Laparoscopic ureterolithotomy: Its role and some controversial technical considerations

Authors


Kittinut Kijvikai md, Division of Urology, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama 6 Road, Tungphyatai, Rajathevee, Bangkok 10400, Thailand. Email: kittinutk@hotmail.com

Abstract

Objective:  To define the role of laparoscopic ureterolithotomy in the management of urolithiasis and evaluate the controversial techniques of this operation.

Methods:  Between July 1997 and December 2004, retroperitoneoscopic ureterolithotomy was performed as a primary procedure in 30 patients who had either large or impacted stones in the upper ureter. The other indications were stones which could not be fragmented by shock wave lithotripsy or the patients could not afford the cost of shock wave lithotripsy. The mean (range) age of the patients was 44.07 years (17–78) and the mean (range) stone size was 19.03 mm (10 – 40). The ureter was closed with intracorporeal laparoscopic suture without placing a stent.

Results:  The stone was removed in all but one case. The mean (range) operative time was 121.38 min (75–270). No intraoperative complications were recorded. The mean (range) postoperative drain removal was 2.86 days (2–10). Postoperative complications included prolonged urinary leakage in one patient. On the sixth month of follow up, all patients were stone free without any evidence of ureteral stricture.

Conclusion:  Laparoscopic ureterolithotomy is a minimally invasive treatment and may be considered as the useful first-line management for large impacted upper ureteric stones. The technical recommendations were retroperitoneal access and suturing the ureterotomy incision. Ureteral stent should be placed in only cases of severe inflammation of the ureter or inappropriate suturing.

Introduction

Currently, the managements of upper and middle ureteral stones are treatments with shock wave lithotripsy (SWL), ureteroscopic lithotripsy (UL) or percutaneous lithotripsy (PL).1,2 However, Park et al.3 have treated 218 patients with upper ureteral stones, achieving a 72.4% stone-free rate after a single SWL session, and its rate decreases from 84% to 42% when the stone is larger than 1 cm. In developing countries including Thailand, the cost of SWL and UL is more expensive than surgery, and most patients want their stone removed within single procedure.4 In open surgery, the stone can almost be removed within one procedure, even if invasive, and it is better than performing surgery in multiple sessions. Therefore, open ureterolithotomy is common and still has a role in our circumstances. The disadvantage of open surgery is that it always results in definite patient morbidity. The laparoscopic approach is a minimally invasive alternative to open surgery.5,6 However, the details of the laparoscopic technique were different between authors, such as the route of access, whether a stent should be placed and whether suturing of the ureter should be performed.

In this communication, we present our experience in retroperitoneoscopic ureterolithotomy (RPU) for the treatment of upper ureteral stones and evaluated the controversial techniques of this operation.

Materials and methods

Patients

Between July 1997 and December 2004, 30 Thai patients (male : female = 20:10) underwent RPU. The mean (range) age was 44.07 years (17–78). RPU was used as a primary procedure in patients who had either a stone ≥15 mm in size of the upper ureter or an impacted stone (Fig. 1). The definition of impaction was that the stone remained fixed at the same site more than 2 months. The other indications were a stone which could not be fragmented by SWL or the patient could not afford the cost of SWL. Intravenous pyelography (IVP) and ultrasonography (USG) were also used preoperatively to evaluate the urinary system.

Figure 1.

Preoperative scout film of a patient with large left upper ureteric stone (arrow).

Technique

The patient was placed in the full flank position with the side ipsilateral to the stone up, and 1.5 cm incision was performed just below the tip of the 12th rib. The transversalis fascia was incised, and the posterior pararenal space was developed bluntly as far as possible with an index finger aiming at pushing the peritoneum forward and creating sufficient space for the introduction of a balloon dilator. We used two fingers of a number 8 glove tied over each other and fixed on the end of an 18-F red rubber catheter. The dilator was placed under digital control and inflated to 500 mL with normal saline solution. The inflated balloon was left for a few minutes to achieve hemostasis before being deflated and removed. A 10-mm trochar was sutured into the incision. A pneumoretroperitoneum was created at a pressure of 15 mmHg. A 0 degree 10-mm telescope was inserted to view the retroperitoneal space and to-and-fro movements of laparoscope were performed to create a working space as large as possible. Another 10-mm trochar was introduced under endoscopic control two fingerbreadths above the iliac crest in the anterior axillary line. This port served mainly for the fan retractor throughout the procedure. A third 5-mm port was inserted under vision at the junction of the lateral border of paraspinal muscles and the 12th rib. The ureter was located, dissected, and traced to the stone, which was identified by a bulge. The ureter was opened over the stone using an electrical cutting-mode hook starting from the most bulging part of stone, further upward 5–10 mm beyond the upper most part of the stone. The stone was extracted by leverage or angling the ureter with the assistance of a laparoscopic hook and grasper. Then, the stone was placed on the psoas muscle for later removal in a bag if it could not pass through the 10-mm port. The distal obstruction was ruled out by inserting a number 8 feeding tube into the ureter and injecting saline through one of the laparoscopic ports. Ureteral incision was closed in all cases with interrupted intracorporeal laparoscopic suture of 3–0 Dexon without a stent. A double J (DJ) stent was inserted in one case due to inappropriate suturing and the stent was removed in 2 weeks later.

Intravenous morphine given p.r.n. was used for analgesia. The upper urinary system was evaluated by IVP or USG at the sixth month of follow up.

Results

The operation was successfully performed in 29 cases and the findings are shown in Table 1. The mean (range) stone size was 19.03 mm (10–40). The stone was removed in all cases within single operation (Fig. 2). The mean (range) operation time was 121.38 min (75–270). Although data are not shown in Table 1, the mean (range) operative blood loss was 39.31 mL (20–100) and the mean (range) analgesic requirement was 5.66 mg (0–12) of parenteral morphine. The operation was converted to open surgery in one case due to the difficulty locating the stone. In open conversion, the stone was successfully removed within 150 min of total operative time and a 16 mg intravenous morphine was used for pain relief. The operative blood loss was 100 mL.

Table 1.  Details of patients and procedures used in the removal of ureteral stone
NumberAge/SexStone size (mm)LocationOperative time (min)Drain removed (Postoperative days)ComplicationsIndications (Stone size)
  1. DJ stent, double-J stent; SWL, shock wave lithotripsy.

 154/F25Upper left1752≥15 mm
 217/F18Upper right2103≥15 mm
 336/F22Upper right2003≥15 mm
 445/M20Upper right1852Pneumoscrotum≥15 mm
 539/F15Upper right2702Impacted
 642/F18Upper left1503≥15 mm
 740/F30Upper left1103≥15 mm
 857/M15Upper right 852 (+ DJ stent)Unsuccessful SWL
 974/M25Upper right 752≥15 mm
1038/M20Upper right1102Pneumoscrotum≥15 mm
1145/M12Upper left1053SWL cannot locate stone
1219/F15Upper left 901Impacted
1338/M18Upper right1754≥15 mm
1427/M15Upper left1202Impacted
1541/M15Upper right 952≥15 mm
1652/M10Upper left1502Converted to open surgeryUnsuccessful SWL
1725/F15Upper right1154Impacted
1833/M10Upper left 853Unsuccessful SWL
1940/M15Upper right1053≥15 mm
2060/M12Upper right 804Impacted
2134/M10Upper left 853Unsuccessful SWL
2265/F15Upper left 802≥15 mm
2347/M10Upper right1104Cannot afford SWL
2432/M25Upper right1204≥15 mm
2569/F25Upper right 752≥15 mm
2674/M40Upper left 902≥15 mm
2723/M22Upper left 902≥15 mm
2834/M15Upper right1202≥15 mm
2978/M20Upper left1202≥15 mm
3052/M35Upper right 9010Prolonged drainage (corrected by DJ stent)≥15 mm and Impacted
Figure 2.

Postoperative scout film of the same patient showing stone-free status.

The drain was removed on the same day from patients who were dry (drain ≤ 30 mL). The mean (range) of postoperative drain removal time was 2.86 days (2–10). The patients were discharged from the hospital on the next day after drainage removal.

The drainage was prolonged more than 7 days in one case and a DJ stent was inserted to correct this problem. Pneumoscrotum (two cases) were observed and disappeared within one week.

The ureter was normal in 24 cases without any evidence of ureteral stenosis on IVP or USG at the sixth month of follow up. However, the other five patients were lost from our series.

Discussion

Since the advent of SWL and ureteroscopy devices, ureterolithotomy has had a limited role in the management of ureteric stones. Ureterolithotomy is reserved for those difficult cases that are refractory to SWL, and in centers where ureteroscopy devices are not readily available. However, in our country the cost of SWL and ureteroscopy is much higher than surgery, and most patients want their stone removed within a single operation. The high stone-free rate after a single procedure means that patients do not spend a long period with indwelling ureteric stents and can return quickly to their regular activities.7 These factors are very important to patients with socioeconomic problems. A large impacted and long-standing upper ureteral stone is still an ideal indication for ureterolithotomy.8 Therefore, ureterolithotomy is a useful alternative treatment for upper ureteric stone in this situation. Laparoscopic ureterolithotomy (LUL) has proved to be comparable with open surgery for operative duration and blood loss.9 In addition, LUL has more advantages over open surgery in various aspects such as analgesia, hospital stay, recuperation and cosmesis.9

Although our series seems small (30 cases), it is still the third largest series which has ever been reported in the world literature.9,10

Laparoscopic ureterolithotomy can be performed via a transperitoneal or a retroperitoneal approach. A transperitoneal route provides a wider working space, a better view and clearer anatomical landmarks as compared with a retroperitoneal approach.8 However, we preferred to perform through the retroperitoneal route. The retroperitoneal approach has several advantages over the transperitoneal approach, such as no need to mobilize the colon, and a low risk of visceral organ injury.5,10 In addition, postoperative urinary leakage does not interfere with the peritoneal cavity.5,10 The retroperitoneal technique is also associated with a shorter period of convalescence.11 The main disadvantage of this approach is the limit of working space. In the first few cases in our series, we spent a long operation time. However, after adoption of the Gaur's balloon dissection technique12 and increased experience, we rarely encountered difficulty with the working area limitation and the operative time was much improved. With the familiarity of the retroperitoneal anatomical landmarks by the urologist, and imitation of open ureterolithotomy technique, we encourage the retroperitoneal approach to be the access of choice for this operation.

Regarding the problem of stone adhering to the mucosa, Demirci et al.13 have recommended laparoscopic stylet to overcome this difficulty, whereas we used the laparoscopic hook without electrode with the assistance of grasping forceps to resolve this task.

We ruled out distal obstruction by inserting a feeding tube into the ureter via one of the laparoscopic ports and injecting saline solution. We spent only 5 min or less and faced a little gas leak for this step; this important step could prevent the complications such as urinary leakage from undetected distal obstruction.

It is not clear from previous reports whether the ureterotomy incision should be sutured and whether a ureteral stent should be placed. Demirci et al.13 have observed that suturing of the ureter is more effective than placement of DJ stent into the ureter to reduce urine extravasation in even their small series. Our series is unique in these controversial points. Like an open ureterolithotomy, the ureters were stitched with interrupted absorbable suture without placing the stent in all except in one case. Generally, the ureteral mucosa could be seen clearly by the magnification of the laparoscope and we could close the ureteral incision with mucosa to mucosa. In our center, the cost of a DJ stent is $US80, which is equal to the cost of eight nights’ hospital stay. With the watertight suturing and the high cost of the ureteral stent in our country, we did not place the stent in most of the patients. In addition, the technique of placing the stent via laparoscopy is also difficult and sometimes it needs fluoroscope guidance. With these difficulties, Goel and Hemal9 have not placed a stent in 20 of the last 26 patients of their series and it is placed only in patients with stone impaction and poor renal function. Nevertheless, we could not suture the ureteral incision with the proper watertight technique due to severe inflammation of the ureter in the one exceptional case. Instead, we placed the DJ stent to reduce urinary leakage and prevent further complications. In our series, retroperitoneal drainage was completed within 48, 72 and 96 h in fifteen, eight and five cases, respectively. Our mean postoperative drain removal (2.86 days) was much better than those in other series13,14 in which ureteral suturing as well as ureteral stenting are not systematic. We did not encounter postoperative bowel ileus, either. However, in one case, even with the proper technique of suturing, urine still leaked for more than 7 days (prolonged leakage) and it was difficult to explain the exact cause. The possible causes were prolonged impaction, chronically inflamed and friable after infection of the ureter. Gaur and colleagues4 have recommended that the ureter should only be stented and not sutured in these circumstances. We resolved this complication by inserting a DJ stent and the leakage was stopped within 24 h after placing the stent. Even with the absence of a stent in most patients, our series had a low incidence (3.4%) of urinary leakage. This may suggest that the ureteral stent should be placed only in cases of severe inflammation. We converted RPU to open ureterolithotomy in one case because we lost more than 1 h in looking for the ureter and locating stone. In this case, the stone size was small (only 10 mm) and associated with severe inflammation; thus, the small and inflamed stone might not be suitable for laparoscopy.

Most authors place a drain into the retroperitoneum.4,5,15 We also recommended placing a drain to prevent urinoma or collection.

A major complication of LUL is stenosis, which has been reported to occur in 15% to 20% in separate series.7,16 However, the incidence summarized from a review of the literature by Nouira et al.14 was only 2.5%. The etiologies of postoperative ureteral strictures are not clear. In the series described by Keeley and associates,7 the two patients who developed ureteral stenosis were those who underwent suturing of the ureterotomy. Nouira et al.14 have explained that too tight sutures may have caused local ureteral wall ischemia and resulted in stenosis. They have suggested that ureteral suturing should be attempted only to approximate the ureteral edges in order to facilitate healing and not to be watertight. However, with watertight sutures, no ureteral strictures were found in our series within the 6 months of follow up. Nouira et al.14 have also recommended that use of a cold knife for opening the ureter is a wiser choice to prevent ureteral stricture; nevertheless, we believed that with the use of cutting-mode, an electrical hook is much easier and this technique is encouraged in a large series of Gaur and colleagues.4 Harewood and colleagues8 have also used a diathermy hook electrode to open the ureter in six patients, and no ureteral strictures were reported in this series. Mitchinson and Bird17 have proposed that prolonged postoperative urinary drainage with retroperitoneal fibrosis is a possible cause of ureteral stenosis. Therefore, we encouraged the watertight ureteral closure to decrease the stricture formation. In addition, this procedure could reduce postoperative ileus, decrease urinary leakage and reduce hospital stay.

Conclusion

Laparoscopic ureterolithotomy is a minimally invasive treatment for impacted and difficult stones in the upper ureter. It may be considered the first-line management for large impacted ureteric stones, especially to ensure patients become stone-free within a single operation. The technical recommendations are retroperitoneal access, and watertight suturing of the ureterotomy incision. Moreover, a ureteral stent should be placed in only cases of severe inflammation of the ureter or inappropriate suturing.

Acknowledgment

We wish to thank Professor Amnuay Thithapandha for his help and advice concerning the preparation of this manuscript.

Ancillary