Transperitoneal laparoscopic pyelolithotomy after failed percutaneous access in the pediatric patient

We present our experience with transperitoneal laparoscopic pyelolithotomy in pediatric patients in whom percutaneous renal access failed and the stone burden warranted open intervention.

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.

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%.

Transperitoneal laparoscopic pyelolithotomy is feasible when percutaneous access fails and open pyelolithotomy is considered due to a large stone burden.