Ureterolithotomy

Ureterolithotomy refers to the open or laparoscopic surgical removal of a stone from the ureter. Today in the United States, ureterolithotomy is seldom performed given the advent and rise of minimally invasive procedures for fragmentation and removal. Minimally invasive options are now preferable and include extracorporeal shock wave lithotripsy (ESWL) and endoscopic techniques such as ureteroscopy (URS) with laser lithotripsy and stone basketing, and percutaneous nephrolithotomy (PCNL).

Despite this trend, there have been recent advances in ureterolithotomy involving laparoscopic and laparoendoscopic single-site surgery (LESS). Even robotic-assisted laparoscopic ureterolithotomy has been reported in the literature.[1]  Open ureterolithotomy still has a role when the above, more sophisticated modalities are unavailable or when other therapies have failed. It can also be utilized in cases involving significant ureteral strictures that preclude endoscopic access.

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

In 1979, Wickham introduced laparoscopic ureterolithotomy via a retroperitoneal approach. Subsequently, in 1992, Raboy performed the first transperitoneal laparoscopic ureterolithotomy.

In the current age of Urology in developed nations, open ureterolithotomy has been all but entirely replaced by minimally invasive techniques of extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL). In fact, a recent study analyzing urologists’ practice patterns for management of upper urinary tract stones from 2003-2012 revealed an increase in the proportion of ureteroscopy from 40.9% to 59.6%. ESWL decreased from 54% to 36.3%. PCNL use remained stable around 4-5% and was more frequently performed by endourologists. The use of ureterolithotomy was not mentioned in that study.

Stone disease (urolithiasis) is common, affecting approximately 9% of American adults at some point during their lives. It is also very costly, accounting for $5.3 billion in direct and indirect costs annually.

Obstructing ureteral stones can cause severe pain, fever, urosepsis, and possibly even death if left untreated. They require treatment that often includes prompt and appropriate renal drainage and decompression (eg, ureteral stent placement or percutaneous nephrostomy tube placement) and subsequent definitive stone removal. Ureterolithotomy is used most commonly when minimally invasive therapies have failed.

Most ureteral stones form in the kidney and migrate into the ureter. Many of these stones are passed spontaneously. Stones larger than 10 mm are unlikely to pass spontaneously. These larger stones and even some small stones may require surgical intervention at some point. During ureteral passage, stones most commonly become lodged in narrow areas of the ureter. The most common locations in which ureteral stones become lodged are in the upper (proximal) ureter at the ureteropelvic junction (UPJ), in the mid-ureter where the ureter crosses over the iliac vessels, and in the lower (distal) ureter at the ureterovesical junction (UVJ).

United States data

Today in the United States, ureterolithotomy is seldom performed given the advent and rise of minimally invasive procedures for stone fragmentation and removal. It is considered an option if minimally invasive techniques of extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL) fail.

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.

Signs and symptoms of urolithiasis

Ureteral stones often present as renal colic. The pain is typically intermittent, but may be constant, with radiation of pain into the ipsilateral groin or testicle. The pain varies from severe, sharp/stabbing pain to a dull ache.

Frequently, the patient constantly shifts his or her body, as it can be difficult to find a comfortable position.

Urinalysis and urine microscopy is usually positive for occult blood. Some patients present with gross hematuria.

Non-obstructing stones can be asymptomatic.

Physical examination findings are often unremarkable except for some costovertebral angle tenderness.

Obtain a complete blood count (CBC), basic metabolic panel (BMP), including blood urea nitrogen and creatinine levels, as well as a urinalysis and urine culture.

The following imaging studies are recommended:

• In most cases, a non-contrast CT abdomen/pelvis scan has already been obtained for flank pain evaluation prior to urology consultation. CT scans reveal the size and location of the ureteral stone, the presence of any other stones, and the presence or absence of associated hydroureteronephrosis or other causes of flank/abdominal pain.
• Plain radiography (KUB) should be performed following the identification of ureteral stones on CT if medical explusive therapy (MET) is planned. A KUB can show radiopaque stones and are useful for following stones over time. If a radiopaque stone is seen at the time of diagnosis, its presence/movement can be assessed later with repeat KUB. This approach is favored over repeat CT and its associated cost and radiation exposure to the patient. Of course, if the stone is radiolucent (not visible on KUB), then a repeat CT is necessary to follow stone presence/movement over time.
• Ultrasonography is useful for identifying hydroureteronephrosis, but is not reliable for visualizing stones or their location. Intravenous pyelography (IVP) is now rarely performed.

An ECG and chest radiograph are often part of the preoperative anesthesia evaluation and are especially useful in those patients with known cardiopulmonary disease.

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.

Ureterolithotomy is not a first-line treatment of urolithiasis but can be considered as an additional management option.

Today in the United States, ureterolithotomy is seldom performed given the advent and rise of minimally invasive procedures for stone fragmentation and removal. Minimally invasive options are now preferable and include extracorporeal shock wave lithotripsy (ESWL) and endoscopic techniques such as ureteroscopy (URS) with laser lithotripsy and stone basketing, and percutaneous nephrolithotomy (PCNL).

A meta-analysis compared laparoscopic ureterolithotomy with ureteroscopic lithotripsy and holmium laser for the removal of large proximal ureteral stones. Patients who underwent ureterolithotomy had better initial and final stone-free rates; however, lithotripsy was associated with shorter operative times and length of hospital stays.[2]

Ureterolithotomy still has a role when minimally invasive modalities are unavailable, other therapies have failed, and in cases involving significant ureteral strictures that prevent endoscopic access.

Ureterolithotomy is contraindicated in patients who are unable to undergo general anesthesia for open or laparoscopic surgery.

A mechanical bowel preparation with a clear liquid diet for 24 hours prior to surgery and 2 L of electrolyte solution may be helpful, but is not necessary; though, it may reduce 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 1-2 cm of the calculus and then secured to the Foley catheter to prevent ureteral catheter migration.

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.

The goals of ureterolithotomy are to remove all stones and fragments and to avoid complications such as causing a ureteral stricture or urine leak.

Surgical therapy depends on the location of the stone in the ureter—upper (proximal) third, middle third, or lower (distal) third.

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

• Jack-knife kidney position with the table flexed is preferable. Kidney rest may be raised.
• 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.
• 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.
• Insert a urethral Foley catheter
• 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, instill 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 to avoid causing stricture. If the edges are not approximated easily or when in doubt, stent the ureter with a double J stent and do not close the ureterolithotomy site.
• Analogously, in  Similar to cases of partial ureteral transection in urologic trauma, the ureter is often closed via Heineke-Mikulicz procedure by closing a longitudinal incision transversely 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.
• Injection 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 3-0 nylon suture the drain.

Laparoscopic ureterolithotomy

In general, upper and mid-ureteric stones are safely approached retroperitoneally, while lower ureteric stones are better approached transperitoneally

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

Laparoscopic ureterolithotomy. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.

Retroperitoneal laparoscopic ureterolithotomy

Retroperitoneal laparoscopic ureterolithotomy is described as follows[3, 4, 5] :

• 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[5] :

• 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.

Mobilize the patient on the day of surgery from bedrest as soon as possible.

Remove the urethral Foley catheter after the second day.

Remove the drain after 5 days if the drainage is scant. If a ureteral catheter is used, leave it in place for 5 days.

A CT urogram performed 3-6 months postoperatively is helpful in recognizing a stricture or residual stones. Ultrasound can be used to evaluate for silent hydronephrosis.

Patients should be evaluated for metabolic 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. Metabolic studies for stone prevention analysis are essential for determining the underlying risk factors for new stone formation. Evaluation 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 urine volume. Appropriate preventive measures then can be instituted based on the findings from the above studies.

Possible open and laparoscopic ureterolithotomy complications

Bleeding due to unrecognized injury to adjacent gonadal vessels or inferior vena cava can result in a retroperitoneal hematoma.

Persistent urine leak may occur and is most often treated conservatively with an indwelling stent inserted via a cystoscope. Occasionally, percutaneous nephrostomy is needed.

Ureteral stricture can be recognized by persistent hydronephrosis on retroperitoneal ultrasound and a narrow area on delayed CT images. 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 during laparoscopic ureterolithotomy, especially with intraoperative stone migration, severe adhesions, or intraoperative vascular injury.

Residual stone fragments require additional procedures.