BJU International (1999), 84, 765–769

Laparoscopic ureterolithotomy: the Edinburgh experienceF.X. KEELEY*, I . GIALAS, M. PILLAI, M. CHRISOFOS and D.A. TOLLEY*Southmead Hospital, Bristol and Scottish Lithotriptor Centre, Western General Hospital, Edinburgh, UK

Objective To review our experience with laparoscopic Results All procedures were completed laparoscopicallyand all patients were rendered stone-free after a singleureterolithotomy.

Patients and methods Since 1993, we have performed procedure. The mean operative duration was 105 min.Ureteric strictures were incised in three patients, inlaparoscopic ureterolithotomy in 14 patients with

ureteric stones. Laparoscopy was carried out in nine two of whom dilatation was subsequently required;all three had a successful result. There were threepatients as a salvage procedure after failed ureteros-

copy (six), shock wave lithotripsy (two), or both (one), minor complications.Conclusions Laparoscopic ureterolithotomy can be a safeand in five patients as a primary procedure for large

stones (mean 27.2 mm, range 18–40). Patients in the and eCective procedure; it should be considered as aprimary procedure for large mid- and upper uretericformer group had already undergone a mean of 1.88

procedures (range 1–4). Laparoscopic ureterolitho- stones.Keywords Laparoscopy, urinary calculi, ureter, outcometomy was carried out via a transperitoneal approach.

Associated ureteric strictures were incised at the timeof ureterotomy.

Introduction Patients and methods

Between March 1993 and February 1998, 14 patientsSince the introduction of shock wave lithotripsy (SWL)[1] and ureteroscopy [2] the routine use of an open (13 men and one woman, mean age 65.7 years, range

43–84) were selected for the laparoscopic removal ofsurgical approach for removing ureteric calculi hasrapidly declined. In some medical centres with access to ureteric stones (four left and 10 right). Nine patients

had undergone previous treatment, including uretero-advanced endourological equipment, open stone surgeryis obsolete. However, some large ureteric stones pose a scopy (six), SWL (two), or both (one), with a mean of

1.88 procedures (range 1–4). An additional five patientssignificant challenge for modern endourological tech-niques, often requiring several endoscopic procedures as were treated electively for large stones (mean size

27.2 mm, range 18–40).well as SWL. Multiple procedures and prolonged periodswith indwelling stents are not only expensive but also a Laparoscopic ureterolithotomy was performed via a

transperitoneal route with the patient in the flank pos-burden to patients in terms of time oC work and persist-ent pain. ition. In cases where a stent had previously been placed,

this was left in situ. Of five patients with no stent, aSince laparoscopic surgery has become widely adopted,nearly every operation has been reported via the laparo- ureteric catheter was placed in two before positioning

for laparoscopy, while three patients had none.scopic approach, including laparoscopic ureterolitho-tomy. Gaur et al. have reported the largest series to date, Laparoscopic ports were placed: (a) at the lateral edge ofall of which were performed extraperitoneally [3]. Wehave performed transperitoneal laparoscopic uretero- Table 1 Treatment choices for ureteric stones during a 5-yearlithotomy as a salvage procedure for patients who fail period at the Scottish Lithotriptor Centreconventional endoscopic procedures, and have oCered it

Treatment No. of patients (%)electively as an alternative to ureteroscopy and/or SWLin patients with large ureteric stones.

Ureteroscopy 715 (57.6)Shock wave lithotripsy 509 (41.0)Laparoscopic ureterolithotomy 14 (1.1)Open ureterolithotomy 2 (0.2)Total 1240 (100)

Accepted for publication 15 June 1999

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766 F.X. KEEL EY et al.

the rectus, level with the umbilicus; (b) in the anterior estimated blood loss was <100 mL in every patient andnone required a blood transfusion. Patients required aaxillary line below the costal margin; and (c) in the

anterior axillary line in the iliac fossa. In the first few mean (range) of 21 (0–70) mg of parenteral morphinesulphate (or equivalent) after treatment. Drains werepatients, a fourth port was placed in the mid-axillary

line, level with the umbilicus, but this was rendered removed after a mean of 3.1 (1–5) and the mean lengthof stay was 5.6 (4–8) days.unnecessary as experience increased. The colon was

reflected medially and the ureter exposed. A vertical No intraoperative complications occurred; there wereno conversions to open surgery. Immediate postoperativeincision was made in the ureter over the stone and the

stone removed. The ureterotomy was closed with a single complications consisted of prolonged urinary drainagein a patient who had an associated ureteric stricture4–0 polyglactic acid suture in five patients; in the

remaining nine, no sutures were placed. A drain was incised, and a temperature of 38°C in an 84-year-oldman, both of which resolved with conservative manage-routinely left in the retroperitoneal space through the

inferior trocar site. After surgery, plain abdominal radio- ment. There was one late complication; a 76-year-oldpatient developed a symptomatic incisional hernia at thegraphs were taken in all patients, with IVU and/or

nuclear renography conducted at 6 months and repeated inferior trocar site, which was subsequently repaired.Three patients with associated ureteric strictureswhen indicated.

underwent laparoscopic incision of the stricture at thetime of ureterotomy. Two of these subsequently required

Resultsfurther endoscopic treatment of residual stricture disease(balloon dilatation in one and dilatation with graduatedAll cases were successfully completed laparoscopically

and all patients rendered stone-free (Fig. 1). The mean dilators in the other). Both patients had a successfulresult, as shown by diuretic renography. The remaining(range) operative duration was 105 (60–160) min; the

Aa Ab Ba BbFig. 1. A. Plain abdominal radiographs before (a) and after (b) laparoscopic ureterolithotomy in a patient with a 22-mm upper uretericstone. B. Plain abdominal radiograph before (a) and intravenous urogram after (b) laparoscopic ureterolithotomy in a patient with an18-mm left mid-ureteric stone (arrow) causing obstruction.

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patients had normal findings on follow-up IVU or diuretic a retroperitoneal drain, and by the presence of anindwelling ureteric stent. The only prolonged urine leakrenography.

Of the nine patients with stents and the five without occurred in a patient who had neither a stent nor closureof the ureterotomy.ureteric drainage, one patient in each group had an

immediate postoperative complication. Two patients with For several reasons, the ideal location of a stone isthat portion of the ureter between the lower border ofstents and none without required further treatment for

associated ureteric strictures. Of the five patients with the kidney and the common iliac vessels. First, the ureteris easier to locate and minimal dissection is required.and nine without sutures placed close to the uretero-

tomy, one in each group had an immediate complication. Second, large stones below the level of the iliac vesselsare best treated ureteroscopically; likewise, large stonesTwo patients with sutures and none without required

further treatment for associated ureteric strictures. above the lower border of the kidney are best treatedpercutaneously.Notably, one patient undergoing laparoscopic ureteroli-

thotomy and incision of a ureteric stricture had a ureteric The indications for laparoscopic ureterolithotomy inthe age of modern endourology include stones whichcatheter placed just before the procedure; the uretero-

tomy was not closed. He developed a urine leak through cannot be accessed ureteroscopically or cannot be frag-mented. We also consider large (�15 mm) proximalthe drain, which resolved after 12 days of conservative

management. A renogram subsequently showed no ureteric stones a relative indication; patients meetingthese criteria are rare. This series of 14 patients wasobstruction. Procedures involving closure of the uretero-

tomy required a mean additional 15 min of operating accrued during a 5-year period, during which over 700ureteroscopic procedures and >500 SWL treatmentstime; however, the actual suturing time was not

recorded. The operative duration for patients in whom were carried out for ureteric stones (Table 1). Only 3.7%of all ureteric stones treated at our centre during thea stent was present required a mean of 14 min less

than those with no stent. study period were �15 mm. During this period, laparo-scopic ureterolithotomy compared well with primaryureteroscopy and SWL for very large (�15 mm) upper

Discussionand mid-ureteric stones (Table 2). However, as endos-copic technology and techniques improve the indicationsThe first series of laparoscopic ureterolithotomy was

reported by Gaur et al. [3,4], who pioneered the retroperi- for laparoscopic ureterolithotomy may become morerestricted. In particular, the combination of flexible uret-toneal approach for a variety of laparoscopic procedures.

Others have since reported small series via both transper- eroscopy and holmium laser lithotripsy holds great prom-ise for the treatment of large proximal ureteric calculiitoneal and retroperitoneal approaches [5–8]. The pre-

sent series of 14 patients undergoing transperitoneal [9–13].The AUA Guidelines Panel has recently reported itslaparoscopic ureterolithotomy for large proximal ureteric

stones is the largest reported to date, comprising both recommendations for the treatment of ureteric stones[14]. While the report was clear in its recommendationssalvage and primary procedures. There were no conver-

sions to open surgery and all patients were rendered of in situ SWL for the treatment of small upper uretericstones, it was less clear for large (>1 cm) upper uretericstone-free after a single procedure.

The duration of hospitalization in this series reflects stones. Most published series of SWL for upper uretericstones either exclude large stones from the analysis orlocal patterns of practice, as patients required little

postoperative analgesia; perioperative complications report disappointing results [15]. Our experience withSWL for large (>10 mm) upper ureteric stones is poor,were minor. By contrast, in his initial series, Gaur [4]

reported that all of the patients were discharged home with only a 33% stone-free rate after SWL alone, usingthe Dornier MPL-9000X [16].on the first day after treatment, despite three requiring

conversion to open surgery. A distinct advantage of laparoscopic ureterolithotomyfor large upper ureteric stones is the high probability ofThere are several technical points; because of the lack

of tactile feedback, small and/or multiple stones may be removing the entire stone in one procedure. The highstone-free rate after a single procedure means thatdiBcult to locate and thus laparoscopic ureterolithotomy

is not appropriate in such cases. The ureterotomy does patients do not spend long periods with indwellingureteric stents, waiting for fragments to pass. In addition,not generally require suturing, especially when a stent

is in situ, as laparoscopic suturing techniques at present the risk of ultimately leaving a patient with residualfragments in the kidney or ureter is eliminated. Thedo not permit confident placement of mucosal sutures

in an undilated or inflamed ureter. While this approach laparoscopic approach allows these stone-free patientsto return quickly to regular activities. The disadvantageshas a theoretical risk of inducing an intraperitoneal

urinary leak, the risk is minimized by accurately placing include a longer hospital stay, the risk of injury to

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768 F.X. KEEL EY et al.

Table 2 Treatment choices for upper andmid-ureteric stones of �15 mm, over a5-year period at the Scottish LithotriptorCentre

LaparoscopicVariable Ureteroscopy SWL ureterolithotomy

Patients 15 17 14Stone-free after 1° treatment alone (%)* 5 (33) 5 (29) 14Total stone-free (%) 11 (74) 16 (94) 14Mean (range) number of procedures 2.8 (1–7) 3.4 (1–8) 1

*Number of patients rendered stone-free after primary treatment alone. Included in theureteroscopy and SWL groups are several patients who underwent more than one of thesame type of procedure, e.g. several patients were rendered stone-free after two sessions oflithotripsy.

5 Harewood LM, Webb DR, Pope AJ. Laparoscopic ureteroli-intra-abdominal structures inherent in the laparoscopicthotomy: the results of an initial series, and an evaluationapproach, and the risk of conversion to open surgery. Inof its role in the management of ureteric calculi. Br J Uroladdition, a case of postoperative urinoma has been1994; 74: 170–6reported recently [17].

6 Raboy A, Ferzli GS, IoCreda R, Albert PS. LaparoscopicSince the advent of SWL and ureteroscopy, the use ofureterolithotomy. Urology 1993; 39: 223–5

open ureterolithotomy has declined rapidly and may be7 Bellman GC, Smith AD. Special considerations in the

lost from the urological armamentarium. In a series from technique of laparoscopic ureterolithotomy. J Urol 1994;the 1970s, open ureterolithotomy constituted 42% of all 151: 146–9surgical procedures for ureteric calculi [18]. In a large 8 Micali S, Moore RG, Averch TD, Adams JB, Kavoussi LR.series from the mid-1980s, this proportion had declined The role of laparoscopy in the treatment of renal andto 28% [19]. After the introduction of SWL, open surgery ureteral calculi. J Urol 1997; 157: 463–6

9 Razvi HA, Denstedt JD, Chun SS, Sales JL. Intracorporealhad decreased to just 4.1% of all stone surgery [20]. Atlithotripsy with the holmium:YAG laser. J Urol 1996;the Thomas JeCerson University Hospital in Philadelphia,156: 912–4there has been no open surgery for stones in >10 years

10 Wollin TA, Chun SS, Razvi HA, Sales JA, Nott L, Denstedt(D. Bagley, personal communication). At the ScottishJD. Ureteroscopic fragmentation of upper urinary tractLithotriptor Centre, open surgery constituted just 0.2%calculi using the holmium laser. J Endourol 1998; 12:of all procedures performed for ureteric calculi duringP20–1 (Abs)the past 5 years.

11 Teichman JMH, Rao RD, Rogenes VJ, Harris JM.In conclusion, percutaneous surgery, ureteroscopy Ureteroscopic management of ureteral calculi:electrohyd-

and SWL have made open stone surgery a rarity in raulic versus holmium:YAG lithotripsy. J Urol 1997;many hospitals. Nevertheless, for some large ureteric 158: 1357–61stones, ureterolithotomy, which can now be performed 12 Erhard M, Salwen J, Bagley DH. Ureteroscopic removal oflaparoscopically, may be the most eCective treatment. mid and proximal ureteral calculi. J Urol 1996; 155: 38–42The laparoscopic approach, a natural extension of the 13 Grasso M, Conlin MJ, Bagley DH. Ureteroscopic treatment

of large (>2 cm) upper urinary tract calculi: Multicenterminimally invasive philosophy, may provide uretero-experience. J Urol 1998; 159 (Suppl): 320, abstract 1228lithotomy with a role in the modern management of

14 Segura JW, Preminger GM, Assimos DG et al. Ureteralstone disease.Stones Clinical Guidelines Panel Summary Report on themanagement of ureteral calculi. J Urol 1997; 158:

References 1915–2115 Mobley TB, Myers DA, Jenkins JM et al. ECects of stents on1 Chaussy C, Schmeidt E, Jocham D et al. First clinical

lithotripsy of ureteral calculi: treatment results with 18,825experience with extracorporeally induced destruction ofcalculi using the Lithostar lithotriptor. J Urol 1994;kidney stones by shock waves. J Urol 1982; 127: 417–20152: 53–62 HuCman JL, Bagley DH, Lyon ES. Extending cystoscopic

16 Keeley FX, Pye SD, Smith G, Tolley DA. Optimizing resultstechniques into the ureter and renal pelvis: ureteroscopyof lithotripsy using a robust electromagnetic probe.and pyeloscopy. JAMA 1983; 250: 2002–5J Endourol 1999; in press3 Gaur DD, Agarwal DK, Purohit KC, Darshane AS, Shah

17 Bauer JJ, Schulam PG, Kaufman HS, Moore RG, Irby PB,BC. Retroperitoneal laparoscopic ureterolithotomy for mul-Kavoussi LR. Laparoscopy for the acute abdomen in thetiple upper mid ureteral calculi. J Urol 1994; 151: 1001–2postoperative urologic patient. Urology 1998; 51: 917–94 Gaur DD, Agarwal DK, Darshane AS, Purohit KC.

18 O’Flynn JD. The treatment of ureteric stones: report onLaparoscopic ureterolithotomy: our experience with 17patients. Bombay Hosp J 1993; 35: 65–8 1120 patients. Br J Urol 1980; 52: 436–8

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19 Bishop MC, Lawrence WT, Lemberger RJ. Ureteric stone Authorssurgery in practice. Br J Urol 1987; 59: 137–41 F.X. Keeley Jr, MD, Formerly Endourology Fellow, currently

20 Assimos DG, Boyce WH, Harrison LH et al. The role of Consultant Urologist.open stone surgery since extracorporeal shock wave I. Gialas, MD, Visiting Endourology Fellow.lithotripsy. J Urol 1989; 142: 21 M. Pillai, MBBS, FRCS(Urol), Specialist Registrar.

M. Chrisofos, MD, Visiting Endourology Fellow.DA. Tolley, MBBS, FRCS, FRCS(Edin), Consultant Urologist

and Director.Correspondence: Mr F.X. Keeley Jr, Bristol Urological Institute,Southmead Hospital, Bristol BS10 5NB, UK.e-mail: keeleys@wot99.freeserve.co.uk

© 1999 BJU International 84, 765–769