Impacted renal pelvic calculi as well as multiple ureteric calculi coursing along the entire length of the ureter in a solitary functioning kidney with acute obstructive uropathy pose unique challenges. Despite advances in endourology, ureteroscopy has reintervention rates of 2–7% for multiple large calculi [7, 8]. This case could have been managed with staged endourologic procedures—ureteroscopy and laser fragmentation of lower and mid-ureteric calculi followed by push back percutaneous nephrolithotomy. However, every additional procedure would have meant subjecting the patient to the risk of urosepsis and acute kidney injury . Open ureterolithotomy in this case would have resulted in a long muscle cutting incision, and the stones were present along the entire length of the ureter. Previous literature has reported prolonged hospital stay and increased post-operative pain with open ureterolithotomy .
In tertiary care centre with expertise of laparoscopy, both European and American urology association recommends the use of laparoscopic ureterolithotomy in large ureteric calculi. Therefore, a laparoscopic approach was planned for this patient.
Port insertion is the one of the most important steps in performing laparoscopic procedures successfully. In this case as well, port placement was planned as described to gain access to the entire length of ureter and the renal pelvis. Localization of the ureter and its dissection were easy as the ureter was dilated. On having palpated the lower ureteric calculi and hooking below the lowermost calculi, a clean incision was taken with a knife. Diathermy was avoided as it decreases the vascularity and may result in injury by lateral currents . Mid-ureteric calculi were removed from the same lower ureteric incision. Each stone was carefully retrieved and bagged, thereby avoiding losing any stone in the peritoneal cavity which is a major disadvantage of transperitoneal over retroperitoneal laparoscopic ureterolithotomy. Upper ureteric incision was used to retrieve the upper ureteric and renal pelvis calculi, and double J stent was placed laparoscopically which saved operative time. The incisions were meticulously sutured. Double J stent was used as mentioned in the previous literature to prevent complications like urinoma post-operatively in multiple large impacted calculi . All the bagged stones were retrieved through an incision over the 12-mm port site to avoid slippage of any stone.
Laparoscopic procedures have their own set of disadvantages of injury to the viscera and loss of stone in peritoneal cavity as compared to endourologic procedures . However, following principles of laparoscopy meticulously as mentioned above, the advantages outweigh these disadvantages in patients with such a large burden of stones and history of acute kidney injury. Also, perioperative antibiotics and urinary diversion helped prevent post-operative complications.