|Year : 2019 | Volume
| Issue : 2 | Page : 103-108
Laparoscopic ureterolithotomy: Experience of 60 cases from a developing world hospital
Mudassir Maqbool Wani1, Abdul Munnan Durrani2
1 Department of Surgery, Government Medical College Srinagar, India
2 Department of Urology, Jaypee Hospital, Uttar Pradesh, India
|Date of Submission||14-Oct-2017|
|Date of Acceptance||18-Mar-2018|
|Date of Web Publication||12-Mar-2019|
Dr. Mudassir Maqbool Wani
House No.:132, Green Lane Hafiz Colony Peerbagh, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Objective: Laparoscopic ureterolithotomy, which has been quoted to have a success rate equivalent to open ureterolithotomy for uretric stones, can be performed transperitoneally and retroperitoneally. The aim of the present study is to report our experience with laparoscopic retroperitoneal ureterolithotomy, its results and advantages in the current era of minimally invasive surgery in a developing country.
Patients and Methods: It was a prospective study carried from May 2010 to December 2012. 60 patients diagnosed with upper and middle uretric calculi, with sizes more than 1 cm and with value of more than 1500 hu on CT Urography ,underwent laparoscopic retroperitoneal ureterolithotomy.
Results: All patients underwent retroperitoneal laparoscopic ureterolithotomy successfully. The mean operative time was 64.53 min. The mean blood loss was 39.83 ml. 3 patients had minor intra-operative complications which were tackled on table. Post-operative complications developed in 3 patients, all minor. There were no major complications. The removal of drain was at (2.7 days). Mean hospital stay was of 3.3 days. Patients reported to their routine activities in 1.78 weeks. During follow-up 3 months later, CT urography revealed normal ureter in all cases.
Conclusion: Laparoscopic retroperitoneal ureterolithotomy has low rate of conversion to open surgery and an acceptable overall complication rates. In selected patients with impacted, hard, large ureteral stones, which are likely to cause diffi-culty in endo-urological procedures, laparoscopic ureterolithotomy is a reason-able treatment option.
Keywords: Endourological procedures, laparoscopic surgery, retroperitoneal laparoscopy, shock wave lithotripsy, ureteric stones
|How to cite this article:|
Wani MM, Durrani AM. Laparoscopic ureterolithotomy: Experience of 60 cases from a developing world hospital. J Min Access Surg 2019;15:103-8
| ¤ Introduction|| |
Although urolithiasis is fairly common, there have been a few reports of laparoscopic ureterolithotomy (LUL) as there are a few indications for its use in the current era, with most patients being treatable by minimally invasive methods, for example, extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS). Wickham carried out the first retroperitoneoscopic ureterolithotomy in 1979, and Raboy et al. performed the first transperitoneal LUL in 1992. The former technique was later popularised by Gaur et al. in 1993.,, Since that time, a few reports have been described, especially those with large numbers of patients because most of the ureteral stones can be managed by shock wave lithotripsy (SWL), URS or percutaneous nephrolithotomy (PNL). The introduction of effective methods of endoscopic stone fragmentation, such as electrohydraulic, pneumatic lithotripters and the laser, has rendered the indications for open surgery more limited.,
We report a series of 60 patients in whom retroperitoneal LUL was done. The objective of this study was to analyse the experience with the procedure, its results and benefits in the current era. This study covers all aspects of 60 patients including the operative time, blood loss, conversion rate to open surgery, complications, intraoperative and post-operative, analgesia requirements, hospital stay and convalescence.
| ¤ Patients and Methods|| |
This prospective study was conducted in the Department of Surgery, Government Medical College Srinagar, Jammu and Kashmir, India, between May 2010 and December 2012. All patients with large (1–2.6 cm, average size 1.8 cm), dense and impacted upper and middle ureteric stones, which had more than 1500 hu on computed tomography (CT) urography, were included in the study, irrespective of age, sex and race. Patients, who could be managed easily by endourological procedures such as PCNL and URS and smaller size (<1 cm) of stone, were excluded from the study. After following exclusion criterion, 60 patients underwent laparoscopic retroperitoneal uretrolithotomy. Age of the patients was in the range of 21–40 years. The mean age was 33 years. A total of 39 patients were male and 21 were female. Male:female ratio was 1.85:1, with the side of the disease being right sided in 31 and left sided in 29. Of 60 stones, 35 stones were located in the upper ureter and 25 were in the mid-ureter. All LULs were extraperitoneal [Table 1].
The patients were initially evaluated in the outpatient department and then admitted for surgery. On admission, a detailed history was asked from the patient including the presenting complaints, duration of the complaints and history, especially with reference to the previous operation and any associated condition such as chronic ailment, steroid and immunosuppressive therapy. General physical examination was conducted with particular consideration of build, height and weight followed by systemic examination with particular reference to any comorbid illnesses. Thorough abdominal examination was conducted in each patient. Each patient and his/her attendants were fully explained about the nature of laparoscopic surgery in the language which they understood and the possible complications including adjacent organ injury and unrecognised bowel injury and conversion to open surgery, and consent was obtained. Investigations performed included routine investigations such as complete haemogram, coagulogram, urine examination, kidney function tests, serum electrolytes, ECG and CXR. Imaging studies were done for anatomic examination of the urinary tract which included ultrasonography, X-ray kidneys, ureters and bladder and CT urography. Differential renal function was assessed using computerised isotope renography (DTPA renal scan). All patients had blood grouping and cross matching performed prior to planned surgery. Meticulous part preparation with povidone-iodine 10% was done in all cases to ensure asepsis. All laparoscopic retroperitoneal ureterolithotomies were done by a single surgeon of expertise in the field of laparoscopic urology in the Department of Surgery, Government Medical College Srinagar. Pre-anaesthetic check-up was done in all patients. Pre-operative prophylactic antibiotics (injection ceftriaxone 1 g IV at the time of intubation) were given in all cases.
All the procedures were done as elective surgeries under general anaesthesia. The following parameters were recorded in a pre-structured pro forma.
- Information on gender, age, body mass index, comorbidities and past surgical history
- Indication of surgery, side of the disease, kidney size, differential function, estimated blood loss and transfusions
- Operative time was recorded from the time of incision to the closure of skin and port sites
- Intra-operative complications, major and minor; conversion to open/reason for conversion if any
- Pain was evaluated by the visual analogue scale and the number of analgesic doses required
- Infection was assessed using clinical examination and treated as appropriate
- Post-operative hospital stay was noted (the day of surgery being day zero)
- Patients were asked to give a score for their satisfaction with the operation on a zero–ten scale at 1 month follow-up.
Laparoscopic retroperitoneal ureterolithotomy
The patient was initially positioned supine for intravenous access, the induction of general anaesthesia, endotracheal, intubation and bladder catheterisation. The patient was then placed in the flank position, with the umbilicus over the break in the operating table, similar to open ureterolithotomy. A 15-mm incision was made 1 cm below the tip of 12th rib, which served as the middle trocar and was usually used for the camera port. A hole was created from the skin through the muscle into the retroperitoneal space using a blunt haemostat. The index finger was inserted through the incision and used for blunt dissection for the creation of space and sweeping the peritoneum anteriorly. The potential working space was then created with a balloon dissector (PDB ® Baloon Trocar). The balloon was insufflated with 800–1000 ml of air and kept in place for a minimum of 5 min to achieve haemostasis. After removal of the balloon, two working ports, 11 mm and 5 mm, were made under finger guidance, one in the renal angle just below the 12th rib at the lateral border of sacrospinalis muscle, and the other above and anterior to the anterior superior iliac spine. Finally, Hasson cannula was secured at the primary port site and 30° telescope advanced. Additional trocar for retraction was used when necessary. The first step was to identify the psoas muscle and psoas tendon. From the psoas tendon, medial dissection revealed the ureter. Ureterotomy was done using endoscissors over the bulge of the ureter due to stone and stone removed using cup forceps. Then, a specially designed double J stent (6 Fr with both ends closed mounted on a specially designed compatible short guidewire) was placed in the ureter. Ureterotomy was then closed using 4-0 polyglactin 910 (vicryl), taking interrupted sutures, the suturing being done intracorporeally. A drain was placed through the most dependent port, followed by the relaxation of retropnuemoperitonuem and the removal of trocars and closure of port sites. A Foley's catheter was put per-urethra if not placed at the beginning of the procedure.
For the immediate post-operative, pain relief injectable diclofenac sodium 50 mg intramuscular was used. Later, oral diclofenac 50 mg tablet was used. Patients were made ambulatory on the same day of operation at evening. Orals were usually started on the 1st postoperative day. Foley's catheter was removed the day when the drain was minimal followed by the removal of drain thereafter if the drain did not increase. After discharge from the hospital, patients were called for follow-up at 1 week, 4 weeks, 12 weeks and 6 months thereafter.
| ¤ Results and Analysis|| |
Age and sex
A total of 60 patients underwent laparoscopic retroperitoneal ureterolithotomy; the mean age of patients included in the study was 33 years and the range was 21–40 years. There were 39 males and 21 females in the study cohort [Table 1].
Body mass index
Forty-one patients in the study cohort fell in the ideal group, 18 were overweight and the remaining 1 was underweight (underweight: <18.5, ideal: from 18.5 to 25, overweight: from 25 to 30, obese: >30).
Presentation of patients
A total of 60 patients had ureteric stones, 35 of them had in the upper ureter, 25 were having in the middle ureter, 31 were right sided and 29 were left sided. The most common indication was as a primary procedure for large impacted upper or mid-ureteric stones 54 (%), followed by failed URS in 4% and failed SWL in 2% of cases.
The mean operative time was 64.53 min (range is between 42 and 86 min) and the approximate amount of estimated mean blood loss was 39.83 ml (range between 20 and 40 ml). There was no requirement of transfusions.
There were no major complications. The number of patients among the operated 60 patients experiencing minor complications was 3 (5%) which included the inadvertent opening of the peritoneum in three patients. A veress needle was put into the peritoneal cavity to maintain the adequate space and pressure in the retroperitoneum. All the three procedures were completed laparoscopically without much difficulty. There was no conversion to open surgery.
Post-operative complications occurred only in 3 out of the 60 patients. Two patients developed subcutaneous emphysema and another one developed a prolonged urinary leak. All of these were managed conservatively. The mean drain removal time was 2.7 days (range 2–6) [Table 2].
Hospital stay (days)
The mean duration of stay was 3.3 days (range 2–7 days) and patients were discharged as soon as they became ambulant, tolerated orals and after removal of the drain. The longest hospital stay was in the patient who developed a prolonged leak for 6 days.
Post-operative pain relief
Post-operative pain relief was achieved by giving diclofenac sodium (I/M Injection+Oral tablets).
Follow-up and patient satisfaction
All patients were followed strictly after the surgery. Post-operative renal function was assessed with CT dye study and DTPA scans. Mean follow-up of the patients was 7.5 months (range 1–30 months). No patient was lost to follow-up. Patients undergoing laparoscopic surgery were overall satisfied. They were usually surprised by the results of the laparoscopic surgery in the post-operative period, with no incision and only three small dressings (band-aids) at the port sites.
The laparoscopic surgery was significantly costly due to the use of trocars. However, due to a brief hospital stay, lesser morbidity and shorter convalescence, the overall costs associated are expected to be reduced.
| ¤ Discussion|| |
Minimally invasive methods such as ESWL, PCNL and URS have replaced conventional surgical approach to the management of ureteric stones. However, the ideal treatment is still debatable, particularly for patients with complex ureteral stones or anatomic abnormalities. Studies recommend that ESWL should not be used as the first-line treatment option for the management of large ureteral stones with severe hydronephrosis. Other studies reveal stone clearance with URS and PCNL between 60% and 90% only.,,
It is reported that the clearance rate after a single session of SWL would decrease from 83.6% to 42.1% when the stone is larger than 10 mm. Although the improvement of equipment and technology enhances the ability of URS in the treatment of ureteral calculi, URS is still limited by its clearance rate and complications. An overall complication rate after URS is about 25%; proximal location and stone impaction are common factors predicting unfavourable results.
As such, ureterolithotomy is often recommended as an ultimate means to achieve a complete stone clearance. Before the advent of laparoscopic urologic procedures, those stones were removed by open surgery. LUL provides an alternative to such large dense and impacted stones. Several large series have revealed that LUL compares favourably with open surgery with regard to operative duration and blood loss, but the laparoscopic procedure has significant advantages over open surgery for analgesia, hospital stay, recuperation and cosmesis. Hospital stay has been decreased by 50% and the time to full convalescence has been reported to be markedly less than that with open ureterolithotomy. With growing expertise and experience, current operative times have decreased dramatically and are comparable to those in the open group.
LUL can be performed by either the transperitoneal or retroperitoneal route, with the primary determinant being the surgeon's preference and experience. Laparoscopic retroperitoneal ureterolithotomy has advantages over open ureterolithotomy which includes quicker access and early vascular control, easier dissection in individuals who are obese and the avoidance of irritation. The disadvantages of the retroperitoneal approach include a limited working space that can result in difficulty with orientation, visualisation, trocar spacing and organ entrapment. Even though this provides an extraperitoneal intervention, injury to intraperitoneal organs and a hernia can occur during balloon dilatation of the extraperitoneal space. The retroperitoneal approach results in complication rates, pain medication requirements, length of hospital stay and time to return to normal activity after surgery similar to those of transperitoneal route.
The retroperitoneal access allows a procedure without manipulation of the intraperitoneal organs, reducing the risk of direct and indirect damage to these structures. In addition to reducing the incidence of a dynamic ileus and adhesions, the retroperitoneal access keeps the peritoneal cavity isolated from urinary fistulas and post-operative infectious processes.
LUL shares potential risks with open surgery; however, there are differences in the type and presentation of these complications. Complications can arise at each step of the procedure. Access-related problems such as solid organ injury, bowel injury, abdominal wall haematoma and injury to epigastric vessels have been reported. In addition, reported common complications include an incisional hernia, transient thigh numbness, prolonged ileus, pulmonary embolus, pneumonia, brachial nerve injury and unrecognisable injury.
LUL has become a serious supplement to established operative techniques. LUL has to be considered as a clear winner over open ureterolithotomy with progressive technological development in laparoscopic surgery combined with routine practice. Skrepetis et al. and many others have also suggested that the stones that are large, dense, impacted, obstructing the upper urinary tract, longstanding and located in the ureter are difficult to treat by other means, and therefore, LUL should be selectively considered as the method of choice. Over the years owing to its safety and reproducibility, LUL is now the standard of care and should be offered to every patient with dense, impacted stone who is scheduled for elective ureterolithotomy.
Goel and Hemal  reported the experience of 81 patients of ureterolithiasis (55 undergoing laparoscopic retroperitoneal surgery and 26 open intervention) from All India Institute of Medical Sciences. They concluded that in laparoscopic group average operating time was 98.8 min against 108.8 min in open group. The results also showed that the hospital stay (3.3 vs 4.3 d) was less in laparoscopic group compared to open group. Study also revealed that convalescence (3 vs 5weeks) was better in laparoscopic ureterolithotomy patients than the patients undergoing open ureterolithotomy.
In the present study which consisted of 60 patients, the overwhelming majority of the patients were in their reproductive age group. There were more males than females in both groups. The most common age group was 21–40 years in both groups. With respect to the operative time, in published literature, there is no significant difference in average operative times. In this study the mean operative time was 64.53 minutes. The average blood loss in this study was 39.83 ml, which correlates with the reported literature. This is of an important consideration as female patients in our setting are often anemic. Patients from the laparoscopic group reported less post-operative pain, and the mean analgesic requirements in laparoscopic was 65 mg of diclofenac.
Patients in laparoscopic group had an earlier resumption of oral intake by 2–3 h. These factors in addition to less post-operative pain and early ambulation resulted in a shorter hospital stay. The mean hospital stay was 3.3 days.
In this study, a total of two (6.66%) minor intra-operative complications occurred in the laparoscopic retroperitoneal ureterolithotomy group where two patients had a breach in peritoneum where a veress needle was used to let the air out of the peritoneal cavity and maintain the pressure and space in the retroperitoneum; the rent being closed primarily. The intra-operative complication rate in this study is less than the complication rates in the reported literature. This can be attributed to careful patient selection, and also to the experience of the operating surgeon.
All the laparoscopic procedures were completed successfully, and none had to be converted to open. Of the 60 patients taken up for laparoscopy, one patient had a past history of URSL on the opposite side. The post-operative complications were mostly wound related. Post-operative complications occurred only in three patients of laparoscopic group. Two patients from the laparoscopic group developed subcutaneous emphysema and another developed prolonged urinary leak. All of these were managed conservatively.
All the patients were followed strictly after the surgery. The mean follow-up of the patients in laparoscopic group was 7.5 months. Cost factor needs to be addressed with respect to the laparoscopic retroperitoneal ureterolithotomy. The main contributor to the cost of laparoscopy is the disposable nature of trocars. However, due to a briefer hospital stay, lesser morbidity and shorter convalescence, the overall costs associated are expected to be less.
Authors MMW and MD were involved in all aspects of this publication.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]