Laparoscopic Anatrophic Nephrolithotomy: Developments of the Technique in the Era of Minimally Invasive Surgery Camilo Giedelman, 1 Juan Arriaga, 1 Odwaldo Carmona, 1 Robert de Andrade, 1 Eduardo Banda, 2 Roy Lopez, 3 Glenn Preminger, M.D., 4 and Rene J. Sotelo, M.D. 1 AU1 c Abstract Background and Purpose: The complete removal of the stone is the ultimate goal in management, a result that might not be attained even after several sessions of percutaneus 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. Patients and 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. Introduction T he complex staghorn calculus is a difficult manage- ment entity, especially when the goal is to achieve complete removal of the stone with minimal renal damage and with the least number of procedures. Traditionally, the standard of care was open surgery, which evolved into percutaneous nephrolithotomy (PCNL) with or without shockwave lithotripsy (SWL). This combination approach of PCNL followed by SWL has the disadvantage of necessi- tating multiple treatment sessions and not always achieving effectiveness. 1 The pioneers in the technique of open anatrophic ne- phrolitotomy were Boyce and Elkins, 2 who used anatomic and physiologic principles mixed with reconstructive tech- niques to performed this operation. With the development of laparoscopic and robot-assisted surgery in urology, there is the possibility to duplicate complex open surgical techniques, even complex procedures, such as extended pyelolithotomy and anatrophic nephrolithotomy. In fact, there have been a number of reports comparing laparoscopic nephrolithotomy with standard open techniques. 3,4 The goal of the laparoscopic approach is to ultimately im- prove the outcomes of open nephrolithotomy by eliminating 1 Department of Urology, Instituo Medico La Floresta, Caracas, Venezuela. 2 Department of Urology, Hospital Carlos Andrade Marin, Quito, Ecuador. 3 Department of Urology, Hospital Clı ´nica Cato ´ lica, San Jose, Costa Rica. 4 Department of Urology, Duke University, Durham, North Carolina. JOURNAL OF ENDOUROLOGY Volume 26, Number X, XXXX 2012 ª Mary Ann Liebert, Inc. Pp. ---–--- DOI: 10.1089/end.2011.0193 1 END-2011-0193-ver9-Giedelman_1P.3d 01/24/12 2:44pm Page 1 END-2011-0193-ver9-Giedelman_1P Type: research-article