open surgical resection and reanastomosis of the abnormal ureteral segment was described by kuster in 1892 and later popularized by anderson and hynes . reported success rates of over 90% made dismembered pyeloplasty the procedure of choice for upj obstruction . to circumvent the postoperative morbidity of open surgery in the adult population initially reported in 1983 , percutaneous endopyelotomy provided patients with an alternative to open surgery associated with less postoperative morbidity and success rates approaching 85% . the acucise cutting balloon ( applied medical resources , rancho santa margarita , ca ) was initially described for retrograde treatment of ureteropelvic junction obstruction in the early 1990s and provided reasonable success rates approaching 80% . similarly , use of the holmium : yag laser to perform a ureteroscopic endopyelotomy has improved drainage in 83% of patients presenting with primary and secondary ureteropelvic junction obstruction . laparoscopic pyeloplasty was first described in 1993 , and recent follow - up data have shown success rates of over 90% for both primary and secondary disease . the presence of ureteropelvic junction obstruction associated with concomitant ipsilateral calculus disease presents a challenging situation for the urologist . all patients were referred to our university for evaluation of suspected unilateral , single - system ureteropelvic junction obstruction . computed tomography ( ct ) and mercaptoacetyltriglycine ( mag-3 ) nuclear renography were completed preoperatively by all patients to confirm the diagnosis and assess perinephric anatomy . all patients had an obstructive pattern with at least > 20% differential renal function of that renal unit on diuretic nuclear scintigraphy . informed surgical consent was obtained , including discussion of possible open conversion , blood transfusion , urinary tract infection , and any subsequent stone removal procedure . one patient with a partial staghorn calculus elected to undergo a percutaneous nephrolithotomy followed by laparoscopic pyeloplasty and was excluded from the study . once adequate anesthesia was obtained , the patient was placed in the dorsal lithotomy position on the operating room table . if a double - j ureteral stent was not present , then one was subsequently placed on the operative side in standard fashion under fluoroscopic guidance . if a double - j stent had been present for several months , then it was exchanged for a new one by using the established technique . the selected double - j stent size was 2 cm longer than usual , which helped to prevent inadvertent proximal migration out of the bladder with manipulation during the repair . a retrograde pyelogram was performed to define the upj obstruction and clear the distal ureter . a foley catheter and a nasogastric tube the foley was subsequently clamped after establishment of pneumoperitoneum to allow distention of the renal pelvis to assist with dissection . the patient was then placed in a 45 lateral decubitus position , carefully padding all pressure points , and secured in position by a a pneumoperitoneum was achieved with carbon dioxide by using either a veress needle or the hasson technique to achieve 15 mm hg of intraabdominal pressure . a 12-mm port was positioned infraumbilically , followed by two 12-mm ports in the midclavicular line and , occasionally , a 5-mm port in the lateral position to complete a diamond arrangement ( figure 1 ) . general inspection of the abdominal cavity was performed followed by reflection of the colon medially . the renal pelvis and upj were identified and dissected free , carefully preserving any crossing vessels if present . once the anatomical configuration of the hilum was identified and the area of the ureteropelvic junction was examined , either a foley y - v ( if no crossing vessels ) or a dismembered pyeloplasty ( if crossing vessel ) was initiated ( figure 2 ) . the ureter was partially incised , and the internal stent was removed from the renal pelvis , thus allowing access for nephroscopy and stone removal . the pyelotomy was made of appropriate length to achieve the pyeloplasty and was not elongated for the nephroscopy . diagram of laparoscopic port placement . mobilized collecting system ( no crossing vessel present ) . a second endoscopy tower with camera and light source was brought into the room as we continued our dissection . when ready , continuous irrigation was assembled and through the uppermost midclavicular port , a 16 fr storz flexible cystoscope ( karl storz endoscopy - america , inc . , culver city , ca ) was passed under laparoscopic vision directly into the previously made pyelotomy . intermittent suction controlled the continuous irrigation of saline via the nephroscope ( figure 3 ) . with preoperative knowledge of stone number and location , inspection of individual calices allowed identification of the calculi , which were then extracted by using a 2.4 fr nitinol  zero tipped  basket ( microvasive , boston scientific inc . the irrigant was aspirated by placing the suction probe just below the pyelotomy through the accessory laparoscopic port . neither lithotripsy nor fluoroscopy was required , rather endoscopy continued until all counted stones were removed . the ureter and renal pelvis were appropriately positioned , and completion of the anastomosis was performed by using interrupted 2-zero polyglycolic acid sutures tied intracorporeally to provide a tension - free , watertight closure over the internal stent . the two 12-mm ports were closed under direct vision with the carter - thomason port closure device ( inlet medical , edina , mn ) . a 19 fr blake drain was placed through the lateral 5-mm port ; and finally , the infraumbilical port was closed . endoscopic basket retrieval of nephrolithiasis . in the postoperative period , a plain abdominal film ( kub ) the foley catheter was removed in 48 hours , and the drain was removed in 72 hours to 96 hours if recorded output was minimal . the stent was removed at approximately 6 weeks , and a mag-3 nuclear renal scan was performed at 8 weeks to 10 weeks after the corrective procedure . out of 50 patients who underwent laparoscopic pyeloplasty from august 1998 to may 2002 , we identified 8 patients who presented with unilateral , single - system ureteropelvic junction obstruction , and concurrent ipsilateral nephrolithiasis . one patient with a partial staghorn calculus elected to have a percutaneous stone extraction prior to the laparoscopic pyeloplasty , and therefore was excluded from analysis . all patients had an obstructed pattern ( t1/2 > 15 minutes ) by mag-3 renography with at least > 20% confirmed differential renal function of the involved kidney . the longest individual stone diameters ranged from 4 mm to 13 mm ( mean , 10.3 mm ) , and an average of 2.5 stones was removed from each patient ( range , 1 to 4 stones ) . current mean follow - up from time of the last visit was 8.5 months ( range , 2 to 17 months ) . the postoperative abdominal film confirmed a stone - free status in 6 of the 7 patients . one patient with approximately 2 dozen stones each measuring <3 mm in diameter had several suspected residual lower calyx calculi in association with a thick proteinaceous material , and this patient remains asymptomatic without progression of stone disease . in four of the 7 patients who had stone analysis performed calcium oxalate patient characteristics , preoperative imaging findings , and surgical procedure anterior crossing vessel was present . calculi characteristics * com = calcium oxalate monohydrate , cod = calcium oxalate dihydrate , ca = carbonate apatite , uad = uric acid dihydrate , chpd = calcium hydrogen phosphate dihydrate . the incidence of concurrent renal calculi and ureteropelvic junction obstruction is 20% , and this scenario presents some controversy in regards to cause and treatment alternatives . a possible cause of the obstruction may be stenosis of the ureteropelvic junction , a result of an obstructing stone , or both . one hypothesis is that renal obstruction secondary to the stenotic ureteral segment results in urinary stasis , promotion of nucleation and stone formation , and that correction of this obstruction results in a decreased incidence of recurrent calculi . in contrast , others profess the importance of a metabolic evaluation because patients who present with both ureteropelvic junction obstruction and calculi may have a fundamental underlying metabolic abnormality , as most patients with ureteropelvic junction obstruction do not have stones . thorough evaluation of a patient 's symptoms , renal function , anatomy , and previous attempts at correction will help direct the physician in selecting the most appropriate surgical intervention . percutaneous nephrolithotomy followed by simultaneous or subsequent antegrade endopyelotomy is an option often presented to patients in this situation . the overall success rate of endopyelotomy decreased to 39% when a crossing vessel and a large redundant renal pelvis were present . primary percutaneous stone removal followed by retrograde endopyelotomy using the acucise device or the holmium laser is an additional proposed option . traditional open pyeloplasty may be accompanied by pyelolithotomy for concurrent stone removal . likewise , performance of laparoscopic pyeloplasty and subsequent stone removal is a therapeutic alternative . performance of concomitant stone removal allows for a minimally invasive one - stage therapeutic option . the technique of using a flexible nephroscope for removal of renal calculi during a laparoscopic procedure has been described by a group from johns hopkins university . the authors initially presented successful laparoscopic stone removal in 15 of 17 patients , of whom 9 went on to have laparoscopic pyeloplasty repair . key points to their described technique included ( 1 ) the importance of not transecting the ureter before stone removal , ( 2 ) the use of the 2-camera system to pass the cystoscope under laparoscopic guidance , ( 3 ) the placement of the laparoscopic suction device below the renal pelvis to provide a clear operative field , ( 4 ) the intraoperative use of fluoroscopy as a crucial tool in locating and confirming complete stone removal , and ( 5 ) the maneuver of pulling the proximal end of the stent through the pyelotomy incision to allow maximal cystoscope mobility . at median follow - up of 13.7 months , all patients were asymptomatic , stone free , and without obstruction based on postoperative intravenous pyelography . subsequently , an updated series was recently reported , involving 19 patients with a mean follow - up of 12 months and a long - term stone - free rate of 80% . the authors report the use of the holmium laser to perform lithotripsy as an adjunct measure for stone removal . the use of the 2-camera system allows superb visualization and laparoscopic guidance of the flexible endoscope . overflow of saline irrigation is easily managed by intermittent suction , which will maintain the established pneumoperitoneum . thorough preoperative review of each patient 's radiological studies allowed us to adequately assess complete stone burden and location , and therefore we found intraoperative use of fluoroscopy not to be essential . not bringing a portable  c - arm  into the operating room provided additional working space in an often times crowded suite , and operative time our 1 patient with residual calculi was noted to have nearly 2 dozen small ( <3 mm ) stones interlaced with a thick proteinaceous material that likely would have been missed even if intraoperative fluoroscopy had been utilized . preoperatively , it was believed this area was 1 or 2 small lower pole stones . our 1 patient who elected percutaneous nephrolithotripsy prior to undergoing laparoscopic repair underwent the procedure of choice for her stone burden . treatment of calculi > 20 mm or branched staghorn calculi are most likely amenable to such an approach . all additional stones in the 6 remaining patients were accounted for at the end of the procedure and , subsequently confirmed to be stone free with postoperative imaging . we have presented herein a series of patients who underwent successful laparoscopic pyeloplasty with concurrent nephrolithiasis removal via flexible pyeloscopy . this is a simple , attractive alternative for the simultaneous treatment of upj obstruction with coexisting nephrolithiasis and should be offered preoperatively to the patient if laparoscopic repair is considered . it appears to be more efficacious when a limited number of radiographically identified stones are present and individual calculi range in diameter size from 5 mm to 20 mm .
background and objective : ureteropelvic junction obstruction and concomitant calculus disease may coexist . 
 therapeutic controversy exists regarding their ideal management . 
 we report our use of flexible nephroscopy during laparoscopic pyeloplasty for caliceal stone removal.methods:from august 1998 through may 2002 , 50 laparoscopic pyeloplasties were performed . 
 seven patients had documented ureteropelvic junction obstruction and ipsilateral nephrolithiasis . 
 preoperative stone burden and location were assessed . 
 after pyelotomy , a 16 fr flexible endoscope was passed through the uppermost trocar under direct laparoscopic guidance into the collecting system . 
 stone extraction was performed with a 2.4 fr nitinol basket . 
 postoperative imaging was assessed.results:complete stone - free status confirmed by postoperative imaging was achieved in 6 of 7 patients . 
 the longest individual stone diameter ranged from 4 mm to 13 mm ( mean , 10.3 mm ) , and an average of 2.5 stones per patient was removed ( range , 1 to 4 stones ) . neither intraoperative fluoroscopy nor lithotripsy was required . 
 no intraoperative or delayed complications were noted during a mean follow - up of 8.5 months ( range , 2 to 17 months).conclusions : laparoscopic pyeloplasty and concomitant flexible nephroscopy with basket extraction is a simple , attractive alternative for the simultaneous treatment of ureteropelvic junction obstruction presenting with coexisting nephrolithiasis . 
 it appears more efficacious when the stone number is limited and diameters measure from 5 mm to 20 mm .