Despite the technical development and expanding indications, the new technologies in ESWL, URSC, RIRS and PNL have not been able to complete replace open surgery(OS). In these cases, laparoscopic surgery could be the most suitable option.

Various factors must be considered in order to offer an optimized surgical treatment.

When patient is counseled on the need for multisession surgery, the overall treatment cost and patient's preferences are important factors to decide treatment modality. Urologist should balance the invasiveness of the procedure and patient's morbidity with stone free rate (SFR). The more invasive selected procedure is, the higher one-session, SFR and a greater postoperative morbidity would be expected.

With rapidly increasing application of laparoscopy in the field of urology, acceptance of laparoscopic stone surgery (LSS) as an alternative to OS is growing.

While 2007 EAU urolithiasis guidelines considered LSS as an "option", in the 2009 edition it was "highly recommended" and since 2012 to the nowadays edition, it's "preferred" LSS before proceeding to OS.

To optimize surgical technique and improve SFR, Salvadó et al. recommended routine exploration of renal pelvis and caliceal system with flexible nephroscopy during LSS.

LSS can be used at different levels of the urinary tract, expanding the indications.

Our aim is to report LSS advantages experienced in a 4 cases mini-serie combining laparo-endoscopic approach.

During 2 years, PNL wasn't available at our institution. PNL in referral hospital was offered. LSS performed in our department was also offered as "alternative approach". The lacks of PNL, stone characteristics (size and Hounsfield units) and patients preferences were considered to proceed to LSS.

2 ureterolithotomy, 1 pielolithotomy and 1 pieloplasty are reported. Grasping forceps and nitinol baskets were used to remove ureteral and intrarrenal stones under laparo-endoscopic combined vision.

Pielolithotomy was performed in extra-renal pelvis. Complete "en-block" staghorn removal was achieved.

Laparoscopic techniques were combined with endourology. Through laparoscopic trocars, a flexible ureteroscope and cistoscope were guided into renal pelvis after uretero-pelvic junction (UPJ) was transected, allowing to extract intra-renal stones during UPJ syndrome pyeloplasty.

Clinical cases are described in the video.

After surgery, patients were classified in low and high risk recurrence, also treated and followed by EAU guidelines recommendations.

LSS advantages include:

Simple manipulation, poor bleeding, short operative time and hospital stay.

LSS represented a safe alternative for impacted ureteral lithiasis in which previously endourologic procedure failed.

Multitrack or multisession surgery could be avoided for staghorn extra-renal pielic lithiasis, achieving no harm to the nephron and saving operative time.

Laparo-endoscopic approach could be related with acceptable SFR.

More comparative studies are needed to define the role of LSS in relation to endourologic and open techniques, especially in complex circumstances.