LAPAROSCOPIC URETEROLITHOTOMY fmrx~ ~A13oyM.D. GEORGE S. FERZLI, M.D. RICHARD IOFFREDA, M, D PETER S. ALBERT. M.D.
From the Departments of Urology and Surgery, Staten Island Universit!, Hospital. Staten Island, and the Department of Urology, State [Jniversity of New York. Health Science Center, Brooklyn, New York
ABSTRACTWe describe the successful laparoscopic removal of a distal ureteral cystine stone not amenable to ureteroscopic or medical therapy. This approach offers an alternative to open ureterolithotomy in patients when less invasiw measures fail.
With the development of extracorporeal shockwave lithotripsy (ESWL), improved endourologic instrumentation. and medical dissolution therapy, the need for open ureterolithotomy has become less common. Open operation is occasionally necessary when less invasive techniques fail. As in many of the surgical specialties. laparoscopy has become more common in urologic surgery. The distal ureter is readily encountered during laparoscopic pelvic lymph node dissect ion (LPLND) . Using a similar laparoscopic approach, we recently performed a laparoscopic Ilreterolithotomy to remove a distal ureteral stone. Material
pliant after a few weeks. The subsequently underwent laparoscopic moval. Operative
\1.4l~Cll
and Methods
IW’?
VOI,I:ME
XXNIX.
NUMBER
technique
Preoperative abdominal x-ray films were taken to localize the stone position. General anesthesia with tracheal intubation was carried out followed by placement of a nasogastric tube attached to suction and placement of a Foley catheter to drain the bladder. The patient was then placed in lithotomy position (w:ith slight Trendelenburg) and the left (ipsilateral) side rotated toward the operator. The patient was then prepared in sterile fashion. A small umbilical incision was made, and the Veress needle was inserted. The abdomen was insufflated to 15 mm Hg with the pat:ient fully relaxed. Correct placement of the needle was confirmed with percussion and the Palmer test. The umbilical incision was widened and a lo-mm trocar was inserted. Through this trocar a zero-degree laparoscope with video camera attached was inserted. Under video control, two operating trocars were placed on the contralateral side of the stone, and one trocar was placed through the abdomen on the ipsilateral side (Fig. 1A). With the surgeon operating from the contralateral side, and an assistant on the ipsilateral side of the stone, the peritoneal attachments to
A twenty-seven-year-old cystinuric male presented tco the hospital with left renal colic and intractable pain. On intravenous urogram he was found to have a 14-mm ureteral stone impacted at the pelvic brim with obstruction. The patient underwent ureteroscopy, and pulseddye laser lithotripsy with complete failure to fragment the stone despite using 140 mJ of f:nera. The stone was too large for safe basketing and could not be manipulated toward the kidney. A Double-J stent was placed, and the patient l,\.as given a trial of medical stone dissolution. The dissolution regimen was poorly tolcrated viith the patient becoming poorly com-
l~l~oI.o(:~
patient stone re-
3
223
FIGURE: 1. (A) Trocar sites for ureterolithotomy include umbilical trocar for placcment of laparoscope, two contralateral operating trocars. ipsilateral trocar in upper quadrant for lower ureteral stones, or lower quadrant ipsilateral trocar for proximal stones. Two ipsilateral trocars can be used for more difficult dissections. (B) Colon is refleeted medially to expose weter. Ureterotomy is performed and stone removed. (C) Large ureterotomie.y can be closed with absorbable suturea placed laparoscopically.
retracted, stone
..
Ureterotomy closed over a stent
: I
the descending colon were dissected to reflect the colon medially and to expose the retroperitoneum (Fig. 1B). Using sharp and blunt dissection, the ureter was exposed as it crossed the psoas muscle and iliac vessels. Dissection was carried into the pelvis, and the distal ureter was isolated as it crossed the iliac vessels and pelvic brim. By grasping the ureter gently with graspers, the stone was localized. Following localization, a small longitudinal ureterotomy was made with scissors, and the stone was then removed with graspers. A stent was left in place to allow for healing of the ureterotomy. The abdomen was then deflated; the trocars were removed, and the wounds were sutured. Results The procedure was tolerated well except for a mild ileus which resolved by postoperative day 3. Diet was then well tolerated, and the patient resumed all his usual activities within a
week. No urinary leaks or other sequelae were encountered postoperatively. The ureterotomy healed well with the stent -removed after four weeks. Comment Despite the development of ESWL ant 1 improved endourologic techniques, there are still occasions when stone removal by open operation is required. Assimos et al.’ report 23 cases of ureterolithotomy in a large series of stone procedures. Ureterolithotomy has a definite role in algorithms for managing cystine stones.2 Laparoscopic operations have replaced some open operative procedures in many surgical specialties. The goal of laparoscopy over open operation is to provide patients with shorter hospital stays and periods of convalescence. Schuessler and colleagues” recently popularized the laparoscopic pelvic lymph node dissection for staging of prostate carcinoma. In this approach the ureter is commonly encountered as
it crosses the ihac vessels into the pelvis. Similarly, laparoscopic ureteral operation is feasible. \Ve describe a successful laparoscopic ureteroli thotom:\.. We performed the procedure with one irmbilical trocar for the laparoscope, and three operating trocars. We recommend two S-mm trocars Ire used for graspers and scissors, and one lo-mm trocar be used if hemoclips are needed for hemostasis. Dissection is easier if the ipsilateral trocar is in the upper quadrant of the abdomen for distal stones, and in the lower cluadrant of the abdomen for proximal stones. If dissection is difficult, a fourth operating trocar can be added to the ipsilateral side (Fig. IA). Stone localization provided no difficulty in our patient. The stone was easil!. found h?, ljalpation with graspers. Alternatively, if this fails, intraoperative fluoroscopy or simultaneous ureteroscopy can aid in localization. The aIdvantage of a laparoscopic approach to rrreterolithotomy is the removal of the stone without the need for a large incision. Obviouslv, the patient can have a shorter convalescence and hospital stay with less time lost from work. A, potential disadvantage of the laparoscopic method is the need to approach the ureter transperitoneally. Open operation allows for a completely retroperitoneal approach to the
ureter and confinement of any urincn leaks to the retroperitonelrn~. This potential disadv~antagc had no real consequences in our patient. In addition. a vvater-tight closure of the ureterotom!, can be cumbersome laParoscol)icail~. Leaving a small ureterotorn!’ open, or placing a fevv spaced sutures to close the defect should offer no disadvantage in a stented ureter.” Several interrupted sutures can be placed laparoscopicall!, to close the ureter. and with practice and the development of better needles and needle holders, laparoscopic suturing will lwcorne easier (Fig. 1C). Stents (*an be I)laced inor niorc easil!. traoperativel!. v.ia a trocar, during simultaneous or preoperativ’r qstoscop>:
From the Departments of Urology and Surgery, Staten Island Universit!, Hospital. Staten Island, and the Department of Urology, State [Jniversity of New York. Health Science Center, Brooklyn, New York
ABSTRACTWe describe the successful laparoscopic removal of a distal ureteral cystine stone not amenable to ureteroscopic or medical therapy. This approach offers an alternative to open ureterolithotomy in patients when less invasiw measures fail.
With the development of extracorporeal shockwave lithotripsy (ESWL), improved endourologic instrumentation. and medical dissolution therapy, the need for open ureterolithotomy has become less common. Open operation is occasionally necessary when less invasive techniques fail. As in many of the surgical specialties. laparoscopy has become more common in urologic surgery. The distal ureter is readily encountered during laparoscopic pelvic lymph node dissect ion (LPLND) . Using a similar laparoscopic approach, we recently performed a laparoscopic Ilreterolithotomy to remove a distal ureteral stone. Material
pliant after a few weeks. The subsequently underwent laparoscopic moval. Operative
\1.4l~Cll
and Methods
IW’?
VOI,I:ME
XXNIX.
NUMBER
technique
Preoperative abdominal x-ray films were taken to localize the stone position. General anesthesia with tracheal intubation was carried out followed by placement of a nasogastric tube attached to suction and placement of a Foley catheter to drain the bladder. The patient was then placed in lithotomy position (w:ith slight Trendelenburg) and the left (ipsilateral) side rotated toward the operator. The patient was then prepared in sterile fashion. A small umbilical incision was made, and the Veress needle was inserted. The abdomen was insufflated to 15 mm Hg with the pat:ient fully relaxed. Correct placement of the needle was confirmed with percussion and the Palmer test. The umbilical incision was widened and a lo-mm trocar was inserted. Through this trocar a zero-degree laparoscope with video camera attached was inserted. Under video control, two operating trocars were placed on the contralateral side of the stone, and one trocar was placed through the abdomen on the ipsilateral side (Fig. 1A). With the surgeon operating from the contralateral side, and an assistant on the ipsilateral side of the stone, the peritoneal attachments to
A twenty-seven-year-old cystinuric male presented tco the hospital with left renal colic and intractable pain. On intravenous urogram he was found to have a 14-mm ureteral stone impacted at the pelvic brim with obstruction. The patient underwent ureteroscopy, and pulseddye laser lithotripsy with complete failure to fragment the stone despite using 140 mJ of f:nera. The stone was too large for safe basketing and could not be manipulated toward the kidney. A Double-J stent was placed, and the patient l,\.as given a trial of medical stone dissolution. The dissolution regimen was poorly tolcrated viith the patient becoming poorly com-
l~l~oI.o(:~
patient stone re-
3
223
FIGURE: 1. (A) Trocar sites for ureterolithotomy include umbilical trocar for placcment of laparoscope, two contralateral operating trocars. ipsilateral trocar in upper quadrant for lower ureteral stones, or lower quadrant ipsilateral trocar for proximal stones. Two ipsilateral trocars can be used for more difficult dissections. (B) Colon is refleeted medially to expose weter. Ureterotomy is performed and stone removed. (C) Large ureterotomie.y can be closed with absorbable suturea placed laparoscopically.
retracted, stone
..
Ureterotomy closed over a stent
: I
the descending colon were dissected to reflect the colon medially and to expose the retroperitoneum (Fig. 1B). Using sharp and blunt dissection, the ureter was exposed as it crossed the psoas muscle and iliac vessels. Dissection was carried into the pelvis, and the distal ureter was isolated as it crossed the iliac vessels and pelvic brim. By grasping the ureter gently with graspers, the stone was localized. Following localization, a small longitudinal ureterotomy was made with scissors, and the stone was then removed with graspers. A stent was left in place to allow for healing of the ureterotomy. The abdomen was then deflated; the trocars were removed, and the wounds were sutured. Results The procedure was tolerated well except for a mild ileus which resolved by postoperative day 3. Diet was then well tolerated, and the patient resumed all his usual activities within a
week. No urinary leaks or other sequelae were encountered postoperatively. The ureterotomy healed well with the stent -removed after four weeks. Comment Despite the development of ESWL ant 1 improved endourologic techniques, there are still occasions when stone removal by open operation is required. Assimos et al.’ report 23 cases of ureterolithotomy in a large series of stone procedures. Ureterolithotomy has a definite role in algorithms for managing cystine stones.2 Laparoscopic operations have replaced some open operative procedures in many surgical specialties. The goal of laparoscopy over open operation is to provide patients with shorter hospital stays and periods of convalescence. Schuessler and colleagues” recently popularized the laparoscopic pelvic lymph node dissection for staging of prostate carcinoma. In this approach the ureter is commonly encountered as
it crosses the ihac vessels into the pelvis. Similarly, laparoscopic ureteral operation is feasible. \Ve describe a successful laparoscopic ureteroli thotom:\.. We performed the procedure with one irmbilical trocar for the laparoscope, and three operating trocars. We recommend two S-mm trocars Ire used for graspers and scissors, and one lo-mm trocar be used if hemoclips are needed for hemostasis. Dissection is easier if the ipsilateral trocar is in the upper quadrant of the abdomen for distal stones, and in the lower cluadrant of the abdomen for proximal stones. If dissection is difficult, a fourth operating trocar can be added to the ipsilateral side (Fig. IA). Stone localization provided no difficulty in our patient. The stone was easil!. found h?, ljalpation with graspers. Alternatively, if this fails, intraoperative fluoroscopy or simultaneous ureteroscopy can aid in localization. The aIdvantage of a laparoscopic approach to rrreterolithotomy is the removal of the stone without the need for a large incision. Obviouslv, the patient can have a shorter convalescence and hospital stay with less time lost from work. A, potential disadvantage of the laparoscopic method is the need to approach the ureter transperitoneally. Open operation allows for a completely retroperitoneal approach to the
ureter and confinement of any urincn leaks to the retroperitonelrn~. This potential disadv~antagc had no real consequences in our patient. In addition. a vvater-tight closure of the ureterotom!, can be cumbersome laParoscol)icail~. Leaving a small ureterotorn!’ open, or placing a fevv spaced sutures to close the defect should offer no disadvantage in a stented ureter.” Several interrupted sutures can be placed laparoscopicall!, to close the ureter. and with practice and the development of better needles and needle holders, laparoscopic suturing will lwcorne easier (Fig. 1C). Stents (*an be I)laced inor niorc easil!. traoperativel!. v.ia a trocar, during simultaneous or preoperativ’r qstoscop>:
