
authors.initials: P
authors.lastname: Casale
authors.forename: Richard W
authors.initials: RW
authors.lastname: Grady
authors.forename: Byron D
authors.initials: BD
authors.lastname: Joyner
authors.forename: Ilia S
authors.initials: IS
authors.lastname: Zeltser
authors.forename: Ramsay L
authors.initials: RL
authors.lastname: Kuo
authors.forename: Michael E
authors.initials: ME
authors.lastname: Mitchell
mesh_terms: D002648:Child; D002675:Child, Preschool; D006801:Humans; D007223:Infant; D007669:Kidney Calculi / Q000601:surgery*; D010535:Laparoscopy; D019233:Retreatment; D017211:Treatment Failure