Endopath

The LVR procedure closely followed the technique initially described by D'Hoore et al.[13 ]. Throughout the study period, modifications were introduced[14 ]. Notably, the approach for attaching the polypropylene mesh to the sacral promontory evolved from employing an endofascial stapler (Endopath™, EMS; Ethicon Endo-Surgery, Cincinnati, OH, USA) to using titanium tacks (Autosuture Protack™; Tyco Healthcare, Mansfield, MA, USA) since July 2014. Additionally, the method of mesh insertion underwent a transformation, transitioning from the original intraabdominal technique[13 ] to a modified technique in female patients[14 ] from July 2012. This adapted technique involved passing a nylon thread with a straight needle through the posterior vaginal wall during dissection of the rectovaginal septum down to the pelvic floor. The nylon thread was retrieved from the abdominal cavity and secured at the end of the extracorporeal mesh, which was then introduced and maneuvered towards the pelvic floor.

Under general anesthesia, patients were placed in the semi-lateral decubitus position with the ipsilateral side up. The laparoscopic port placements are shown in Figure 1A. After entering the retroperitoneal space, the retroperitoneal fat was separated first, the Gerota fascia was then uncovered at the lower pole, and the perinephric fat was eliminated to expose the renal hilum. As the isthmus existed in the lower poles in all our cases, we released the lower pole of the kidney to expose the isthmus (Figure 2A). When the isthmus was isolated with a stapler (Endopath, Ethicon Endo-Surgery, United States) (Figure 2B), we dissected the renal pelvis to extract the stones (Figure 2C and D). Distilled water was applied to flush the renal pelvis to promote stone removal. After a Double-J ureteral stent was inserted into the ureter (Figure 2E), renal pelvic anastomoses were performed with a 4-0 absorbable V-LOC suture. A flexible cystoscope was used in one patient to view all small calyces to guarantee complete clearance of renal stones.