Laparoscopic Pyelolithotomy बैंगलोर में

Laparoscopic Pyelolitotomy is a minimally invasive surgical procedure to remove stones from the renal pelvis (the funnel-shaped, dilated area in each kidney) or the ureter (the tubes in each kidney that connect the kidney to the urinary bladder). “Pyelo” means renal pelvis, and “lithotomy” means stone removal. Pyelolithotomy is a surgical intervention used to remove stones from the ureter and pelvis when performing a laser or an ultrasound method for breaking down the stones is not feasible. Pyelolithotomy is recommended when a large kidney stone obstructing the renal pelvis is present. Pyelolithotomy can be performed by open, laparoscopic, or retroperitoneal approaches.

Stones in the kidney are hard masses of different compositions that are formed from crystals in the urine. Calcium stones are the most common type of kidney stones. Other types include uric acid stones, struvite, and cystine stones. The size of the stone varies from being small gravel-like to larger stones like staghorn (like the antlers of the deer, filling the renal pelvis and calyces) calculi. These stones can cause symptoms like pain in the flanks, abdomen, lower groin, or back, blood in urine, nausea, vomiting, etc. When these stones become big and block the passage of urine or cause infection, they can damage the kidneys. 

If the stones are small, they can be passed automatically through the kidney and excreted through the urine. Larger stones can cause continuous and recurrent symptoms; hence, they must be broken into smaller bits and removed. The surgeon can remove kidney stones by different techniques, like Extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureteroscopy, laparoscopy, and open surgery बैंगलोर में .

Recent studies have proved the safety and efficacy of Laparoscopic Pyelolithotomy in treating large and complex stone diseases. LP as a treatment modality is increasingly used for renal stones and is recommended in patients:

• In whom endoscopic procedures like SWL, retrograde intra-renal surgery बैंगलोर में , or PCNL have failed to remove the calculi (stones).
• With renal anomalies like ureteropelvic junction abnormalities and ectopic kidney.
• With large stones filling the renal pelvis and the ureter.
• With obesity
• Poorly complaint to open surgery बैंगलोर में .
• With coral stones/ staghorn stones.

Laparoscopic Pyelolithotomy is a safe and effective procedure for most patients, but it is contraindicated in some.

• If you have a clotting disorder-- In some patients, the blood may take time to form a clot- this can be genetic or when you are on some medications that prevent clotting of the blood. LP is contraindicated in these subsets of people as there may be a high risk of bleeding during and post the surgery.
• If you are pregnant- Laparoscopic Pyelolithotomy is not performed during pregnancy.
• If you have an infectious disease- Your surgeon will first treat your infectious disease and then only will operate on you.
• If you have severe kyphoscoliosis (abnormal curvature of the spine).
• If there is severe inflammation - The surgery will not be performed as the inflammation may spread into the abdominal cavity during the laparoscopic procedure.

Before undergoing the surgery, it is important to prepare for it. Your urologist will take a detailed history of your symptoms and discuss further action.

• The following tests will be recommended to confirm the diagnosis:
  • RFT (Renal Function Test)- This type of blood test evaluates your blood urea nitrogen (BUN) and creatinine levels.
  • Routine urine analysis- To check for any bacterial urinary tract infections.
  • Urine cytology- This test will examine your urine microscopically to check for abnormal cells since the cancer cells related to kidney tumors are most often shed in the urine.
  • Intravenous pyelogram (IVP)- A special dye will be injected into your veins. The flow will be checked through X-ray images to check for the stones causing a blockage (where the stone burden is present) and also about the collecting system anatomy).
  • Ureteroscopy- This test uses a special scope that is a thin tube with a light source and camera to view the interior of the ureter and renal pelvis and takes tissue samples.
  • Other imaging tests like CT (Computed Tomography) and MRI (Magnetic Resonance Imaging) scans.
• You will be advised to:
  • Avoid the medications like blood thinners for at least 2 weeks before the procedure to minimize the risk of bleeding.
  • Avoid smoking and alcohol for 2 weeks pre-procedure to prevent delayed wound healing.
  • Be on a liquid diet 24 hours before the procedure and fast after midnight.

Laparoscopic pyelolithotomy is a minimally invasive surgical procedure performed under general anesthesia.

• On the day of the surgery, your nurse will check your vitals (blood pressure, heart rate, pulse, blood sugar levels, urine output) and insert a urinary catheter (a tube to drain urine).
• An Intravenous (IV) line will be placed for antibiotics, painkillers, and fluid replacement, during and after the surgery. 
• You will be taken to the operating theatre at your scheduled time of surgery.
• You will be made to lie towards the side (depending on which kidney is being operated on). The surgical area will be prepped by disinfecting it using antiseptic solutions to remove surface contaminants.
• Your anesthesiologist will administer general anesthesia through IV infusions to completely sedate you. 
• Your surgeon can use two approaches to make 3 to 4 small keyhole-sized incisions:
  • The transperitoneal approach- The Incision is made through the peritoneum (a tissue that lines the abdominal cavity)
  • Retroperitoneal approach- The incision is made through the back of the abdomen (flank region)
• The surgical site is inflated using gas (carbon dioxide) to improve the visibility for the surgeon to perform the procedure. A special scope known as a laparoscope is inserted through one of the incisions. It is a flexible tube with a light source and lens (camera) at the tip to view the surgical site through the images captured by the camera. 
• Your surgeon will insert the other surgical instruments through the remaining r incisions. 
• The renal capsule and parenchyma are cut and carefully separated to reach the renal pelvis ( a procedure known as pyelotomy) to locate the renal calculi (kidney stones). 
• The calculi will be carefully grasped using forceps (a surgical instrument that consists of tongs to hold tissue), and carefully removed.
• The incision is closed with sutures, with or without a J-stent (a special, thin, flexible tube inserted through the kidney into the bladder for draining the urine.
• A surgical drain will be placed to facilitate the drainage of fluids and blood near the surgical site. The drain is held in place with the help of sutures. It will be removed 2 to 3 days after all the fluid has been drained off.
• The procedure takes around 2 to 3 hours.

You are expected to stay in the hospital for 2 to 3 days following a laparoscopic pyelolithotomy.

• You will be kept in a PACU (Post-anesthesia care unit) for an hour or two to monitor your vitals (especially the urine output).
• Once the effect of anesthesia wears off, you are shifted to your room for further recovery.
• Post-op pain and discomfort are normal and should resolve gradually. Painkillers and antibiotics will help manage the pain and infection.
• You will be given sips of water 4 to 6 hours post-op and gradually progress to a liquid diet the same evening. 
• Your surgeon will evaluate your wound and other vitals to check your healing progress the next day.
• You will be encouraged to walk to prevent blood clots and regulate proper blood flow.
• Refrain from lifting heavy objects and strenuous exercises for the initial days post-surgery.
• Proper rest, a healthy diet, and hydration will accelerate healing.
• You can resume work within 2 weeks of the procedure.
• However, complete recovery usually takes 3 to 4 weeks, depending on your condition.
• However, stent removal will be performed 6 weeks after the surgery through a procedure called cystoscopy (a procedure that uses a cystoscopy similar to a laparoscope to look inside the bladder and can also help extract the stent out).

Laparoscopic pyelolithotomy is a safe and effective procedure that helps remove the renal calculi within the renal pelvis. It is gaining momentum over other procedures like PCNL due to its benefits:

Benefits: 

• Small incisions with minimal scarring.
• Involves less bleeding during the procedure.
• Shorter hospital stay
• Quick recovery
• Minimal postoperative complications.

Risks: 

Like any surgical procedure, laparoscopic pyelolithotomy involves the following risks:

• Injury to surrounding tissues due to compromised visibility.
• Allergic reactions to anesthesia cause hives, rash, confusion, rapid heart rate, and shortness of breath.
• Post-op infection that may lead to pus discharge.
• Damage to the nearby nerves (causing numbness and tingling sensation).
• Swelling beneath the tissue due to inflammation (hematoma)
• Blood clots in the legs may lead to deep vein thrombosis. If the clot dislodges, it may travel to the lungs and heart, causing fatal complications.

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