British Journal of Urology (1975), 41, 613-616 0

Transperitoneal Ureterolithotomy T. K. BOSE and RICHARD E. SHAW Department of Urology, Walsgrave Hospital, Coventry

The transperitoneal approach to the ureters for ureterolithotomy has been commended by a number of authors and notably by Qvist, Jaber Muhsen and Al-Waidh (1962). They drew attention to the following advantages enjoyed by this technique. 1. The transperitoneal approach is quicker, easier and less traumatic than the retroperitoneal approach. 2. Incisional herniae are less common following operations on the lower anterior abdominal wall than on the postero-lateral area. 3. The stone can be located immediately on opening the peritoneum and its position maintained by digital control. 4. Removal of the stone involves minimal dissection and mobilisation so that haematoma formation and devascularisation of the ureter is minimal. 5. The transperitoneal approach is easier than the retroperitoneal approach for recurrent calculi. 6. Multiple stones can be removed without extensive mobilisation of the ureter, if necessary by separate ureterotomy incisions. 7. Bilateral ureterolithotomy can be performed through one abdominal incision. In addition the authors claimed that the transperitoneal operation is safer than the extraperitoneal procedure. They argued that the defensive ability of the peritoneum far exceeds that of the extraperitoneal tissues in relationship to infection and they specifically advised that, after removal of the stone from the ureter, the peritoneal incision over the ureter should not be sutured but the peritoneal cavity drained. In this respect the authors’ advice is contrary to that of Michalowski and Modelski (1958), who urged the importance of retroperitoneal drainage if the risks associated with urinary extravasation and infection are to be prevented. So satisfied were Qvist and his colleagues with their results in 22 patients that they recommended the transperitoneal approach in all cases where the stone lay in the juxtaperitoneal part of the ureter and employed it in operations on the abdominal as well as the pelvic ureter.

Material We have examined the records of all ureterolithotomies carried out in the Urological Department of Coventry from 1967 to 1975 with special reference to the incidence of postoperative complications. The cases have been divided into 2 groups according to the position of the stone in the abdominal or pelvic parts of the ureter.

Results There were 84 ureterolithotomies performed during this period. Unlike Qvist and his colleagues all the operations on the abdominal ureter were by the traditional extraperitoneal method but the majority of those carried out in the lower third were by the transperitoneal approach. 613

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Table I Complications Minor

Major

&

Site of stone Abdominal ureter

Pelvic ureter

Surgical approach

No. of cases

7 u 7

Wound Transient Severe General infection ileus ileus peritonitis

.

2 (pulmonary embolism)

1

2

..

2

..

..

..

..

..

..

..

Extraperi toneal

41

6

..

..

Transperitoneal with drainage across peritoneum

16

1

1

Transperitoneal with extraperitoneal drainage

20

1

3

.. ..

Extraperitoneal Transvesical

4

Other

,

..

-

84

It is clear that the extraperitoneal approach to the upper two-thirds of the ureter is very satisfactory. Of 41 patients, 2 suffered pulmonary embolism in the postoperative period but 1 was under treatment for carcinoma of the prostate while the other had recently undergone a prolonged period of in-patient treatment for deep vein thrombosis. Both made good recoveries and there is no reason to relate these complications to the type of surgical approach employed. The remaining patients had an uninterrupted convalescence, the only complications being from a minor degree of wound infection in 6 cases. The transperitoneal approach was employed in nearly all cases where the stone lay in the pelvic portion of the ureter. In the first 16 cases, the technique recommended by Qvist and his colleagues-namely, non-suture of the peritoneum over the ureter and intraperitoneal drainage-was employed. The results were less than satisfactory. 3 of the 16 patients had serious postoperative complications, 1 of whom suffered severe ileus, while 2 others developed general peritonitis requiring abdominal exploration.

Case Report Mr R. S. H., aged 72 This patient attended in April 1971 with right renal colic. 12 years previously a bladder stone had been removed, and 2 years later he passed a stone following an attack of left renal colic. His blood pressure was 160/100 but otherwise physical examination was negative. An intravenous pyelogram showed 2 stones in the pelvic portion of the right ureter. On 20th April 1971 transperitoneal ureterolithotomy was performed. The peritoneal incision over the ureter was not sutured but the abdomen was drained. The following day he was vomiting and the abdomen was moderately distended; bowel sounds were absent. 2 days after the operation he was an ill man with signs of general peritonitis and the abdomen was re-explored. During induction of anaesthesia cardiac arrest took place but the heart was re-started, A large volume of purulent fluid was evacuated from the peritoneal cavity and 2

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intraperitoneal drains were inserted and the abdomen closed. Proteus and Coliform organisms were cultured from the peritoneal fluid. During the next few days his condition slowly improved but on 4th May a third operation for burst abdomen was carried out. Thereafter he continued to improve until his discharge from hospital on 19th May. A large incisional hernia was the final legacy of his operations. Following this unhappy experience of transperitoneal ureterolithotomy our technique was altered. The peritoneal incision over the ureter was securely closed, a stab incision was made in the flank and a tunnel developed from it to the site of the ureterotomy. An extraperitoneal drain was inserted along the track so formed to allow urine to escape without contamination of the peritoneal cavity. In some cases an intraperitoneal drain was also inserted. Results of operations in the next 20 cases in which this technique was employed were entirely satisfactory and no serious postoperative complications were encountered. Our experience was in harmony with that of Michalowski and Modelski (1958) who carried out the same procedure in 3 cases.

Discussion

We do not support Qvist et af. in their advocacy of the transperitoneal approach for the removal of stones lying in the abdominal ureter. Our experience confirms that the extraperitoneal approach is very satisfactory and we see no advantage in opening the peritoneal cavity in the majority of cases. There may be special circumstances in which the approach may be considered-for example when multiple bilateral ureteric calculi are present-but so far we have not encountered such indications. On the other hand, these authors are entirely correct in drawing attention to the many advantages of the transperitoneal approach to the lower ureter. The ureter lies immediately under the peritoneum and can be easily identified even in an obese patient. The surgeon is spared the blind dissection of the cellular tissues of the pelvis, which may produce troublesome venous bleeding and which may be especially difficult if there have been previous operations or inflammatory trouble. The transperitoneal approach is quicker and much less traumatic. It is quite clear, however, that leakage of infected urine into the peritoneal cavity is to be avoided at all costs and that satisfactory extraperitoneal drainage must be established before the operation is completed. Operations on the last 3 to 4 c of the ureter have their own difficulties. In this area the ureter is no longer related to the peritoneum and is crossed by the vas in the male and the uterine vessels in the female. If the ureter is isolated at a higher level it can then be mobilised, drawn upwards above these structures and, whilst supported on the pad of the index finger, may be incised over the stone, which is then extracted. This is usually fairly easy in the female, but in an obese male with a narrow pelvis it may present formidable difficulties. We now usually employ the transvesical approach as described by Barnhouse et al. (1973) and Landes, Gavigan and Fehrenbaker (1973) for this type of case.

Summary The transperitoneal approach to the pelvic ureter has many advantages over the extraperitoneal technique for ureterolithotomy but the operation is safe only if contamination of the peritoneal cavity is avoided by establishing extraperitoneal drainage after closing the incision in the peritoneum over the ureter. We are grateful to Mr J. R. Geddes for permission to study patients admitted under his care and to Miss Y.White for secretarial assistance.

References BARNHOUSE,D. H., JOHNSON,S. H.,

MARSHALL, M. and PRICE, S. E. (1973). Transvesical ureterolithotomy. Journal of Urology, 109, 585-586. LANDES, R. R., GAVIGAN, J. R. and FEHRENBAKER, L. G. (1973). Transvesical meatal-sparing ureterolithotomy. Journal of Urology, 109, 587-588.

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MICHALOWSKI, E. and MODELSKI, W. (1958). Transperitoneal ureterolithotomy. British Journal of Urology, 30, 161- 162. QVIST,G.,JABER MUHSEN,M. and AL-WAIDH, M. (1962). Transperitoneal ureterolithotomy. British Journal of Surgery, 50, 502-505.

The Authors T. K. Bose, FRCS, Urological Registrar (now Surgical Registrar, Victoria Hospital, Blackpool). Richard E. Shaw, ChM, FRCS, Consulting Urological Surgeon (now Consulting Urologist, Coventry Group of Hospitals).

Transperitoneal ureterolithotomy.

The transperitoneal approach to the pelvic ureter has many advantages over the extraperitoneal technique for ureterolithotomy but the operation is saf...
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