title: Laparoscopic anatrophic nephrolithotomy: developments of the technique in the era of minimally invasive surgery.
abstract: OBJECTIVE
  The complete removal of the stone is the ultimate goal in management, a result that might not be attained even after several sessions of percutaneous nephrolithotomy (PCNL) and/or extracorporeal shockwave lithotripsy (SWL) and/or retrograde intrarenal surgery (ureteroscopy). The objective of this study is to assess our technique of anatrophic nephrolithotomy, with decreased renal ischemia and reduced patient morbidity.
  
  
  METHODS
  From 2007 to 2010, we performed eight anatrophic laparoscopic nephrolithotomies in adult patients with staghorn renal calculus. The mean patient age was 49 years (range 35-62 y). The mean stone size was 53 mm (range 35-70 mm). All patients had complex renal calculi, with stones occupying more than 80% of the caliceal system. In all cases, a Double-J stent was placed before surgery. After clamping the hilum, the incision was made laterally and longitudinally through full thickness of cortex using a laparoscopic scalpel. A running cortical suture was performed with Hem-o-lok reinforcement. Renal function was assessed in three patients, using renography with technetium-99m-diethylenetriaminepentacetic acid (99mTc-DTPA), before and 3 months after the surgery.
  
  
  RESULTS
  Procedures for all patients were completed laparoscopically. The mean operative time was 142.5 minutes, and the mean warm ischemia time was 20.8 minutes. The estimated blood loss was 315 mL. The hospital stay average was 3.5 days. Only one patient had a complication--a vascular fistula with permanent postoperative hematuria. This patient subsequently underwent successful endovascular embolization. Residual stones were identified in 37% of cases (three patients) during follow-up imaging at 15 days. There were minimal changes on serum creatinine values.
  
  
  CONCLUSIONS
  Laparoscopic surgery is feasible when anatrophic nephrolithotomy is indicated. This technique minimizes the barriers of an open flank incision, while achieving excellent stone-free rates. This minimally invasive technique should be considered for complex stones that would necessitate multiple renal access tracks and secondary procedures.
authors.affiliation: Department of Urology, Instituo Medico La Floresta, Caracas, Venezuela. Camgiedel@gmail.com
authors.forename: Camilo
authors.initials: C
authors.lastname: Giedelman
authors.forename: Juan
authors.initials: J
authors.lastname: Arriaga
authors.forename: Odwaldo
authors.initials: O
authors.lastname: Carmona
authors.forename: Robert
authors.initials: R
authors.lastname: de Andrade
authors.forename: Eduardo
authors.initials: E
authors.lastname: Banda
authors.forename: Roy
authors.initials: R
authors.lastname: Lopez
authors.forename: Glenn
authors.initials: G
authors.lastname: Preminger
authors.forename: Rene J
authors.initials: RJ
authors.lastname: Sotelo
mesh_terms: D000328:Adult; D000368:Aged; D003404:Creatinine / Q000378:metabolism; D003710:Demography; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007669:Kidney Calculi / Q000601:surgery; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D009403:Nephrostomy, Percutaneous / Q000379:methods*; D011182:Postoperative Care; D011300:Preoperative Care; D013525:Surgical Instruments
chemical_list: D003404:Creatinine