Laparoscopic ureterolithotomy is a good alternative to open surgery when endourological means are not sufficient for stone retrieval. Urologist would prefer putting a double J stent beforehand but stenting not only takes away significant operating room time but at times it becomes difficult to negotiate the stent beyond the stone. This technique describes laparoscopic stenting by using routinely available double J stent.
Once the stone is localized by 'ureteral pinching', clean cut is made over the stone using tailor-made laparoscopic knife. Stone is retrieved and secured in the glove finger for removal at the end of the surgery.
For making a safe placement of the stent and to obviate the need for fluoroscopic confirmation, mathematical calculation is helpful to achieve the goal of placing the stent correctly. Bony landmark for the ureteric orifice is 1-1.5 cm above and lateral to the pubic tubercle. This bony landmark and the midpoint of the renal pelvis correspond to the ureteric length which is approximately 25 cm. (In a digital X-ray, a proportion of distance can be used considering ureter length 25 cm.) Slit in the double J stent is then made according to the location of the stone from the bony landmark of the ureterovesical junction with Number 11 surgical blade. The rigid end of the guide wire is then cut a little short of the stent and then the guide wire is placed inside the double J stent to make both the ends straight. A silk thread is tied to the guide wire at the slit, which helps in pulling the guide wire out.
Placement of the Double J Stent
Once the stone is taken out, one end (usually the close end) of the stent is put in proximally to its complete length. As the proximal ureter is dilated, pushing the whole length of the stent with knot on it is not a problem. Then, holding the other end of the double J stent, which is straight due to the presence of a guide wire, the stent is pushed in distally till the knot is visualized at the ureterotomy site. Supporting the stent with Maryland in the left hand and holding the knot with the right hand instrument, the guide wire is then taken out. This ensures safe placement of both the ends of a double J stent. Once the stent is in place, 4-0 vicryl is used to close the ureterotomy with interrupted stitches and a tube drain is placed before closing the ports. The fact that the tensile strength of the double J stent was not affected by the slit was proved by a lab test in which equal weights were hung from stents with or without a slit. Of eight cases done so far there was no failure in stent placement with a median stenting time of 3 min (2 to 6 min). In all the patients, the stent could be removed without breakage.