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Retroperitoneoscopic management of caliceal diverticular calculi
SURGICAL TECHNIQUES IN UROLOGY
RETROPERITONEOSCOPIC MANAGEMENT OF CALICEAL DIVERTICULAR CALCULI STEPHEN FREDERIC WYLER, ALEXANDER BACHMANN, CHRISTIAN JAYET, ROBERTO CASELLA, THOMAS C. GASSER, AND TULLIO SULSER
ABSTRACT Introduction. The management of caliceal diverticular calculi has changed from an open surgical approach to endoscopic management. Technical Considerations. Different minimally invasive treatment modalities, such as extracorporeal shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, laparoscopy, and retroperitoneoscopy, can be offered to the patient. We report on a retroperitoneoscopic operative technique using endosonography for location and performing nephrotomy with complete excision of the caliceal diverticulum and ligation of the diverticular neck with an Endo-loop. Conclusions. The advantages of this minimally invasive technique include total excision of the diverticulum with no risk of recurrence and easy and complete closure of the diverticular neck. UROLOGY 65: 380–383, 2005. © 2005 Elsevier Inc.
C
aliceal diverticula are cystic intrarenal cavities lined with nonsecretory urothelium that communicate with the collecting system by way of a narrow neck and are typically located at a caliceal fornix or infundibulum.1 They are usually asymptomatic, but may present in up to one third of patients with infection or stones. The management of symptomatic caliceal diverticula has changed from an open surgical approach to endoscopic management. Extracorporeal shock wave lithotripsy (ESWL), once considered an alternative therapy for caliceal diverticular calculi, is of limited value because of the inadequate passage of stone fragments through the tight diverticular neck.2 Other minimally invasive treatment modalities such as ureteroscopy or percutaneous nephrolithotomy have high stone-free rates, but the diverticulum persists with potential for recurrence. We present a minimally invasive surgical technique allowing an immediate definitive therapy.
From the Department of Urology, University Hospital of Basel, Basel, Switzerland Reprint requests: Tullio Sulser, M.D., Department of Urology, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland. E-mail: [email protected] Submitted: June 9, 2004, accepted (with revisions): September 28, 2004 © 2005 ELSEVIER INC. 380
ALL RIGHTS RESERVED
MATERIAL AND METHODS CASE REPORT A 46-year-old woman with a single left kidney because of right nephrectomy after recurrent pyelonephritis for renal calculi presented with a symptomatic caliceal diverticular stone (Fig. 1). She had frequent episodes of pyelonephritis and had undergone several sessions of ESWL without any passage of the fragments. To protect the function of her single kidney and to free the patient of her kidney stones, a retroperitoneoscopic approach with complete excision of the diverticulum with the stone and ligation of its neck was performed. The postoperative course was uneventful. The histologic examination showed partially degenerated urothelium with acute and chronic inflammation. Intravenous urography after 8 weeks showed an amputation of the superior calix with homogenous parenchyma of the kidney (Fig. 2). During the 9 months of follow-up, the patient remained asymptomatic with no ultrasonographic evidence of stone recurrence, and the creatinine value remained normal.
SURGICAL TECHNIQUE Under general anesthesia, the patient was positioned in an overextended flank position. A 10-mm incision was made in the triangle under the 12th rib toward the lateral edge of the erector spinae muscle. Next, a tunnel was created through the external oblique muscle by blunt dissection with a Kocher forceps, allowing a finger to push the peritoneum forward, creating a retroperitoneal small space. For dissection of the retroperitoneum, we use a modification of the Gaur balloon technique.3,4 Two index fingers of a powder-free surgical glove are placed into each other and ligated onto the 10-mm trocar sheath. The dissection is performed by filling 500 to 1000 mL warm saline through the insufflation channel of the trocar. After completed dissection, 0090-4295/05/$30.00 doi:10.1016/j.urology.2004.09.060
FIGURE 1. Preoperative computed tomography scan showing caliceal diverticular stone of upper calix. a pneumoretroperitoneum was established with a pressure of 10 to 15 mm Hg. This port served as a camera port. A 12-mm trocar was inserted over the anterior superior iliac spine and a 5-mm trocar between the first two trocars. Gerota’s fascia was incised parallel to the psoas muscle and the perirenal fat dissected. The stone was localized with endosonography, followed by nephrotomy at the corresponding place with electrosurgical scissors, and the diverticulum was evolved without opening it. The diverticular neck was clamped and cut (Fig. 3), and the specimen bearing the excised diverticulum with the stone was retrieved in an Endobag. The neck of the diverticulum was ligated with a Roeder Endo-loop (Fig. 4). The renal capsule was closed with two stitches, a drainage was placed next to the nephrotomy, the trocars were removed, and the incisions were closed.
FIGURE 2. Postoperative intravenous urography with amputation of superior calix after complete excision of caliceal diverticulum with stone.
COMMENT Minimally invasive treatment modalities such as percutaneous renal surgery, laparoscopy, and flexible ureteroscopy have supplanted the need for open surgical marsupialization and fulguration of diverticular cavities.2 Previous reports have shown that 60% to 75% of patients with stone-containing caliceal diverticulum can be successfully treated with ESWL.5,6 However, no long-term follow-up studies have been reported concerning the stone recurrence UROLOGY 65 (2), 2005
FIGURE 3. Diverticular neck clamped and cut.
rate. Small diverticula with large mouths are the ones most likely to remain asymptomatic after ESWL. However, the diverticulum persists with its 381
FIGURE 4. Neck of diverticulum ligated with Roeder Endo-loop.
anatomic pathologic features, and additional complications are likely to occur. The ureteroscopic access is limited mainly to upper and middle pole caliceal diverticula, but diverticula located in the lower pole of the kidney are often very difficult to enter. Therefore, stone fragmentation in this location is extremely challenging. Batter and Dretler7 showed, in a series of 26 patients, a success rate of 84% in identifying and treating upper and middle caliceal diverticular stones, but only 29% of lower caliceal diverticula could be identified and treated with flexible ureteroscopy. In those patients in whom the diverticulum could be entered and the stone fragmented, 83% were immediately stone free, and 100% were symptom free at a mean follow-up of 39 months. Taking all patients of the series into account, the immediate stone-free rate was 58%. Percutaneous renal surgery may be difficult, particularly in the case of anteriorly located diverticula. Landry et al.8 reported on 31 cases, with 5 of the 11 failed cases located anteriorly. The overall stone-free rate was 84% at 1 year, and diverticulum obliteration was obtained in 68% of patients. The expected failure rate was postulated to be 20% to 25%, mainly because of incomplete treatment of the diverticulum. An interesting alternative percutaneous technique is to create a “neoinfundibulum.” An access needle is advanced through the diverticular wall into the renal pelvis, with subsequent balloon dilatation. Next, after standard lithotripsy, a Councill catheter is kept in place for 5 to 7 days to allow complete epithelialization and drainage.9 The reported stone-free rate was 80%, and 94% of the 22 patients were symptom free. Long-term results after percutaneous endosurgical management in 30 patients were reported by Shalhav et al.10 The 382
stone-free rate was 93%, obliteration of the diverticulum occurred in 76%, and 85% of all patients remained asymptomatic at an average follow-up of 3.5 years. Laparoscopy is the “most invasive” of the minimally invasive treatment options. Anteriorly located caliceal diverticula (which would exclude percutaneous access) with a narrow neck (difficult ureteroscopic access) and only thin overlying renal parenchyma are an ideal indication for laparoscopy.11 About 20 cases of laparoscopic12,13 and retroperitoneoscopic1,14 –16 management of caliceal diverticula have been reported. The largest series of 5 patients was reported by Miller et al.1 Complete stone clearance and obliteration of the diverticular cavity was achieved in all cases without the need for open conversion. A ureteral catheter was put in place before retroperitoneoscopy to locate the stone-bearing diverticulum either by retrograde injection of indigo carmine (successful in only 1 of 5 cases with thin overlying renal parenchyma) or by fluoroscopy (successful in only 1 of 5 cases). In the other 3 cases, intraoperative laparoscopic color Doppler ultrasonography was necessary to locate the stone. After extraction of the calculi, indigo carmine was injected through the ureteral catheter to check for any leakage. In 2 cases, a pinhole leak was fulgurated, and in 2 cases a larger leak was sutured. Hoznek et al.16 reported on a series of 3 patients treated successfully with retroperitoneoscopic marsupialization and fulguration with gelatin resorcinol formaldehyde glue. The disadvantage of transperitoneal laparoscopic access is the potential risk of bowel injury on entering the abdomen and also while separating the bowel to enter the retroperitoneal space. By using retroperitoneoscopic access and limiting the working field to the retroperitoneum, this risk is minimal. Another advantage of retroperitoneoscopic access is that it can even be performed in obese patients. It seems crucial to us to evolve the diverticulum completely and not to open it whenever possible. Thus, bacterial contamination can be avoided, and the diverticular neck can be visualized easily (no need for ureteral catheter placement and retrograde filling with indigo carmine) and ligated elegantly with a Roeder Endo-loop. As a backup plan for cases of large diverticula with anticipated deep intrarenal dissection, we recommend preparing the kidney as for partial nephrectomy with placement of a ureteral catheter to secure drainage and dissecting the renal artery and vein to be able to clamp them if necessary (hilar control). Retroperitoneoscopic free-hand suturing within the parenchyma of the kidney to close a diverticular neck can be an extremely challenging procedure, and UROLOGY 65 (2), 2005
we, therefore, strongly recommend using a Roeder Endo-loop if possible and free-hand suturing only if this is not possible (large diverticulum, not well visualized). If it is not possible to dissect the diverticulum down to the neck because of its large size or because of inflammation, we recommend fulgurating the urothelium and performing free-hand suturing to close the collecting system, and then close the nephrotomy and place a drainage catheter. Larger series of patients are necessary to confirm our preliminary experience with this operative technique. The combination of the principles of open surgery, allowing complete excision of the diverticulum and meticulous ligation of its neck, with the advantages of minimally invasive retroperitoneoscopy, make this new technique a promising treatment option. We hope to encourage further development in this field of surgery. REFERENCES 1. Miller SD, Ng CS, Streem SB, et al: Laparoscopic management of caliceal diverticular calculi. J Urol 167: 1248 – 1252, 2002. 2. Canales B, and Monga M: Surgical management of the calyceal diverticulum. Curr Opin Urol 13: 255–260, 2003. 3. Gaur DD: Laparoscopic operative retroperitoneoscopy: use of a new device. J Urol 148: 1137–1139, 1992. 4. Sulser T, Gürke L, Langer I, et al: Retroperitoneoscopic living-donor nephrectomy: first clinical experiences in 19 operations. J Endourol 18: 257–262, 2004.
UROLOGY 65 (2), 2005
5. Psihramis KE, and Dretler SP: Extracorporeal shock wave lithotripsy of caliceal diverticular calculi. J Urol 138: 707–711, 1987. 6. Streem SB, and Yost A: Treatment of caliceal diverticular calculi with extracorporeal shock wave lithotripsy: patient selection and extended followup. J Urol 148: 1043–1046, 1992. 7. Batter SJ, and Dretler SP: Ureterorenoscopic approach to the symptomatic caliceal diverticulum. J Urol 158: 709 – 713, 1997. 8. Landry JL, Colombel M, Rouviere O, et al: Long term results of percutaneous treatment of caliceal diverticular calculi. Eur Urol 41: 474 – 477, 2002. 9. Auge BK, Munver R, Kourambas J, et al: Neoinfundibulotomy for the management of symptomatic caliceal diverticula. J Urol 167: 1616 –1620, 2002. 10. Shalhav AL, Soble JJ, Nakada SY, et al: Long-term outcome of caliceal diverticula following percutaneous endosurgical management. J Urol 160: 1635–1639, 1998. 11. Wolf JS Jr: Caliceal diverticulum and hydrocalix. Urol Clin North Am 27: 655– 659, 2000. 12. Gluckman GR, Stoller M, and Irby P: Laparoscopic pyelocaliceal diverticula ablation. J Endourol 7: 315–317, 1993. 13. Ruckle HC, and Segura JW: Laparoscopic treatment of a stone-filled, caliceal diverticulum as definitive, minimally invasive therapeutic option. J Urol 151: 122–124, 1994. 14. Curran MJ, Little AF, Bouyounes B, et al: Retroperitoneoscopic technique for treating symptomatic caliceal diverticula. J Endourol 13: 723–725, 1999. 15. Harewood LM, Agarwal D, Lindsay S, et al: Extraperitoneal laparoscopic caliceal diverticulectomy. J Endourol 10: 425– 430, 1996. 16. Hoznek A, Herard A, Ogiez N, et al: Symptomatic caliceal diverticula treated with extraperitoneal laparoscopic marsupialization fulguration and gelatin resorcinol formaldehyde glue obliteration. J Urol 160: 352–355, 1998.
383
RETROPERITONEOSCOPIC MANAGEMENT OF CALICEAL DIVERTICULAR CALCULI STEPHEN FREDERIC WYLER, ALEXANDER BACHMANN, CHRISTIAN JAYET, ROBERTO CASELLA, THOMAS C. GASSER, AND TULLIO SULSER
ABSTRACT Introduction. The management of caliceal diverticular calculi has changed from an open surgical approach to endoscopic management. Technical Considerations. Different minimally invasive treatment modalities, such as extracorporeal shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, laparoscopy, and retroperitoneoscopy, can be offered to the patient. We report on a retroperitoneoscopic operative technique using endosonography for location and performing nephrotomy with complete excision of the caliceal diverticulum and ligation of the diverticular neck with an Endo-loop. Conclusions. The advantages of this minimally invasive technique include total excision of the diverticulum with no risk of recurrence and easy and complete closure of the diverticular neck. UROLOGY 65: 380–383, 2005. © 2005 Elsevier Inc.
C
aliceal diverticula are cystic intrarenal cavities lined with nonsecretory urothelium that communicate with the collecting system by way of a narrow neck and are typically located at a caliceal fornix or infundibulum.1 They are usually asymptomatic, but may present in up to one third of patients with infection or stones. The management of symptomatic caliceal diverticula has changed from an open surgical approach to endoscopic management. Extracorporeal shock wave lithotripsy (ESWL), once considered an alternative therapy for caliceal diverticular calculi, is of limited value because of the inadequate passage of stone fragments through the tight diverticular neck.2 Other minimally invasive treatment modalities such as ureteroscopy or percutaneous nephrolithotomy have high stone-free rates, but the diverticulum persists with potential for recurrence. We present a minimally invasive surgical technique allowing an immediate definitive therapy.
From the Department of Urology, University Hospital of Basel, Basel, Switzerland Reprint requests: Tullio Sulser, M.D., Department of Urology, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland. E-mail: [email protected] Submitted: June 9, 2004, accepted (with revisions): September 28, 2004 © 2005 ELSEVIER INC. 380
ALL RIGHTS RESERVED
MATERIAL AND METHODS CASE REPORT A 46-year-old woman with a single left kidney because of right nephrectomy after recurrent pyelonephritis for renal calculi presented with a symptomatic caliceal diverticular stone (Fig. 1). She had frequent episodes of pyelonephritis and had undergone several sessions of ESWL without any passage of the fragments. To protect the function of her single kidney and to free the patient of her kidney stones, a retroperitoneoscopic approach with complete excision of the diverticulum with the stone and ligation of its neck was performed. The postoperative course was uneventful. The histologic examination showed partially degenerated urothelium with acute and chronic inflammation. Intravenous urography after 8 weeks showed an amputation of the superior calix with homogenous parenchyma of the kidney (Fig. 2). During the 9 months of follow-up, the patient remained asymptomatic with no ultrasonographic evidence of stone recurrence, and the creatinine value remained normal.
SURGICAL TECHNIQUE Under general anesthesia, the patient was positioned in an overextended flank position. A 10-mm incision was made in the triangle under the 12th rib toward the lateral edge of the erector spinae muscle. Next, a tunnel was created through the external oblique muscle by blunt dissection with a Kocher forceps, allowing a finger to push the peritoneum forward, creating a retroperitoneal small space. For dissection of the retroperitoneum, we use a modification of the Gaur balloon technique.3,4 Two index fingers of a powder-free surgical glove are placed into each other and ligated onto the 10-mm trocar sheath. The dissection is performed by filling 500 to 1000 mL warm saline through the insufflation channel of the trocar. After completed dissection, 0090-4295/05/$30.00 doi:10.1016/j.urology.2004.09.060
FIGURE 1. Preoperative computed tomography scan showing caliceal diverticular stone of upper calix. a pneumoretroperitoneum was established with a pressure of 10 to 15 mm Hg. This port served as a camera port. A 12-mm trocar was inserted over the anterior superior iliac spine and a 5-mm trocar between the first two trocars. Gerota’s fascia was incised parallel to the psoas muscle and the perirenal fat dissected. The stone was localized with endosonography, followed by nephrotomy at the corresponding place with electrosurgical scissors, and the diverticulum was evolved without opening it. The diverticular neck was clamped and cut (Fig. 3), and the specimen bearing the excised diverticulum with the stone was retrieved in an Endobag. The neck of the diverticulum was ligated with a Roeder Endo-loop (Fig. 4). The renal capsule was closed with two stitches, a drainage was placed next to the nephrotomy, the trocars were removed, and the incisions were closed.
FIGURE 2. Postoperative intravenous urography with amputation of superior calix after complete excision of caliceal diverticulum with stone.
COMMENT Minimally invasive treatment modalities such as percutaneous renal surgery, laparoscopy, and flexible ureteroscopy have supplanted the need for open surgical marsupialization and fulguration of diverticular cavities.2 Previous reports have shown that 60% to 75% of patients with stone-containing caliceal diverticulum can be successfully treated with ESWL.5,6 However, no long-term follow-up studies have been reported concerning the stone recurrence UROLOGY 65 (2), 2005
FIGURE 3. Diverticular neck clamped and cut.
rate. Small diverticula with large mouths are the ones most likely to remain asymptomatic after ESWL. However, the diverticulum persists with its 381
FIGURE 4. Neck of diverticulum ligated with Roeder Endo-loop.
anatomic pathologic features, and additional complications are likely to occur. The ureteroscopic access is limited mainly to upper and middle pole caliceal diverticula, but diverticula located in the lower pole of the kidney are often very difficult to enter. Therefore, stone fragmentation in this location is extremely challenging. Batter and Dretler7 showed, in a series of 26 patients, a success rate of 84% in identifying and treating upper and middle caliceal diverticular stones, but only 29% of lower caliceal diverticula could be identified and treated with flexible ureteroscopy. In those patients in whom the diverticulum could be entered and the stone fragmented, 83% were immediately stone free, and 100% were symptom free at a mean follow-up of 39 months. Taking all patients of the series into account, the immediate stone-free rate was 58%. Percutaneous renal surgery may be difficult, particularly in the case of anteriorly located diverticula. Landry et al.8 reported on 31 cases, with 5 of the 11 failed cases located anteriorly. The overall stone-free rate was 84% at 1 year, and diverticulum obliteration was obtained in 68% of patients. The expected failure rate was postulated to be 20% to 25%, mainly because of incomplete treatment of the diverticulum. An interesting alternative percutaneous technique is to create a “neoinfundibulum.” An access needle is advanced through the diverticular wall into the renal pelvis, with subsequent balloon dilatation. Next, after standard lithotripsy, a Councill catheter is kept in place for 5 to 7 days to allow complete epithelialization and drainage.9 The reported stone-free rate was 80%, and 94% of the 22 patients were symptom free. Long-term results after percutaneous endosurgical management in 30 patients were reported by Shalhav et al.10 The 382
stone-free rate was 93%, obliteration of the diverticulum occurred in 76%, and 85% of all patients remained asymptomatic at an average follow-up of 3.5 years. Laparoscopy is the “most invasive” of the minimally invasive treatment options. Anteriorly located caliceal diverticula (which would exclude percutaneous access) with a narrow neck (difficult ureteroscopic access) and only thin overlying renal parenchyma are an ideal indication for laparoscopy.11 About 20 cases of laparoscopic12,13 and retroperitoneoscopic1,14 –16 management of caliceal diverticula have been reported. The largest series of 5 patients was reported by Miller et al.1 Complete stone clearance and obliteration of the diverticular cavity was achieved in all cases without the need for open conversion. A ureteral catheter was put in place before retroperitoneoscopy to locate the stone-bearing diverticulum either by retrograde injection of indigo carmine (successful in only 1 of 5 cases with thin overlying renal parenchyma) or by fluoroscopy (successful in only 1 of 5 cases). In the other 3 cases, intraoperative laparoscopic color Doppler ultrasonography was necessary to locate the stone. After extraction of the calculi, indigo carmine was injected through the ureteral catheter to check for any leakage. In 2 cases, a pinhole leak was fulgurated, and in 2 cases a larger leak was sutured. Hoznek et al.16 reported on a series of 3 patients treated successfully with retroperitoneoscopic marsupialization and fulguration with gelatin resorcinol formaldehyde glue. The disadvantage of transperitoneal laparoscopic access is the potential risk of bowel injury on entering the abdomen and also while separating the bowel to enter the retroperitoneal space. By using retroperitoneoscopic access and limiting the working field to the retroperitoneum, this risk is minimal. Another advantage of retroperitoneoscopic access is that it can even be performed in obese patients. It seems crucial to us to evolve the diverticulum completely and not to open it whenever possible. Thus, bacterial contamination can be avoided, and the diverticular neck can be visualized easily (no need for ureteral catheter placement and retrograde filling with indigo carmine) and ligated elegantly with a Roeder Endo-loop. As a backup plan for cases of large diverticula with anticipated deep intrarenal dissection, we recommend preparing the kidney as for partial nephrectomy with placement of a ureteral catheter to secure drainage and dissecting the renal artery and vein to be able to clamp them if necessary (hilar control). Retroperitoneoscopic free-hand suturing within the parenchyma of the kidney to close a diverticular neck can be an extremely challenging procedure, and UROLOGY 65 (2), 2005
we, therefore, strongly recommend using a Roeder Endo-loop if possible and free-hand suturing only if this is not possible (large diverticulum, not well visualized). If it is not possible to dissect the diverticulum down to the neck because of its large size or because of inflammation, we recommend fulgurating the urothelium and performing free-hand suturing to close the collecting system, and then close the nephrotomy and place a drainage catheter. Larger series of patients are necessary to confirm our preliminary experience with this operative technique. The combination of the principles of open surgery, allowing complete excision of the diverticulum and meticulous ligation of its neck, with the advantages of minimally invasive retroperitoneoscopy, make this new technique a promising treatment option. We hope to encourage further development in this field of surgery. REFERENCES 1. Miller SD, Ng CS, Streem SB, et al: Laparoscopic management of caliceal diverticular calculi. J Urol 167: 1248 – 1252, 2002. 2. Canales B, and Monga M: Surgical management of the calyceal diverticulum. Curr Opin Urol 13: 255–260, 2003. 3. Gaur DD: Laparoscopic operative retroperitoneoscopy: use of a new device. J Urol 148: 1137–1139, 1992. 4. Sulser T, Gürke L, Langer I, et al: Retroperitoneoscopic living-donor nephrectomy: first clinical experiences in 19 operations. J Endourol 18: 257–262, 2004.
UROLOGY 65 (2), 2005
5. Psihramis KE, and Dretler SP: Extracorporeal shock wave lithotripsy of caliceal diverticular calculi. J Urol 138: 707–711, 1987. 6. Streem SB, and Yost A: Treatment of caliceal diverticular calculi with extracorporeal shock wave lithotripsy: patient selection and extended followup. J Urol 148: 1043–1046, 1992. 7. Batter SJ, and Dretler SP: Ureterorenoscopic approach to the symptomatic caliceal diverticulum. J Urol 158: 709 – 713, 1997. 8. Landry JL, Colombel M, Rouviere O, et al: Long term results of percutaneous treatment of caliceal diverticular calculi. Eur Urol 41: 474 – 477, 2002. 9. Auge BK, Munver R, Kourambas J, et al: Neoinfundibulotomy for the management of symptomatic caliceal diverticula. J Urol 167: 1616 –1620, 2002. 10. Shalhav AL, Soble JJ, Nakada SY, et al: Long-term outcome of caliceal diverticula following percutaneous endosurgical management. J Urol 160: 1635–1639, 1998. 11. Wolf JS Jr: Caliceal diverticulum and hydrocalix. Urol Clin North Am 27: 655– 659, 2000. 12. Gluckman GR, Stoller M, and Irby P: Laparoscopic pyelocaliceal diverticula ablation. J Endourol 7: 315–317, 1993. 13. Ruckle HC, and Segura JW: Laparoscopic treatment of a stone-filled, caliceal diverticulum as definitive, minimally invasive therapeutic option. J Urol 151: 122–124, 1994. 14. Curran MJ, Little AF, Bouyounes B, et al: Retroperitoneoscopic technique for treating symptomatic caliceal diverticula. J Endourol 13: 723–725, 1999. 15. Harewood LM, Agarwal D, Lindsay S, et al: Extraperitoneal laparoscopic caliceal diverticulectomy. J Endourol 10: 425– 430, 1996. 16. Hoznek A, Herard A, Ogiez N, et al: Symptomatic caliceal diverticula treated with extraperitoneal laparoscopic marsupialization fulguration and gelatin resorcinol formaldehyde glue obliteration. J Urol 160: 352–355, 1998.
383