|Year : 2004 | Volume
| Issue : 2 | Page : 101-105
Retroperitoneal laparoscopic ureterolithotomy - our experience
Tejanshu P Shah, Kirtipal Vishana, Prakash Ranka, Manish Patel, Rajesh Chaudhary
Department of Urology and Kidney Transplantation, Institute of Kidney Diseases and Transplantation Sciences, BJ Medical College and Civil Hospital Campus, Asarwa, Ahmedabad, India
Tejanshu P Shah
65-B Swastik Society, Navrangpura, Ahmedabad - 380 009
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives : Appraisal of indications for laparoscopic ureterolithotomy, its results and advantages in the current era of minimally invasive surgery.
Methods : We performed 56 laparoscopic ureterolithotomy in 54 patients, all by extraperitoneal approach. Out of 56 stones, 34 were located in the upper ureter, 18 in the mid-ureter and 4 in the lower ureter Main indication was large (1.5 to 3.5 cm) impacted stone in 50 cases (89%). Other indications were failed ESWL and a failed attempt at ureteroscopy.
Results : There were no major complications. The procedure failed in two patients. Average duration of hospital stay was 2-4 days. During follow-up 3 months later IVU revealed normal ureter in all cases.
Conclusions : In selected patients with large, hard, impacted ureteral stones, which are likely to cause difficulty in endourological procedures due to its large size and distance from pelviureteral junction or ureterovesical junction, laparoscopic ureterolithotomy is a reasonable treatment option in lieu of open surgery. It offers stone free status by a single procedure with serendipitous advantage of maintaining laparoscopic skill among general urologic community who do not have flexible ureteroscopies and holmium laser facilities.
Keywords: Laparoscopy, ureterolithotomy, ureteral stone.
|How to cite this article:|
Shah TP, Vishana K, Ranka P, Patel M, Chaudhary R. Retroperitoneal laparoscopic ureterolithotomy - our experience. Indian J Urol 2004;20:101-5
| Introduction|| |
Extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS) ensure the instrumental treatment of most renal and uretenc stones.  Despite the usage of these methods, there are some stones that cannot be removed from the urinary tract . 
The surgical treatment options for proximal ureteral stones include ESWL with or without stone manipulation. Ureteroscopy, PCNL and rarely open and laparoscopic stone surgery.  Retroperitoneal  and transperitoneal  approaches for laparoscopic ureterolithotomy have been described. Turk and colleagues reported 26 patients who underwent laparoscopic ureterolithotomy. Keeley and colleagues  reported 14 patients who underwent transperitoneal laparoscopic ureterolithotomy. We report a series of 56 patients in whom retroperitoneal laparoscopic ureterolithotomy was done. Our objective is appraisal of indications, results and benefits of this procedure in the current era with the advent of flexible ureteroscopes and Holmium laser lithotripsy.
| Patients and Methods|| |
We performed 56 laparoscopic ureterolithotomy in 54 patients from January 1999 to December 2001. Age of the patients was in the range of 18 to 48 years. Mean age was 33 years. Forty one patients were males and 13 were females. Out of 56 stones, 34 were located in the upper ureter [Figure - 1], 18 in the mid-ureter and 4 in the lower ureter. All laparoscopic ureterolithotomy were extraperitoneal. Main indication for laparoscopic procedure was large (1.5 to 3.5 cm), impacted stone in 50 cases (80%) [Figure - 2] which were likely to pose difficulty in endourological procedure and reluctant to undergo open surgery. Other indication was failed ESWL in 4 patients and in 2 patients ureteroscopic attempts failed due to acute angulation. Three patients presented with renal failure and preoperative percutaneous nephrostomy was placed in them. Informed consent was obtained for performing this procedure and need for conversion to open surgery was also elaborated. Patients, who can be managed easily be endourological procedures like PCNL and URS because of the location like just below pelviureteral junction or very near ureterovesical junction and smaller size (<1 cm) of stone were excluded from this study.
A retroperitoneal approach was performed in all patients. Under general anesthesia, site of primary port was 1.5 cm below tip of 12 th rib for upper ureteral stone and about 23 cm medial to anterosuperior iliac spine for lower ureteral stone. Skin incision of about 1.5 cm was made with knife and muscles were splitted till retroperitoneal fat was seen. The peritoneum was separated for about 2-3 inches all around with gentle finger dissection. This separated the peritoneum from the abdominal wall without opening it while placing the anterior ports. A modified balloon (made up of surgeon's glove finger) mounted on a catheter was used to create working space in the retroperitoneum, which was maintained by CO 2 insufflation. One primary port and two secondary ports were inserted. The location of the ports on the abdomen for upper ureterolithotomy and lower ureterolithotomy are shown in [Figure - 3]A & B. The ureter was identified and the stone was localized by the clear bulge in ureter. A Babcock type laparoscopic ureteral forceps was applied above the bulge to facilitate the dissection of the ureter and prevent slippage of the stone in to the upper ureter and kidney. The ureter was dissected and incised with laser endoknife. Following extraction of calculus a double J-stent was placed retroperitoneoscopically by passing it over a guide wire through the ureteral incision, first down and then up. Ureteral suturing was done by extracorporeal twist technique using 4/0 atraumatic polyglactin material as we found freehand suturing difficult initially. However, as we gained experience we also used the freehand suturing to close the ureterotomy. The stone was held near one end with grasping forceps and brought near the camera port.
Sutures around the camera port were removed and the incision of the camera port was enlarged. Using the light from an endoscopic light cable into the enlarged incision the stone was visualized. The stone was held with a Babcock forceps from outside near one end and was removed intact by careful maneuvering. The operative time ranged from 60 to 120 minutes (mean 82 minutes).
Problems anticipated and preventive measures taken during laparoscopic ureterolithotomy for upper I ureteral stones-
- Injury to the subcostal vessels was prevented by remaining 1-1.5 cm below the tip of the 12 th rib.
- Opening up of the peritoneum or port placement through the peritoneum was prevented by separating the peritoneum from the abdominal wall muscle by gentle finger dissection carried out anteriorly for 2-3 inches, after the retroperitoneal fat was seen through the split muscles.
- Identification of the ureter was done by observing the peristalsis and the typical blood vessels of the ureter. Structures like the gonadal vein and the inferior vena cava that can be mistaken for the ureter should be kept in mind.
- Upward migration of the stone was prevented by applying a Babcock type forceps on the ureter above the stone bulge.
In lower ureteral stone we were extra cautious in dissection where the ureter was crossing the iliac vessels and the space was less. Hence, the ports were not inserted fully but kept just inside the muscles and fixed with skin sutures. This prevented frequent slippage of the main port and still provided a panoramic view of the retroperitoneum.
| Results|| |
There were no major complications. The procedure failed in two patients and was converted to open surgery. Six patients had minimal localized surgical emphysema, which resolved spontaneously. The ureteral leak stopped in 1-3 days in most patients. Duration of hospital stay was 2-4 days. During follow-up 3 months later, IVU was done, which showed a normal ureter in all the patients. Blood loss was less than 25 ml in all the cases and the maximum urinary leak was 5 days in two cases. In these cases, stent had migrated below the ureterotomy site. After repositioning the stent and keeping an urethral-indwelling catheter, the drainage stopped.
| Discussion|| |
Laparoscopic ureterolithotomy, though minimally invasive is not routinely recommended as an alternative to already existing minimally invasive procedures. Several reports suggested that ureteroscopy should be the primary approach to impacted ureteral stones. Mugiya and colleagues  demonstrated the efficiency of small flexible ureteroscopes (6.9 to 7.5 F) combined with holmium laser lithotripsy in 104 patients with impacted ureteral stones.
At 1 month, the stone free rate was 100%. Because of the technologically intensive nature of ureteral stone management, the availability of equipment can dictate the treatment options. Not every operative environment can have all possible lithotriptors, ureteroscopes, lithotrites or stone retrieval devices immediately. 
An impacted stone is variously defined as a stone that cannot be bypassed by a wire or catheter' or a stone remaining at the same site in the ureter for more than 2 months.  Impacted stones tend to be more resistant ESWL. ,
PCNL is an option for large proximal ureteral stones with a reported meaian stone-free rate of 86%.  However, upper ureteral stones cannot be accessed by antegrade approach, if the distance from pelviureteral junction is more, especially in obese patients and, if the stone size is large.
When a patient might otherwise be considered for open surgery, the advent of laparoscopy may provide a minimally invasive alternative.  In the present series of 56 retroperitoneal laparoscopic ureterolithotomy, the indications were large (1.5 to 3.5 cm) impacted stones, failed ESWL and failed attempts at ureteroscopic removal. We do not have facilities of flexible ureteroscopes and holmium laser lithotripsy in our center. Keeley and colleagues  reported 14 patients who underwent transperitoneal laparoscopic ureterolithotomy. In their series, indications included stones that could not be accessed ureteroscopically or did not fragment with other modalities or large proximal ureteric stones (greater than 1.5 cm). Turk and colleagues  reported 26 patients who underwent laparoscopic ureterolithotomy (transperitoneal approach in 21 and retroperitoneal approach in 5 patients) for stones ranging in size from 20 mm to 45 mm. The vast majority of urologists and stone patients do not have direct access to small flexible ureteroscopies and holmium laser lithotripsy. Therefore, laparoscopic ureterolithotomy is a reasonable minimal invasive treatment option in selected patients.
The technique of retroperitoneal laparoscopic ureterolithotomy is simple and safe. The Gaur balloon (Cook urological, Spencer, IN) recommended by Gaur  is an effective and safe device. We however, used an improvised surgeon's glove two fingers mounted on a catheter as a modified balloon and found it satisfactory in creating the retroperitoneal space neatly and atraumatically. This is inexpensive and easily made with materials available. But the balloon dissection is not adequate in the presence of fibrosis. In the present series, the procedure failed in 2 patients and was converted into an open procedure. The failures were due to retroperitoneal adhesions and unsatisfactory pneumo-retroperitoneum associated with peritoneal tear. In the series of 26 patients reported by Turk and colleagues,  the calculus could not be located laparoscopically in two cases, requiring conversion to open surgery. Gaur et al  reported their experience of laparoscopic ureterolithotomy in 17 patients with three failures, mostly in the early part of the learning curve. Thus, the procedure has certain limitations, viz. dense retroperitoneal adhesions, unsatisfactory pneumoretroperitoneum, inability to locate the calculus along with laparoscopic learning curve.
In the present series ureteral suturing was done in all cases. In the series of 14 patients reported by Keeley and colleagues,  ureteral suturing was done in first five patients, but in the last nine patients, the ureterotomy was left open. Gaur et al  mentioned that it would be better not to suture the ureter, if one is not used to the laparoscopic suturing techniques. In the present series, there were four patients with stone in the lower ureter. We agree with the conclusion of Gaur et al  that this procedure is not suitable for the lower ureter because of truncated space in the pelvic retroperitoneum. However, use of 30° telescope and telescope port kept as superficial as possible help in the procedure.
In this era of laparoscopy and endoscopy, newer techniques are emerging fast. Csaba Toth  reported 52 percutaneous ureterolithotomies (PCUL) in 51 patients. They concluded that PCUL is a safe and effective method for removing large, impacted upper and middle ureteral stones and the same results can be reached as that,of retroperitoneoscopy. They, however, recommended that direct PCUL is advisable only for those endourologists who have outstanding experience in this field.
A survey by See and coworkers  found that 86% of urologists actually performed laparoseopic surgeries during the year after taking a training course in laparoscopy. We envisage that laparoscopic ureterolithotomy is a simple and safe procedure and offers serendipitous benefit of maintaining laparoscopic skill and interest of urologists.
| Conclusions|| |
A large, hard and chronically impacted ureteral stone that is recalcitrant to extra-corporeal shock wave lithotripsy, and difficult to reach with an ureteroscope from either above or below can be treated by retroperitoneal laparoscopy. It is a minimally invasive and maximally effective procedure and is an economically viable option where laparoscopic instruments are easily available. We recommend laparoscopy for large ureteral stone (1.5 cm and above) any where in the ureter. However, while doing laparoscopy for lower ureteral stones, close proximity to iliac vessels and truncated space in pelvic retroperitoneum causing technical difficulties which should be kept in mind when deciding between available treatment options.
In the last decade, several laparoscopic procedures in urology have become established and some are in the process of evolution. In the scenario of historic transition, the laparoscopic ureterolithotomy can aid in the dexterity, smoothness and faster execution of laparoscopy by dedicated enthusiasts who do not have facilities of flexible ureteroscopes and holmium laser lithotripsy.
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[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1]