Ureterolithotomy Treatment & Management

For stones smaller than 5-7 mm, conservative treatment with anticipation of stone passage is possible. Intractable pain, uncontrolled nausea/vomiting, active infection, and impending urosepsis all necessitate surgical intervention, typically with ureteral stent placement followed by future definitive treatment of the calculus.

• The goals of ureterolithotomy are to remove all stones and fragments and to avoid causing a ureteral stricture.
• Surgical therapy depends on the site of the stone in the ureter—upper third, middle third, or lower third.
• Sterile urine is preferable; administer an appropriate preoperative antibiotic with broad-spectrum activity, such as ciprofloxacin.
• KUB radiography: Prior to the operation, stones can move, and surgical strategies vary with the position of the stone. Knowing the precise location immediately before the surgery is essential.

  • Stones move cephalad mostly because of ureteral dilatation.
  • On occasion, stones can also move distally because of peristalsis.
  • Not finding a stone during open ureterolithotomy is disturbing for the surgeon and the patient.

Open upper and middle ureterolithotomy

• Incision is at the 12th rib or is subcostal. Incision is from over the distal third of the 12th rib, extending 6-8 cm anteriorly toward the umbilicus.
• Jack-knife kidney position with the table flexed is preferable. Kidney rest may be raised.
• Insert a urethral Foley catheter
• Cystoscopy and insertion of a stent are useful not only in draining the kidney but also in easily recognizing the ureter and preventing the fragments from downward migration and blockage.
• The ribs do not need to be resected.
• Protect the subcostal nerve.
• Cut the external and internal obliques and the transversalis with the diathermy current with fingers pushing the peritoneum. Push the peritoneum anteriorly.
• Identify the ureter and dissect the serosa and periureteral fat. To avoid compromising the blood supply, do not be overzealous.
• Feel the stone in the ureter between the fingers and visualize the bulge in the ureter. When in doubt, aspirate with a 22-gauge needle and 5-mL syringe.
• Immobilize the stone with 2 vascular loops above and below the stone.
• Cut over the stone with a knife vertically.
• Remove the stone.
• Irrigate the ureterolithotomy site and then irrigate proximally and distally with a rubber catheter. Palpate to ensure no other stone fragments are present.
• If a stent is needed, insert a double J proximally first and then distally. Fluoroscopy is very helpful in locating the proximal and distal ends of the stent for proper positioning. If fluoroscopy is not available, install indigo carmine into the bladder via Foley catheter. The dye should come through the stent at the ureterolithotomy site if stent is in bladder.
• Close the ureterolithotomy site with 4-0 chromic interrupted sutures. Watertight closure is not necessary.
• Confine bite to the serosal layer and do not cause stricture. If the edges are not approximated easily or when in doubt, stent the ureter with a double J and do not close the ureterolithotomy site.
• Analogously, in cases of partial transaction in urologic trauma, the ureter is often closed via Heineke-Mikulicz procedure by converting a longitudinal incision into a transverse one to avoid ureteral stricture; this same principle can be applied in ureterolithotomy. Drain the ureterolithotomy site through a stab incision with a soft Penrose or a suction drain.
• Irrigate the wound with warm water.
• Close the incision with synthetic absorbable interrupted sutures in 2 layers.
• Close the skin with absorbable sutures or surgical staples.
• Fix the drain with a suture.
• Instillation of Marcaine 0.25% or 0.5% may be beneficial for postoperative pain.

Open lower ureterolithotomy

• Lower ureterolithotomy is much more difficult than upper and middle third ureterolithotomies.
• Performing KUB radiography to evaluate the precise location and number of stones is mandatory.
• Drain the bladder with a Foley catheter.
• Perform an oblique muscle-splitting Gibson incision in the lower quadrant ipsilateral to the stone. Split all 3 muscles in the line of the incision. Once the peritoneum is reached, push it medially and remain in the retroperitoneum.
• Cut the muscles with the diathermy current.
• Push the peritoneum medially from the inguinal ligament.
• Identify the ureter when crossing the iliac vessels and put it on a vessel loop.
• Dissect the ureter toward the bladder.
• The vas deferens in men and the uterine artery in women cross the ureter.
• Stabilize the ureter above and below with the vessel loops.
• Perform ureterotomy over the stone and remove the stone.
• Irrigate the upper and lower ureter.
• Drain the ureterolithotomy site.
• Close the ureterolithotomy site with interrupted 4-0 chromic sutures. As described above, the longitudinal ureterotomy can be closed transversely in a Heineke-Mikulicz fashion.
• Close the incision in 2 layers with a synthetic absorbable interrupted suture.
• Close the skin with staples and 3-O nylon suture the drain.

Laparoscopic ureterolithotomy

In 1979, Wickham introduced laparoscopic ureterolithotomy via a retroperitoneal approach. Subsequently, in 1992, Raboy performed the first transperitoneal laparoscopic ureterolithotomy.^[2] In general, upper and mid-ureteric stones are safely approached retroperitoneally, while lower ureteric stones are better approached transperitoneally. However, ESWL and ureteroscopy remain first-line treatments for ureteral stones. Laparoscopic ureterolithotomy is typically reserved for the following:

• When the stone is not amenable to lithotripsy fragmentation
• When the patient’s weight precludes ESWL or prevents ureteroscopic access
• When ESWL or ureteroscopic access is not available
• For stones that are refractory to alternative therapies

Laparoscopic ureterolithotomy functions as a less-invasive intervention for complicated stones that cannot be addressed via extracorporeal or intracorporeal ureteroscopic lithotripsy.

The advantage of this relatively new surgical approach is the capability to definitively treat an impacted stone in a single setting. Endoscopic treatment of ureteral stones often requires future re-treatment. However, disadvantages of laparoscopic ureterolithotomy include the lack of tactile perception, potential for urinary leak, potential for bowel adhesions, and the considerable learning curve; these factors must be considered in surgical planning.

Laparoscopic urterolithotomy is depicted in the video below.

Retroperitoneal laparoscopic ureterolithotomy

Retroperitoneal laparoscopic ureterolithotomy is described as follows:^[3]

• The first port (10-12 mm) serves as the camera port and can be placed via an incision at the 12th rib, bisecting the distance from costal border to iliac crest in the mid-axillary line.
• Create space with the retroperitoneum by finger-sweep, followed by balloon.
• The second port (10-12 mm) is placed in the posterior axillary line at the convergence of the rib cage and erector spinae muscles.
• The third port (10-12 mm) is placed in the anterior axillary line 5 cm medial to first port.
• The fourth port (5 mm) is placed two finger-breadths cephalic to anterior-superior iliac spine.
• The retroperitoneal space is freed by removing the flank fat pad.
• Open Gerota fascia along its junction line with the psoas sheath.
• Begin dissection, progressing medially until identification of ureter.
• Dissect the ureter caudally and localize the stone using ureteral pinching.
• Perform longitudinal ureterotomy with a laparoscopic scalpel and extend it with scissors.
• Extract the stone with a laparoscopic grasper or an endobag.
• Advance the ureteral catheter proximally beyond the ureterotomy site under direct vision into the renal pelvis.
• The ureterotomy incision may or may not be sutured.
• Close the retroperitoneum in layers.
• Leave a drain at the ureterolithotomy site.
• Postoperatively, the ureteral catheter is left in place for 5 days. Remove the drain once the output is less than 50 mL/day. At 3 months postoperatively, urinalysis, ultrasonography, and intravenous urography are performed.

Transperitoneal laparoscopic ureterolithotomy

Transperitoneal laparoscopic ureterolithotomy is described as follows:^[3]

• Mid-ureteral stone

  • The first port (10-12 mm) serves as the camera port and can be placed at the umbilicus.
  • The second port (10-12 mm) is placed at lateral border of rectus abdominus 5 cm cephalad to the umbilicus.
  • The third port (5 mm) is placed at lateral border of rectus abdominus 5 cm caudad to the umbilicus.
• Lower-ureteral stone

  • The first port (10-12 mm) serves as the camera port and can be placed at the umbilicus.
  • The second port (10-12 mm) is placed midway between umbilicus and pubic symphysis.
  • The third port (5 mm) is placed along the mid-clavicular line in the ipsilateral iliac fossa.
• Open Gerota fascia along its junction line with the psoas sheath.
• Begin the dissection, progressing medially until the ureter is identified. The ureter can be identified at the point of crossing iliac vessels.
• Dissect the ureter caudally and localize the stone using ureteral pinching.
• Perform longitudinal ureterotomy with the laparoscopic scalpel and extend it with scissors.
• Extract the stone with a laparoscopic grasper or an endobag.
• Advance the ureteral catheter proximally beyond the ureterotomy site under direct vision into the renal pelvis.
• Suture the ureterotomy incision site, closing it in layers.
• Leave a drain at ureterolithotomy site.

A mechanical bowel preparation with a full liquid diet for 24 hours prior to surgery and 2 L of electrolyte solution reduces interference from bowel contents. Preoperative imaging with abdominal radiography or fluoroscopy in the operating room is used to confirm stone location. After induction of anesthesia, the patient is moved to lithotomy position for cystoscopy and a ureteral catheter is inserted. This ureteral catheter is advanced to within 1 inch of the calculus and then secured to the Foley catheter to prevent motion.

The patient is then repositioned again into a modified lateral decubitus position with the umbilicus over the break in the operating table; the table may be flexed as needed to expose the flank. Axillary rolls, padding, and cloth tape are used to support the buttocks and to flank and secure the patient. The table may be rolled appropriately to assist with bowel retraction.

• Open ureterolithotomy: Stabilize the ureter between 2 umbilical tapes and perform a generous ureterotomy so that the stone can be easily removed. After removal of the stone(s), initially pass a No. 8 red rubber catheter proximally and irrigate so that any remaining stone fragments can be flushed out. Then pass the catheter distally and flush the ureter of any fragments. Watertight closure of the ureterotomy is advisable, taking care not to constrict the ureter. Always drain the ureterotomy site with a Penrose drain or JP (vacuum) drain. Make sure the stone is sent for chemical analysis to determine the composition of the stone, which helps in stone prevention therapy and advice.
• Laparoscopic ureterolithotomy: Watertight closure of the ureterotomy is advisable, taking care not to constrict the ureter. Always drain the ureterotomy site with a Penrose drain or JP (vacuum) drain. Make sure the stone is sent for chemical analysis to determine the composition of the stone, which helps in stone prevention therapy and advice.

Mobilize the patient on the day of surgery from bedrest as soon as possible. Remove the drain after 5 days if the drainage is scanty. Remove the urethral Foley catheter after the second day. If a ureteral catheter is used, leave it in place for 5 days.

Intravenous urography performed 3-6 months postoperatively is helpful in recognizing a stricture or residual stones. Urinalysis and ultrasonography are also of use to evaluate infection and renal anatomy.

Patients should be evaluated for chemical risk factors that lead to stone formation. This should include an analysis of the chemical composition of the stone and an evaluation of the patient's diet. Minimum metabolic studies for stone prevention analysis are essential for determining the underlying risk factors for new stone formation. A minimal study should include serum electrolytes, calcium, creatinine, bicarbonate, and uric acid together with a 24-hour urine collection with analysis of calcium, uric acid, citrate, oxalate, sodium, magnesium, and volume. Appropriate preventive measures then can be instituted.

Open ureterolithotomy

Early complications

• Bleeding due to unrecognized injury to adjacent gonadal vessels or inferior vena cava is a possible early complication.
• Persistent urinary leak may result from urinary fistula. If no distal obstruction is present, treat urinary fistula conservatively or with an indwelling stent inserted via cystoscope. Occasionally, percutaneous nephrostomy is needed.

Late complications

• Ureteral stricture can be recognized by persistent hydronephrosis and a narrow area on the IVP.
• Treatment of residual stones depends on size and location of stones. Ureteroscopy and removal of the stone fragment may be needed.

Laparoscopic ureterolithotomy

Ureteral stricture is a major complication of laparoscopic ureterolithotomy, reported in up to 15%-20% of cases in various series. The etiology is unclear, but it may result from strangulating sutures at the ureterotomy site, leading to ischemia and stenosis, or the use of a diathermy hook electrode.

Adhesion formation with resulting risk of bowel obstruction is a potential complication of transperitoneal laparoscopic ureterolithotomy.

Conversion to open ureterolithotomy is a possibility, especially with intraoperative stone migration, severe adhesions, or vascular injury.

Persistent urinary leak is another complication that is best managed conservatively with an indwelling stent.

Retroperitoneal hematoma may result with damage to gonadal vessels or iliac vessels.

• The stone may migrate.
• Urinary leak and extravasation may not cause problems if the wound is drained. Most leaks heal within 3 weeks. If urinary leak is persistent, rule out distal obstruction via CT scanning or IVP.
• If the obstruction can be removed by cystoscopy, remove it and insert a stent. If the obstruction is due to a mass or a stricture, drain the kidney via nephrotomy, and passing a stent from above into the bladder may be possible.
• Ureterolithotomy continues to be useful. It is used rarely in developed countries but is a mainstay of treatment in the rest of the world.

With the advancement of minimally invasive surgery, the new frontier is the development of single-port, single-incision laparoscopy, or laparoendoscopic single-site surgery (LESS). Since single-port nephrectomy was introduced in 2007, various procedures have been performed via LESS, including ureterolithotomy.^[1] Additional applications include natural orifice transluminal endoscopic surgery (NOTES) with surgical access through physiologic channels such as via umbilicus or vagina.