V1559 LAPAROSCOPIC ROBOT-ASSISTED PYELOLITHOTOMY IN EMPHYSEMATOUS PYELONEPHRITIS

INTRODUCTION AND OBJECTIVES: Emphysematous pyelonephritis is an acute severe necrotizing infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma. The pathogenesis is poorly understood. The cause for mortality in emphysematous pyelonephritis is primarily due to septic complications. Up to 95% of the cases with emphysematous pyelonephritis have underlying uncontrolled diabetes mellitus. A 59 year old female patient presented in our clinic with symptoms of a right pyelonephritis and a history of recurring pyelonephritis and severe sepsis. The computer tomography showed an emphysematic pyelonephritis with an amorphous stone in the right renal pelvis and multiple calculi in the calyces. An exigent ureteral stent was inserted. Proteus mirabilis was demonstrated in the urine culture. Because of the persistent infection with gas formation we decided upon a laparoscopic, robot-assisted pyelolithotomy. This video demonstrates the technique of transperitoneal laparoscopic robot-assisted pyelolithotomy in emphysematous pyelonephritis. METHODS: A transperitoneal access was established and four working trocars and a camera trocar were inserted. After mobilisation of the descending colon, the right colonic flexure und the duodenum as well as identification of the vena cava, the right ureter was identified and the kidney surface denuded. Following its identification the uretero-pyelon junction is incised longitudinally. Now white necrotic masses are to be seen. These are removed piece for piece with the bipolar forceps until, with rinsing and suction the renal pelvis is completely cleared. The existing ureteral stent is removed via the pelvic incision and a new French 7 stent is inserted antegrade into the ureter. The renal pelvis is closed with 3-0 continuous sutures and the corpus adiposum of the renal sinus is re-adapted. A French 6 wound drain is positioned. RESULTS: No results to this instructional video. CONCLUSIONS: The histology shows partially calcified amorphous material imbebbed with coccoand rod-bacteria. The operation was uneventful and the patient could be released on post-op day 8. Four weeks after the procedure the patient was complicationand infection-free so that the ureteral stent could be removed. The laparoscopic, robot-assisted pyelolithotomy is an effective and minimal invasive therapy option for emphysematous pyelonephritis.