title: Coagulum pyelolithotomy "revisited" by laparoscopy: technique modification.
abstract: OBJECTIVE
  Laparoscopic ureteropyeloplasty is a widely accepted treatment option for the obstructed ureteropelvic junction (UPJ). Although it is often a straightforward surgical procedure, there may be technical difficulties in the case of concomitant stone burden, with multiple calicial, small, mobile stones. The authors describe a modification to the classic coagulum pyelolitothomy, using a mixture based on commercially available fibrin sealant, first used in the laparoscopic era.
  
  
  METHODS
  During a laparoscopic transperitoneal dismembered ureteropyeloplasty complemented with coagulum pyelolithotomy, the following steps are suggested: (1) Exposure of the UPJ; (2) ureter clamping with a vessel loop 2 cm distal to the UPJ (to allow pelvis filling); (3) transabdominal puncture of the pelvis with an 18-G, 20-cm needle (under laparoscopic vision) and urine aspiration; (4) recording the volume of urine aspirated; (5) preparing an equal volume of fibrin sealant (to avoid overdistention of the pelvis); (6) injecting the sealer protein solution through that needle + 1 mL of methylene blue (color the coagulum and facilitate its identification in the removal procedure); (7) insertion of another needle to inject the thrombin solution; (8) wait 5 minutes to allow coagulum cast formation; (9) circumferential excision of the UPJ; (10) coagulum removal; (11) pelvis plastic reduction (if needed) and ureter spatulation; (12) double-J stent placement; and (13) tension-free anastomosis completion.
  
  
  RESULTS
  The procedure results in the extraction of a tenacious coagulum containing more stones than normally anticipated from the x-ray studies.
  
  
  CONCLUSIONS
  This technique modification reduces the incidence of incomplete stone removal, when there are small, free stones lying in a large renal pelvis.
authors.affiliation: Urology Department, General Hospital, Centro Hospitalar Universitário Coimbra, EPE, Coimbra, Portugal. rlgborges@gmail.com
authors.forename: Ricardo
authors.initials: R
authors.lastname: Borges
authors.forename: Paulo
authors.initials: P
authors.lastname: Azinhais
authors.forename: Edson
authors.initials: E
authors.lastname: Retroz
authors.forename: Paulo
authors.initials: P
authors.lastname: Temido
authors.forename: Bruno
authors.initials: B
authors.lastname: Pereira
authors.forename: Ricardo
authors.initials: R
authors.lastname: Leão
authors.forename: Vânia
authors.initials: V
authors.lastname: Grenha
authors.forename: Hugo
authors.initials: H
authors.lastname: Coelho
authors.forename: Luis
authors.initials: L
authors.lastname: Sousa
authors.forename: Alvaro
authors.initials: A
authors.lastname: Brandão
authors.forename: Lidio
authors.initials: L
authors.lastname: Cristo
authors.forename: Fernando
authors.initials: F
authors.lastname: Sobral
mesh_terms: D015718:Fibrin Tissue Adhesive / Q000627:therapeutic use*; D006801:Humans; D007669:Kidney Calculi / Q000000981:diagnostic imaging / Q000601:surgery*; D007682:Kidney Pelvis / Q000601:surgery; D010535:Laparoscopy / Q000379:methods*; D011859:Radiography; D013520:Urologic Surgical Procedures / Q000379:methods*
chemical_list: D015718:Fibrin Tissue Adhesive