ABSTRACT In complicated urinary tract infection with ureteral calculi, urinary diversion is inevitable. So, stenting or percutaneous drainage can be an option. In hemodynamically unstable patients, percutaneous drainage is superior to ureteral stenting (1). Once acute infection is controlled, definite treatment of the stone is necessary. According to a guideline, semirigid ureteroscopy is recommended for lower and mid - ureter stone and flexible ureteroscopy for upper ureter stone (2). Semi - rigid ureteroscopy can migrate stone to kidney, especially in upper ureter stone, lowering stone free rate (3). Not only flexible ureteroscopy creates additional costs but also is barely available in developing countries (4, 5). So, the authors would like to introduce anterograde irrigation - assisted ureteroscopic lithotripsy in patients with percutaneous nephrostomy. Retrograde irrigation was connected and flowed minimally enough to secure visual field. Once stone is noted, another saline irrigation, which is placed above 40 cm over the patient is connected to nephrostomy. Retrograde irrigation is disconnected from ureteroscope and the previous connected channel on ureteroscope is opened. Actual pressure detected by barometer from the opened channel of ureteroscope is usually about 30 cmH2 O while anterograde irrigation is administered in maximal flow, which means fully opened anterograde irrigation is not hazardous to kidney. There was no complication in 17 patients submitted to this method. Video shows advantages of our practice: clear visual field; reduced risk of stone migration into kidney; induced spontaneous passage of fragments without using instrumentation; and decreased operation time. In short, most of surgeons, even unexperienced, can perform an excellent procedure with less time consuming using our method.

ABSTRACT Introduction and Objectives: Nephrectomy is occasionally required due to severe extra-renal symptom(s) such as dyspepsia in patients with autosomal dominant polycystic kidney disease (ADPKD), wherein a large incision is required for specimen extraction. Considering problems such as hernia, wound dehiscence, incidental bowel injury, and poor wound healing in such cases, we would like to present retroperitoneoscopic nephrectomy and morcellation of the kidney as an ideal minimally invasive technique. Materials and Methods: A 53-year-old man who was undergoing hemodialysis for 6 years due to ADPKD visited the outpatient clinic with a complaint of severe dyspepsia. Kidney length (long axis) was greater than 28 cm. Nephrectomy was the last option to restore his digestive system which was mechanically compressed by an extremely enlarged polycystic kidney. Retroperitoneoscopic nephrectomy was performed using 3 ports. When it was difficult to continue the dissection due to limited space, large cysts were punctured and aspirated to create additional working space. The specimen was extracted by a morcellator (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany) introduced through a 12mm trocar. Results: Operating time was 230 minutes, wherein the time for morcellation was 52 minutes. No additional incision was required for specimen extraction. He underwent hemodialysis on post-operative days #1 and #3. He was discharged on post-operative day #4 (total hospital stay was 6 days.). Dyspepsia dramatically improved without post-operative complications. Conclusions: Retroperitoneoscopic nephrectomy is feasible for treatment of ADPKD. By using a morcellator, an additional incision is not required and wound complication would not occur.