laparoscopic pyelolithotomy was successfully performed in a pelvic kidney with an operative time of 310 minutes .
the use of intraoperative fluoroscopy and a semi - automatic suturing device greatly facilitated the procedure .
the patient 's operative pain was managed with 3 doses of ketorolac ; she resumed a regular diet the day after surgery , and was discharged on the first postoperative day .
for patients with a large stone in the renal pelvis of an ectopic kidney , laparoscopic pyelolithotomy provides an effective approach .
pelvic kidneys are typically incidental findings , but may pre - sent due to underlying obstructive or calculous disease
. the anatomical characteristics of the ectopic kidney can pose a significant challenge to the treatment of calculous disease .
treatment of larger renal calculi in these kidneys had been uniformly by open surgery until laparoscopically guided percutaneous nephrostolithotomy ( pcnl ) was described , initially , by esghi , et al . , and later by toth , et al . recently ,
2 cases of laparoscopic pyelolithotomy have been reported in a pelvic kidney . in one ,
due to urine leakage , an indwelling stent and urethral catheter were maintained for 8 days .
hospitalization lasted 6 days . in the second case report , intraoperative fluoroscopy and laparoscopic suturing
were used to perform the procedure , but the pyelotomy closure was not tested for watertightness and the patient experienced peritoneal leakage of urine after the foley catheter was removed .
this necessitated replacement of the foley catheter for an unspecified length of time and the length of hospitalization was not reported .
herein we report the third case of a laparoscopic pyelolithotomy in a pelvic kidney ; in this case , use of the carterthomason needle - point suture passer ( inlet medical inc . , eden prairie , mn ) and laparoscopic suturing of the pyelotomy with an endostitch device ( auto suture , norwalk , ct ) resulted in a waterproof closure .
a 63-year old woman was referred for endourological treatment of a symptomatic 2.5-cm - x-1.5 cm renal pelvis stone in her left pelvic kidney .
intravenous urography ( ivu ) and abdominal / pelvic computed tomography defined the pelvic kidney 's location relative to other structures ; there was mild pyelocaliectasis noted ( figures 1 & 2 ) .
ivu demonstrating ectopic right kidney and left pelvic kidney with laminated 2.5 cm stone at the ureteropelvic junction .
the patient was turned to a 30-degree lateral , left side up position and a 15 mm hg co2 pneumoperitoneum was initiated with the veress needle using a lateral inflation technique .
three 12 mm laparoscopic ports were placed : left lower quadrant in the midclavicular line , umbilicus , and right lower quadrant in the pararectus area .
holding sutures were placed inferiorly and superiorly on the anterior surface of the renal pelvis using intracorporeal suturing ; suture delivery through the skin was accomplished via a carter - thomason needle - point suture passer ( inlet medical inc . ,
eden prairie , mn ) . a 3 cm long pyelotomy was made and a 10 mm biopsy forceps was used to grasp the stone , which was removed intact after the 12 mm cannula was withdrawn from the port site .
a running closure of the renal pelvis was accomplished using the endostitch device with a 2 - 0 polysorb suture ( auto suture , norwalk , ct ) .
the occlusion balloon catheter was changed to an indwelling 7 f double pigtail stent and a bladder catheter was left in place overnight .
the total operative time was 310 minutes ( including pre- and postoperative stent placement ) .
abdominal/ pelvic ct scan demonstrating left pelvic kidney with mild pyelocaliectasis and the stone at the ureteropelvic junction ( arrow at stone ) . after initiating general anesthesia ,
a 7 f/ 11.5 mm balloon occlusion catheter was then passed over the guidewire into the renal pelvis of the left pelvic kidney .
the balloon was inflated with 1 cc of contrast material and was then snugged down at the ureteropelvic junction .
postoperatively , the patient 's discomfort was managed by a total of 45 mg of intravenous ketorolac ( 3 doses ) followed by 2 doses of an oral narcotic .
a follow - up ivu , one week later , revealed the left pelvic kidney to be functional , stone - free , and without extravasation .
our experience ( table 1 ) is similar to the prior reports of successful laparoscopic pyelolithotomy for a large renal calculus in a pelvic kidney .
placement of a retrograde ureteral catheter was instrumental in allowing expeditious localization of the renal pelvis at laparoscopy and for testing the closure of the pyelotomy .
closure of the renal pelvis was facilitated by the use of holding sutures and the endostitch device .
comparison of laparoscopic pyelolithotomy and pcnl for renal pelvis stones > 1.5 - 2 cm .
mac= monitored anesthesia care , pcnu= percutaneous nephroureteral stent the patient experienced minimal pain and a brief hospitalization , findings consistent with previous reports of laparoscopic pyelolithotomy for a normally positioned kidney . in these reports
, the operative time has averaged 2 - 5 hours using a 3- or 4-port approach .
the renal pelvis was sutured closed in only one case and all patients had a surgical drain placed prior to fascial closure . while a stone - free rate of 100% was recorded among 9 patients , it is of note that 3 of those 9 patients required conversion to an open procedure . while these reports concluded that laparoscopic pyelolithotomy in a eutopic kidney was of value in a situation where shock wave lithotripsy ( swl ) or pcnl had failed or could not be done , we believe this represents a rare situation . indeed , despite a vast experience at washington university with laparoscopic renal surgery and a large surgical stone population ( e.g. an approximate annual urolithiasis case load of 500 to 600 swl , 100 to 150 ureteroscopies , and 50 to 100 pcnl ) this is the singular case of a laparoscopic pyelolithotomy at our institution .
with regard to stone treatment in an ectopic or pelvic kidney , we believe the treatment strategy should be similar to that used for stones in a eutopic kidney .
hence , swl or ureteroscopy remain first line therapy for smaller calculi ( less than 2 cm ) , while laparoscopic - assisted percutaneous , pure laparoscopic , or open procedures are reserved for larger calculi . from this standpoint , it is of note that 2 cases of laparoscopically guided pcnl have been reported in pelvic kidneys . the operative time was not reported for these cases and the length of hospital stay was 6 days in one report .
we believe that given advances in laparoscopic equipment it may be just as simple to handle the stone removal entirely laparoscopically .
the benefits of this approach would potentially include a shorter hospital stay and less postoperative morbidity as occurred in the present case . for urologists interested in laparoscopic pyelolithotomy in this situation , the use of intraoperative fluoroscopy to identify the renal pelvis , the placement of holding sutures , the use of the carter - thomason needle - point suture passer , and intracorporeal suturing with the endostitch device are recommended .
 the anatomical characteristics of an ectopic kidney can pose significant challenges to the treatment of calculous disease . 
 this report examines the feasibility of a laparoscopic approach for management of a large renal calculous in a pelvic kidney and reviews current literature regarding this subject . 
Background and Objectives:
Methods and Results:
Conclusions:
INTRODUCTION
CASE REPORT
DISCUSSION