Laparoscopic Surgery

European Eur Urol 2001;40:609–613 Accepted after revision: August 3, 2001

Urology

Laparoscopic Ureterolithotomy for

Ureteral Calculi
Axel Feyaerts, John Rietbergen, Stéphane Navarra, Guy Vallancien,
Bertrand Guillonneau
Department of Urology, Institut Mutualiste Montsouris, Pierre and Marie Curie University, Paris, France

Key Words
Ureteric stone · Laparoscopy

Abstract
Background and Purpose: Most patients with ureteral calculi that do not pass spontaneously
can be treated by either extracorporeal shockwave lithotripsy (SWL) or ureteroscopy. In rare
cases of large, hard and chronically impacted stones, or after failure of first-line treatments, sur-
gical ureterolithotomy is still indicated. Laparoscopy allows performing this procedure in a min-
imally invasive manner.
Patients and Methods: Twenty-four patients (22 men and 2 women) underwent laparoscopic
ureterolithotomy between 1994 and 1999. The procedure was indicated in 10 cases as a salvage
treatment after failure of SWL (5 patients), ureteroscopy (2 patients), both (1 patient), laparo-
scopic ureterolithotomy (1 patient), or even open ureterolithotomy (1 patient), and in 14 pa-
tients as a primary treatment for large stones (median size 11.5, range 8–33 mm). The first 3
procedures were carried out via the retroperitoneal route and the following 21 via the transperi-
toneal approach.
Results: All but 1 stone were successfully removed in a mean operating time of 111 (range 45–
180) min. Postoperative pain was managed with first-line analgesics. Hospital stay ranged from
2 to 10 (mean 3.8) days. The 2 postoperative complications encountered were prolonged ileus
(1 patient) and venous thrombosis (1 patient).
Conclusions: Laparoscopic ureterolithotomy is a safe and effective procedure that enables the
urologist to maintain a minimally invasive strategy when first-line treatment have failed or are
unlikely to be effective.
Copyright © 2001 S. Karger AG, Basel

Introduction are currently recommended as first-line treatment for most

The management of ureteral calculi has completely
changed since the introduction of extracorporeal shock-
wave lithotripsy (SWL) and ureteroscopy. Those methods
ureteral calculi that are unlikely to pass spontaneously [1].
With the development of these minimally invasive tech-
niques, the indication for open surgical ureterolithotomy
has rapidly decreased.
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 2001 S.Karger AG, Basel Dr. Bertrand Guillonneau

0302–2838/01/0406–0609 $17.50/0 Institut Mutualiste Montsouris, Département d’Urologie
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www.karger.com www.karger.com/journals/eur Tel. +33 1 56 61 62 63, Fax +33 1 45 80 60 41, E-Mail bertrand.guillonneau@imm.fr
Table 1. Patients characteristics

Patient Age Stone Side Location Prior Approach Operating Suture Drainage Success
No. years size, mm treatment time

1 71 11 R Lumbar None RP 180 Yes JJ + RP Yes

2 61 10 L Lumbar Open RP 120 Yes None Yes
3 41 17 L Lumbar None RP 120 No JJ + RP Yes
4 46 7 L Pelvic SWL TP 120 Yes None Yes
5 32 15 R Lumbar SWL TP 85 Yes RP Yes
6 56 9 R Lumbar None TP 105 Yes RP Yes
7 53 10 L Iliac USCO TP 90 Yes JJ Yes
8 70 8 R Lumbar None TP 150 Yes None Yes
9 80 20 L Pelvic None TP 150 Yes JJ Yes
10 62 8 R Lumbar USCO TP 100 Yes JJ Yes
11 53 8 L Iliac None TP 80 Yes JJ Yes
12 69 10 L Pelvic None TP 150 Yes JJ Yes
13 61 14 R Lumbar None TP 60 Yes RP Yes
14 58 8 L Lumbar Laparoscopy TP 110 Yes JJ Yes
15 64 12 R Lumbar None TP 100 Yes JJ Yes
16 54 9,5 L Lumbar None TP 130 Yes JJ Yes
17 42 10 L Lumbar None TP 120 Yes JJ No
18 67 33 R Lumbar None TP 180 Yes JJ + RP Yes
19 38 20 L Lumbar SWL TP 90 Yes RP Yes
20 40 8 L Lumbar SWL TP 120 Yes JJ Yes
21 35 13 R Lumbar SWL TP 90 Yes JJ Yes
22 67 7 L Lumbar SWL + USCO TP 85 Yes JJ Yes
23 37 15 L Lumbar None TP 45 Yes JJ Yes
24 57 12 R Lumbar None TP 90 Yes JJ Yes

R = Right; L = left; USCO = ureteroscopy; RP = retroperitoneal; TP = transperitoneal.

In rare cases, however, a surgical approach may still be
required when first-line treatments have failed or when the
characteristics of the stone (size, composition, location)
suggest the need for multiple procedures.
Laparoscopic surgery performed either through a retro-
peritoneal or a transperitoneal approach allows us to realize
ureterolithotomy in a less invasive manner than open
surgery.
Patients and Methods
Between 1994 and 1999, 24 patients (2 females and 22 males) un-
derwent laparoscopic ureterolithotomy. Patients’ data are summarized
in table 1. Median age was 56.5 (range 32–80) years. In 10 patients,
laparoscopy was indicated because other treatments had failed (5 pa-
tients treated by SWL, 2 by ureteroscopy, 1 by SWL and ureteroscopy,
1 by laparoscopic ureterolithotomy performed in another institution,
and finally 1 patient referred to our hospital after failure of open
surgery). In the 14 remaining patients, laparoscopic ureterolithotomy
was the initial treatment. In this group, the median diameter of the
stone was 11.5 (range 8–33) vs. 9 (range 7–20) mm in patients who
underwent the procedure as a salvage therapy.
Stones were located in the lumbar region in 19 cases, in the pelvic
region in 3 cases and in the iliac region in 2 cases.
Technique
The ureter was accessed retroperitoneally in the first 3 cases and via
the transperitoneal route in the 21 following patients.
For the retroperitoneal technique, the patient was in the flank po-
sition and a short incision was performed at the tip of the 12th rib. Af-
ter opening Gerota’s fascia, the retroperitoneum was dissected with
the finger and a 10-mm trocar was inserted for the camera. Insuffla-
tion of carbon dioxide up to 15 mmHg and further dissection of the
retroperitoneal fat with the lens allowed the creation of a space wide
enough for the positioning of 3 other trocars: a 10-mm trocar at the su-
perior edge of the iliac crest, a 5-mm trocar posteriorly and lateral to
the lumbar muscles and a 5-mm trocar anteriorly, after dissection of
the peritoneum that was lifted anteriorly.
For the transperitoneal approach, the patients were positioned in
dorsal decubitus position for distal stones and with moderate lateral
rotation for proximal and mid ureteral calculi. The Veress needle was
inserted in the peritoneal cavity through the umbilicus and a pneu-
moperitoneum of 12 mm Hg was created. Three trocars were placed
identically in all procedures: a 10-mm trocar for the camera pararec-
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Fig. 1. Positioning of a loop around the ureter.
Fig. 2. Longitudinal incision of the ureter.
tally and level with the umbilicus, and two 5-mm trocars in a triangu-
lar pattern on the side of the stone. In addition one or two trocars were
placed when necessary for assistance or suction. For the exposition of
the ureter the colon was mobilized medially.
In both approaches, the ureter was dissected and a loop was placed
around the ureter proximal to the stone to prevent migration (fig. 1). A
longitudinal incision of the ureteral wall was then performed with a
cold knife (fig. 2) over the bulging of the stone which was subse-
quently extracted (fig. 3) and removed via an extraction bag.
The ureterotomy was sutured (fig. 4) with 2 or 3 interrupted 5/0
stiches, except in 1 case with severe periureteral inflammation.
For drainage, an internal stent was positioned in 17 patients for a
mean period of 22 (range 5–90) days. A retroperitoneal drain was
placed in 7 patients and was removed on postoperative day 1 or 2. In
the patient with the unsutured ureterotomy, both types of drainage
were used. Three patients had no drainage at all.
Laporoscopic Ureterolithotomy for Ureteral
Calculi
Fig. 3. Extraction of the stone.
Fig. 4. Transversal closure of the ureter.
Results
The stone was successfully removed by the laparoscopic
procedure in all but 1 patient. In this case, a lumbar stone
was accidentally pushed back into the kidney. This patient
was later successfully treated by SWL.
The mean operating time was 140 (range 120–180) min
for the first 3 cases performed by retroperitoneoscopy and
107 (range 45–180) min for the cases treated by the
transperitoneal route. No preoperative complications oc-
curred and no blood transfusions were required.
Early postoperative complications encountered were a
prolonged (48 h) ileus in 1 case and a deep venous throm-
bosis in another case. Neither fistula nor urinoma were ob-
served.
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 For postoperative comfort, patients required only first- oxalate-monohydrate calculi are optimal candidates for this
line analgesics (pro-paracetamol or paracetamol, and tiemo- noninvasive option.
nium methylsulfate). They were discharge from the hospital Several characteristics of this procedure must be empha-
between postoperative day 2 and 10 (mean 3.8). sized: (1) a stent or a guide wire should be placed past the
IVP, performed in all patients between the 1st and the stone preoperatively when possible; (2) the stone is usually
3rd postoperative month, never demonstrated ureteral stric- easy to identify in the ureter thanks to its bulge and the use
ture. of X-ray is rarely mandatory to locate the stone; (3) the po-
sitioning of a loop around the ureter upstream from the
stone is useful to prevent its migration; (4) ureterotomy is
Discussion adequately performed with a cold knife and the ureteral in-
cision must be longitudinal to decrease the risk of disrupting
The first case of retroperitoneoscopic ureteroluthotomy the ureteral blood supply [12], and (5) suturing is not advo-
was reported by Wickham [2] in 1979. This technique was cated by all authors; however, several cases of prolonged
popularized in the 1990s when Gaur [3] described a balloon urinary leakage or urinoma have been reported in the litera-
technique to create an effective pneumoretroperitoneum. ture [5, 9, 11]. Therefore, we recommend the placement of
The first case of transperitoneal laparoscopic ureterolithoto- 2–3 stitches to close the ureterotomy.
my was published in 1992 by Raboy et al. [4].
Currently, there is still no consensus about the best ap-
proach. The retroperitoneal route has several theoretical ad- Conclusions
vantages over the transperitoneal approach: the risk of vis-
ceral injury (mainly related to the use of the Veress needle) Laparoscopic ureterolithotomy is a safe and effective
is lower, abdominal adherences do not interfere with the procedure that enables the urologist to maintain the current
procedure, and there is no need to mobilize the colon. On strategy of minimally invasive surgery, even when first-line
the ohter hand, the transperitoneal approach offers a better treatments such as SWL and ureteroscopy have failed. In
view and more space to work. Conversion of the retroperi- addition, its effectiveness and low morbidity rate allow us
toneal approach to the transperitoneal route may be required to propose its use as primary procedure, instead of open
in some cases, due to contracted space or unclear landmarks surgery, when other classic methods are unlikely to be ef-
[5, 6]. fective.
In addition, the transperitoneal route provides access to
the whole urinary system and enables the performance of
various surgical procedures on the urinary tract (kidney,
ureter, bladder, prostate) through the same route. The selec-
tion of a standardized approach in a new technique makes it
possible for the surgeon to more rapidly increase his/her ex-
perience and helps to decrease the rate of complications.
In our view, the transperitoneal route offers significant
advantages, and is therefore preferred in our institution.
Nevertheless, each surgeon should choose the method with
which he feels comfortable.
Independent of the approach, laparoscopic ureterolitho-
tomy series have presented success rates of between 88 and
100% after 1 single procedure with an acceptable operating
time, few complications, and short recovery periods [5–11].
Laparoscopy is therefore advocated as an alternative to
open stone surgery when first-line treatments have failed.
In certain circumstances, the characteristics of the stone
suggest the need for multiple procedures over a long period
and laparoscopy may be advocated as a first-choice option.
Ureteral stones bigger than 1 cm, particularly in the upper
ureter, chronically impacted stones, and cystine or calcium-
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