Ureterolithotomy 

Ureterolithotomy refers to the open or laparoscopic surgical removal of a stone from the ureter. Within the last decade, ureterolithotomy has become very rarely performed because of the advent of minimally invasive procedures for stone removal and fragmentation. Ureteroscopically, stone removal is performed via basket extraction under direct vision, while stone fragmentation is achieved with electrohydraulic lithotripsy (EHL), pneumatic contact lithotripsy (lithoclast), and pulsed dye and holmium laser lithotripsy. Alternatively, stones may be fragmented even less invasively via extracorporeal shockwave lithotripsy (ESWL).

The most recent advances in ureterolithotomy involve laparoscopic and laparoendoscopic single-site surgery (LESS).^[1] However, open ureterolithotomy still has a role when such sophisticated modalities are unavailable, when other therapies have failed, and in cases involving significant ureteral strictures that prevent endoscopic access.

Laparoscopic ureterolithotomy is depicted in the video below.

In 1882, Bardenheuer removed a calculus from the upper ureter using an open surgical technique. This represents one of the earliest recorded cases of ureterolithotomy.

Stones that cause severe pain, complete obstruction of the ureter, fever, and urosepsis require treatment that includes prompt appropriate drainage (eg, ureteral stent, percutaneous nephrostomy) and subsequent definitive stone removal. Ureterolithotomy has finite indications and is used most commonly when minimally invasive therapies have failed.

Frequency

Ureterolithotomy (surgical removal of the stone from the ureter) is performed rarely at present; however, it continues to be considered when other modalities, such as ureteroscopy with basket extraction, laser lithotripsy, EHL, or ESWL fails.

Most ureteral stones form in the kidney and migrate into the ureter. Many stones are passed spontaneously. Stones larger than 10 mm are unlikely to pass spontaneously, and some small stones often require surgical intervention, perhaps owing to irregular margins of the stone. During ureteral passage, stones most commonly become lodged at the narrow areas of the ureter, in the proximal ureter at the ureteropelvic junction, in the mid ureter where the ureter crosses the iliac vessels, and in the lower ureter at the ureterovesical junction.

• Ureteral stones often present as renal colic. The pain is typically intermittent but may be constant, with radiation into the groin or testicle. The pain varies from severe to a dull ache and is more common on the left side.
• Frequently, the patient constantly shifts to find the position of maximal comfort.
• Ureteral stones are more common in men. Urinalysis is usually positive for occult blood.
• Results on physical examination may be normal except for some costovertebral angle tenderness.

Although open ureterolithotomy has become very rare within the last decade because of the advent of extracorporeal and intracorporeal lithotripsy, it still has a role when such sophisticated modalities are lacking, when other therapies have failed, and in cases involving significant ureteral strictures that prevent endoscopic access.

Conservative treatment is possible for stones smaller than 5 mm. On occasion, pain, infection, and associated anatomical abnormalities necessitate surgical intervention for smaller stones.

First-line surgical intervention involves minimally invasive procedures. Depending on the location of the stone, experience of the urologist, and preference of the patient, either ESWL or ureteroscopy and intracorporeal lithotripsy are instituted. With the miniaturization of scopes and use of sophisticated wires, dilators, access sheaths, and stents, even cases involving complicated stones (ie, stricture with impacted stone) can be approached with ureteroscopy. Even in patients who present with sepsis and hydronephrosis due to an impacted stone, the preferred treatment is percutaneous drainage of the kidney with nephrostomy and delayed endoscopic treatment of the stone. However, in cases that involve failure or other extenuating circumstances, ureterotomy can be performed.

A ureter is 20-27 cm in length and 5-7 mm in diameter. The narrow portions of the ureter are at the ureteropelvic junction, in the most cephalad part; in the middle, where the ureter crosses the iliac vessels; and in the most caudal part, at the ureterovesical junction (intramural part of ureter). This is crucial in the manifestations of calculus disease. These narrowings may result in ureteral stones becoming trapped and obstructing at these specific levels. These narrowings may also limit retrograde instrumentation performed for diagnostic or therapeutic purposes. For more information about the relevant anatomy, see Ureter Anatomy.

In men, the vas deferens crosses the ureter at its lower one third anteriorly. In women, the round ligament crosses the ureter at its lower one third anteriorly. The ureter is adjacent to the gonadal vessels.

Periureteral vessels, from the pelvic branch of the renal artery, provide the blood supply to the ureter in the upper one third. In the lower one third, the vesicle artery supplies blood. The middle third is supplied by the lumbar vessels; here the blood supply is precarious. During ureterolithotomy, stripping the ureter of its periureteral fat in the middle third has to be performed very carefully.

The urine in the ureter progresses due to peristalsis, and the nerve plexus that runs along the ureter controls peristalsis.

Ureterolithotomy is contraindicated in patients who are medically unfit for an open surgery or who harbor an active infection. Consider noninvasive procedures, such as ESWL, and minimally invasive ureteroscopy first. Consider ureterolithotomy only as a last resort.