There are several first-line treatment options for management of large proximal ureteric stones including ureteroscopic lithotripsy, shock-wave lithotripsy and percutaneous nephrolithotomy. Moreover, laparoscopic ureterolithotomy (LPU) is recommended if first-line treatment options fail or are unlikely to be successful. Recent research has shown that LPU achieves high stone-free rate and lower need for auxiliary procedures for the treatment of large impacted ureteric stones. Reports that illustrate the technical details of LPU are scanty in literature. In this illustrative video, we discussed the surgical technique of LPU step by step and emphasized on the various tips and tricks to extract the stone successfully.
For treatment of large proximal ureteric stones >10 mm, guidelines recommend ureteroscopic lithotripsy (URL), shock-wave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) as first-line treatment options. Laparoscopic ureterolithotomy (LPU) may be considered an alternative in rare cases in which SWL, URL, and PNL fail or are unlikely to be successful. Recently, several randomized control trials (RCTs) and meta-analyses of RCTs have shown higher stone-free rates and lower auxiliary procedures after LPU. We believe that LPU can have more indications in the treatment of large proximal ureteral stones and should be more recognized. Thus, further research should be conducted on the clarification and standardization of LPU indications. In this video, we present tips and tricks of LPU for the treatment of large proximal ureteric stones.
Understanding the relationship of the ureter and gonadal vessels is one of the crucial steps for a successful LPU. Additionally, the ureter can be identified by its peristalsis and glistening white color. A combination of blunt and sharp dissection is used to identify and dissect the ureter. Dissection is continued cranially towards the proposed stone site and is performed in the periureteric tissues. Care should be taken not to vigorously hold or press on the ureteral wall to avoid mobilization or migration of the stone towards the dilated proximal ureter and collecting system. Complete ureterolysis should not be performed in order to preserve the periureteric vasculature and reduce risk of developing ureteral stricture.
The stone is identified by the presence of a bulge with proximal dilatation above it. The exact stone site is confirmed by gentle pinching of the ureter using atraumatic grasping forceps. We should not incise the ureteral wall if the exact stone site is unknown. Fluoroscopic localization would help if one is not sure about its exact site.
We use an electrical cutting-mode hook starting from the most bulging part of stone to make an incision opposite to the upper part of the stone and sufficient enough to extract the stone. The incision length is about 10 mm. Bleeding from the incised ureteral edges indicates adequate preservation of the periureteric vasculature and no attempt should be done to control it as it usually stops spontaneously or after closure of the ureterotomy wound. As an alternative, we can use the laparoscopic knife to incise the ureteral wall instead of with the hook. Some believe that it lowers the risk of ureteral stricture, however, no evidence supports this theory.
The tip of Maryland's forceps or a laparoscopic hook are used to separate the stone from its overlying adherent ureteric mucosa. Then, we deliver the proximal part of the stone from the incision site by leverage or angling the ureter with assistance of the hook or forceps. Further pinching of the ureter with the forceps or flipping of the prominent part of the stone will help delivery of the remaining part of the stone. The spoon forceps are used to extract the stone outside the abdomen.
We routinely insert a JJ stent in all patients either through a retrograde route prior to the procedure or via a laparoscopic antegrade route after the stone extraction.
The ureteral walls are closed with 4/0 Vicryl suture on SH needle. To avoid iatrogenic narrowing of the ureter and to reduce risk of developing ureteral stricture, it is recommended to include a small ureteral mucosal edge about 1 mm or suture the ureteral serosa only.