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Basic and Translational Science

Coagulum Pyelolithotomy “Revisited”by Laparoscopy: Technique ModificationRicardo Borges, Paulo Azinhais, Edson Retroz, Paulo Temido, Bruno Pereira,Ricardo Leão, Vânia Grenha, Hugo Coelho, Luis Sousa, Álvaro Brandão, Lidio Cristo, andFernando Sobral

OBJECTIVE Laparoscopic ureteropyeloplasty is a widely accepted treatment option for the obstructed uret-eropelvic junction (UPJ). Although it is often a straightforward surgical procedure, there may betechnical difficulties in the case of concomitant stone burden, with multiple calicial, small,mobile stones. The authors describe a modification to the classic coagulum pyelolitothomy, usinga mixture based on commercially available fibrin sealant, first used in the laparoscopic era.

METHODS During a laparoscopic transperitoneal dismembered ureteropyeloplasty complemented with co-agulum pyelolithotomy, the following steps are suggested: (1) Exposure of the UPJ; (2) ureterclamping with a vessel loop 2 cm distal to the UPJ (to allow pelvis filling); (3) transabdominalpuncture of the pelvis with an 18-G, 20-cm needle (under laparoscopic vision) and urineaspiration; (4) recording the volume of urine aspirated; (5) preparing an equal volume of fibrinsealant (to avoid overdistention of the pelvis); (6) injecting the sealer protein solution throughthat needle � 1 mL of methylene blue (color the coagulum and facilitate its identification in theremoval procedure); (7) insertion of another needle to inject the thrombin solution; (8) wait 5minutes to allow coagulum cast formation; (9) circumferential excision of the UPJ; (10)coagulum removal; (11) pelvis plastic reduction (if needed) and ureter spatulation; (12) double-Jstent placement; and (13) tension-free anastomosis completion.

ESULTS The procedure results in the extraction of a tenacious coagulum containing more stones thannormally anticipated from the x-ray studies.

ONCLUSIONS This technique modification reduces the incidence of incomplete stone removal, when there aresmall, free stones lying in a large renal pelvis. UROLOGY 79: 1412.e5–1412.e8, 2012. © 2012 Elsevier

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Laparoscopic ureteropyeloplasty is a widely acceptedtreatment option for the obstructed ureteropelvicjunction (UPJ). Although it is often a straightfor-

ard surgical procedure, there may be technical difficul-ies in the case of concomitant stone burden, with mul-iple calicial, small, mobile stones. A wide range ofupplementary techniques has been developed to assisthe surgeon (ie, irrigation of the renal pelvis, flexiblecopes, contact lithotripsy, stone baskets, ultrasoundrobes). On these occasions, the operation may be time-onsuming and result in much trauma to the kidney.1

Despite these additional techniques, small stones or frag-ments of stones are often left behind and these residual

Financial Disclosure: The authors declare that they have no relevant financialinterests.

From the Urology Department, General Hospital, Centro Hospitalar UniversitárioCoimbra, EPE, Coimbra, Portugal

Reprint requests: Dr. Ricardo Borges, General Hospital, Centro Hospitalar Univer-sitário Coimbra, EPE, Department of Urology, Coimbra, Portugal. E-mail:

rlgborges@gmail.com

Submitted: January 10, 2012, accepted (with revisions): February 28, 2012

© 2012 Elsevier Inc.All Rights Reserved

stone particles may contribute to a non-negligible recur-rence rate of stone burden.

To reduce the incidence of incomplete stone removal,Dees et al2 first described the use of coagulum pyelolitho-omy in 1943, with human fibrinogen and clottinglobulin as the major components of the coagulum.any refinements have been added to the procedure.

ts use was restricted in the middle 1980s with thedvent of percutaneous nephrolithotomy, extracorpo-eal shock wave lithotripsy, and the report of adversevents associated with intrapelvic cryoprecipitate usesystemic absorption via the periforniceal venous sys-em,3 hepatitis transmission4).

The authors first describe the technique of laparo-scopic coagulum pyelolithotomy using a new mixturebased on commercially available fibrin sealant.

TECHNICAL CONSIDERATIONSThe type of stone situation complicating a UPJ obstruc-tion most likely to benefit from coagulum pyelolithotomy

would be when there are multiple small, mobile stones or

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stone fragments lying in �1 calix or in a wide renal pelvis(Fig. 1).

Our proposed technique is based in the classic/roboticlaparoscopic transperitoneal dismembered ureteropyelo-plasty complemented with a coagulum pyelolithotomy,according to the following steps:

1. Exposure of the UPJ.2. Ureter clamping with a vessel loop 2 cm distal to the

UPJ (to allow pelvis filling).3. Transabdominal puncture of the pelvis with an 18G,

20 cm needle (under laparoscopic vision) and urineaspiration.

4. Recording the volume of urine aspirated.5. Preparation of an equal volume of fibrin sealant (to

avoid overdistention of the pelvis).6. Injection of the sealer protein solution through that

needle � 1 mL of methylene blue (color the coagulumand facilitate its identification in the removal proce-

Figure 1. (A) Kidney-ureter-bladder x-ray showing multipintravenous pyelogram film revealing a dilated pelvicaliceal

Figure 2. (A) Pelvis punctured by 2 18-G/20-cm needles floop clamping the ureter to allow pelvis filling. (B) Coagulu

dure).

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7. Insertion of another needle to inject the thrombinsolution (Fig. 2A). This second needle is needed toavoid premature fibrin sealant occlusion of its lumen.

8. Wait 5 minutes to allow coagulum cast formation.

Figure 3. Modified technique for removal of coagulum castin difficult cases.

mall caliceal stones (white arrows). (B) Postmicturitionem with UPJ obstruction.

jection of the coagulum ingredients. Note the white vesselmoval. (C) UPJ reconstruction.

le s

or in

9. Circumferential excision of the UPJ.

UROLOGY 79 (6), 2012

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10. Coagulum removal (Fig. 2B). Its tensile strengthmaintains a one-piece specimen, avoiding spillage ofsmall fragments into the peritoneal cavity.

11. Pelvis plastic reduction and ureter spatulation (ifneeded).

12. Double-J stent placement in antegrade fashionthrough partially completed anastomosis.

13. Tension-free anastomosis completion (Fig. 2C).14. Coagulum retrieval in a bag (eg, endo-bag used for

gallbladder).15. Jackson-Pratt drain placement.

Some modifications to the above-mentioned techniqueare possible:

a. When the coagulum cast delivery is complicated by lowtensile strength/elasticity or when it becomes stuck inthe pelvicaliceal system. To avoid coagulum ruptureleaving fragments in the calices, a simple techniquewas described by Gazizadeh et al in 1984,5 which canbe adapted to laparoscopy. After the coagulum casthas been constructed, a wide pyelotomy is made. A12- to 14-F catheter is passed through a 5-mm portdeep into the renal pelvis and connected to a 50-mLsyringe containing normal saline (Fig. 3). While thecatheter is slowly pulled out of the renal pelvis, thesaline is injected with pressure. The coagulum castentrapping the stones will be delivered in one piece. Ifdoubts remain about the coagulum’s complete removal(eg, caliceal group missing or fewer calculi than pre-viously predicted), a flexible laparoscopic ultrasoundtransducer can be used to confirm the results, withfurther exploration with flexible scope if needed toachieve complete stone and coagulum removal.

. In a very large pelvis, when the volume of aspiratedurine is too high (�30 mL), to avoid using an excessive

Figure 4. (A) Coagulum cast showing the multiple stonestone removal.

number of fibrin sealant kits (�3), we can use fresh i

UROLOGY 79 (6), 2012

frozen plasma to complete the volume difference tothe previously aspirated urine volume added of 10%calcium chloride to increase tensile strength of thenew mixture (ratio of 20 mL plasma:1 mL 10% cal-cium chloride).6 After aspiration of 60 mL of urine, weshould use 3 fibrin sealant kits (�30 mL) � 30 mL ofa 20:1 mixture of plasma and calcium chloride � 1 mLof methylene blue. However, this adds difficulty to themixture preparation/instillation and should be avoided ifyour institution has no economic issues.

c. Use of autologous thrombin can be considered regardingthe remote risk of transmission of infectious diseases.The sealer protein solution and the thrombin solution aremade from human plasma. Despite effective manufac-turing steps for the inactivation/removal of viruses,when medicinal products prepared from human bloodor plasma are administered, the possibility of transmit-ting infective agents cannot be totally excluded. Themeasures taken are considered effective for envelopedviruses, such as HIV, hepatitis B virus, and hepatitis Cvirus, and for the nonenveloped hepatitis A virus.Those measures may be of limited value against smallnonenveloped viruses, such as parvovirus B19, un-known or emerging viruses, or other pathogens. Al-though it is time-consuming, if your institution hasthe equipment to extract autologous thrombin, itshould be mentioned in the informed consent pro-vided to the patient.

CONCLUSIONSIn our experience, surgery was successfully completed with nointraoperative complications and resulted in the extraction of atenacious coagulum containing more stones than had beenanticipated from the x-ray studies (Fig. 4A). The postoperative

tured. (B) Kidney-ureter-bladder x-ray confirming complete

cap

maging showed complete stone removal (Fig. 4B).

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The described technique reduces: (1) The incidence ofincomplete stone removal, when there are small, free stoneslying in a large renal pelvis; (2) the complexity of in-sitepreparations, by the use of a commercially available fibrinsealant mixture; and (3) the risk of thromboembolism, with alow concentration of thrombin used (500 IU/mL) and the careto not overdistend the collecting system.

References1. Smith PJ, Roberts JB, Dunn M. Coagulum pyelolithotomy. Br J Urol.

1978;50(5):298-301.

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2. Dees JE, Fox H. The properties of human fibrinogen coagulum.J Urol. 1943;49:503-511.

3. Sonda LP, Fischer CP, Gross MD, et al. Pyelovenous backflow:implications for coagulum pyelolithotomy and nephroscopy. J Urol.1985;133(5):894-896.

4. McVary KT, O’Conor VJ. Transmission of nonA/nonB hepatitisduring coagulation pyelolithotomy. J Urol. 1989;141(4):923-925.

5. Ghazizadeh M, Kurokawa K. A simple technique for removing thecoagulum cast in coagulum pyelolithotomy. Br J Urol. 1984;56(2):229.

6. Kalash SS, Campbell EW Jr., Young JD Jr. Sources of fibrinogen forcoagulum pyelolithotomy, without thrombin. A comparative study.

Urology. 1983;22(5):486-492.

UROLOGY 79 (6), 2012