Ureterolithotomy
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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 (e.g., 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).
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.
Tracy CR, Raman JD, Cadeddu JA, Rane A. Laparoendoscopic single-site surgery in urology: where have we been and where are we heading?. Nat Clin Pract Urol. 2008 Oct. 5(10):561-8. [Medline].
Rofeim O, Yohannes P, Badlani GH. Does laparoscopic ureterolithotomy replace shock-wave lithotripsy or ureteroscopy for ureteral stones?. Curr Opin Urol. 2001 May. 11(3):287-91. [Medline].
Singh V, Sinha RJ, Gupta DK, Kumar M, Akhtar A. Transperitoneal versus retroperitoneal laparoscopic ureterolithotomy: a prospective randomized comparison study. J Urol. 2013 Mar. 189(3):940-5. [Medline].
Tugcu V, Simsek A, Kargi T, Polat H, Aras B, Tasci AI. Retroperitoneal laparoendoscopic single-site ureterolithotomy versus conventional laparoscopic ureterolithotomy. Urology. 2013 Mar. 81(3):567-72. [Medline].
Fang YQ, Qiu JG, Wang DJ, Zhan HL, Situ J. Comparative study on ureteroscopic lithotripsy and laparoscopic ureterolithotomy for treatment of unilateral upper ureteral stones. Acta Cir Bras. 2012 Mar. 27(3):266-70. [Medline].
El-Moula MG, Abdallah A, El-Anany F, Abdelsalam Y, Abolyosr A, Abdelhameed D, et al. Laparoscopic ureterolithotomy: our experience with 74 cases. Int J Urol. 2008 Jul. 15(7):593-7. [Medline].
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Mandhani A, Kapoor R. Laparoscopic ureterolithotomy for lower ureteric stones: Steps to make it a simple procedure. Indian J Urol. 2009 Jan. 25(1):140-2. [Medline]. [Full Text].
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Stolzenburg JU, Katsakiori PF, Liatsikos EN. Role of laparoscopy for reconstructive urology. Curr Opin Urol. 2006 Nov. 16(6):413-8. [Medline].
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George M Ghareeb, MD Resident Physician, Department of Urology, University of Iowa Hospitals and Clinics
Disclosure: Nothing to disclose.
James A Brown, MD, FACS Professor of Urology, Residency Program Director, Medical Director, Department of Urology, Professor of Biomedical Engineering, Andersen-Hebbeln Professor of Prostate Cancer Research, University of Iowa, Roy J and Lucille A Carver College of Medicine
James A Brown, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Society for Basic Urologic Research, Society of Laparoendoscopic Surgeons, Society of University Urologists, Society of Urologic Oncology, American Association of Clinical Urologists, Society of Government Service Urologists
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, Society of University Urologists
Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical; Olympus.
Michael Grasso, III, MD Professor and Vice Chairman, Department of Urology, New York Medical College; Director, Living Related Kidney Transplantation, Westchester Medical Center; Director of Endourology, Lenox Hill Hospital
Michael Grasso, III, MD is a member of the following medical societies: American Medical Association, American Urological Association, Endourological Society, International Society of Urology, Medical Society of the State of New York, National Kidney Foundation, Society of Laparoendoscopic Surgeons
Disclosure: Received consulting fee from Karl Storz Endoscopy for consulting.
Jeffrey M Donohoe, MD, FAAP Assistant Professor of Pediatric Urology, Department of Surgery, Division of Urology, Children’s Medical Center, Medical College of Georgia
Jeffrey M Donohoe, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Urological Association
Disclosure: Nothing to disclose.
Sisir Botta, MD Resident Physician, Department of Urology, Medical College of Georgia
Disclosure: Nothing to disclose.
Subbarao V Cherukuri, MD Consulting Staff, Department of Urology, St Joseph Regional Health Center
Subbarao V Cherukuri, MD is a member of the following medical societies: American Urological Association and Ohio State Medical Association
Disclosure: Nothing to disclose.
Acknowledgments
Medscape Reference thanks Dennis G Lusaya, MD, Associate Professor II, Department of Surgery (Urology), University of Santo Tomas; Head of Urology Unit, Benavides Cancer Institute, University of Santo Tomas Hospital; Chief of Urologic Oncology, St Luke’s Medical Center Global City, Philippines, for the video contribution to this article.
Medscape Reference also thanks Edgar V Lerma, MD, FACP, FASN, FAHA, Clinical Associate Professor of Medicine, Section of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine; Research Director, Internal Medicine Training Program, Advocate Christ Medical Center; Consulting Staff, Associates in Nephrology, SC, for his assistance with the video contribution to this article.
Ureterolithotomy
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