Difficulties in laparoscopic surgery for urinary stones

For centuries, stone disease has been a common health problem-in fact, one of the first surgeries performed on humans was for stones-and traditional open surgery was utilized to manage the problems it caused.¹ Stone disease is still common today, but the pattern of practice in stone management has undergone a revolution in the last few decades. Nowadays, open surgery for stone disease is considered obsolete and has been almost totally abandoned. ² The biggest blow to open stone surgery (OSS) occurred when extracorporeal shock wave lithotripsy (SWL) was applied successfully by Chaussy in Berlin.³ Percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (URL) were also great steps forward, and these procedures have major roles in managing large renal and ureteral stone disease in most parts of the world today. Pneumolithotripsy and laser lithotripsy technologies were another important achievement in dealing with stone disease during PCNL and URL. It is used commonly in many countries due to its efficacy, and especially because of its cost effectiveness. The introduction of flexible instruments also has facilitated navigation through the collecting system. Disposable flexible endoscopes seem to be promising alternative to the costly fiberoptic ones, and solve problems related to their cost and maintenance. All of the above measures, which are today referred to as endourology, have resulted in putting the knife aside in almost all cases of stone disease. In the era of minimally invasive endoscopic procedures and SWL, laparoscopy has a limited role in the urologist's armamentarium for surgical stone management.4 However, in cases of large stones, single or combined endourologic procedures may not be more cost effective than a single, one-session approach for complete stone removal.5 Therefore, OSS, including open ureterolithotomy, pyelolithotomy, and nephrolithotomy, still has a role in many centers. Laparoscopic stone removal is a valuable option in these situations, and offers a less morbid modality for removing large stones in the urinary tract. This chapter focuses on the potential difficulties and complications that may occur during laparoscopic stone surgery. Various approaches to deal with these difficulties will be discussed.