Laparoscopic ureterolithotomy compared to open ureterolithotomy for the treatment large, impacted ureteral stones, "Beyond the Abstract," by Goksel Bayar, MD

BERKELEY, CA (UroToday.com) - In recent years, with development of extracorporeal shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PNL) and with the advances in the technology of ureteroscopy (URS), the rates of surgery for stones in the urinary tract has dropped to levels of 1 to 5.4%.[1, 2]

For patients who are unsuitable candidates for SWL and URS and unresponsive to these treatment modalities, invasive treatment modalities are put forth. For the upper part of the ureter, antegrade percutaneous ureteroscopy is a good alternative. If the patient is not suitable for antegrade percutaneous ureteroscopy, and for stones of the other parts of the ureter, the only alternative treatment is ureterolithotomy. Definitions for impacted stones include the following: if the contrast media is radiologically observed not to have passed to the distal of the stone; and preoperatively, if the guide wire does not pass to the proximal of the stone; and when the stone remains at the same anatomical position for 2 months.[3, 4, 5]

The success rate for laparoscopic ureterolithotomy is usually reported as 90%; however, there are reports of 100% success, too, and of a 0% rate of complication.[6, 7, 8] The duration of hospital stay has been reported to be between 2.9-6.4 days[9, 10] and in our study it is estimated to be 2.9 days. Since the previous studies had been carried out with regard to laparoscopic ureterolithotomy experiences and the comparison with ureteroscopy, there is hardly any mention about the duration of hospital stay. Skrepetis and colleagues reported the duration of hospital stay for the laparoscopy group as 3 days and that for the open surgery group as 8 days.[11] With ureter suturing and placement of a double J ureteral stent, the urinary leakage time in patients decreased from 5.5 days to 3.2 days.[12] In our study, when we compared the groups, the time duration was determined to be significantly lower in the laparoscopy group. Unfortunately, the need for analgesia has not been defined with a common drug or a unit. The number of studies about the need of analgesia for open and laparoscopic ureterolithotomy groups is very limited. Skrepetis et al. reported the daily requirement of analgesics in the laparoscopic group as 1, and that in the open surgery group as 4.[11] In our study, the need for analgesia was expressed as unit analgesia, and this was 1.8 units in the laparoscopy group and 3.5 units in the open group, which is significantly lower in the laparoscopy group.

Ureteral stricture is the main complication concern after the operation. In a review of the literature, Nouira and colleagues reported this complication rate as 2.5%.[9] To prevent strictures, it is important not to disturb the vasculature of the incised part of the ureter during the operation. Gaur and colleagues reported that it is safe to use the hook device in the cutting mode of the electrocautery device for the ureter incision. They reported that in the 10-year follow-up of 75 patients, only 3 had strictures in the part that the stone had been impacted, but they did not mention anything about the incision technique in the patients who had developed strictures. Two of those 3 patients were treated with balloon dilatation and one underwent double J stent placement for 3 months and no recurrence was observed.[12] We used the scalpel for incision, with a unique method and safe technique that we ourselves had developed in our clinic. In the mean follow-up time of 30 months, none of the patients experienced ureteral stricture.

References:

  1. Assimos DG, Boyce WH, Harrison LH, McCullough DL, Kroovand RL, Sweat KR. The role of open stone surgery since extracorporeal shock wave lithotripsy. J Urol. 1989;142:263-7.
  2. Segura JW. Current surgical approaches to nephrolithiasis. Endocrinol Metab Clin North Am. 1990;19:919-35.
  3. Goel R, Aron M, Kesarwani PK, Dogra PN, Hemal AK, Gupta NP. Percutaneous antegrade removal of impacted upper-ureteral calculi: still the treatment of choice in developing countries. J Endourol. 2005;19:54-7.
  4. Erhard M, Salwen J, Bagley DH. Ureteroscopic removal of mid and proximal ureteral calculi. J Urol. 1996;155:38-42.
  5. Morgentaler A, Bridge SS, Dretler SP. Management of the impacted ureteral calculus. J Urol. 1990;143:263-6.
  6. Skrepetis K, Doumas K, Siafakas I, Lykourinas M. Laparoscopic versus open ureterolithotomy. A comparative study. Eur Urol. 2001;40:32-6.
  7. Fang YQ, Qiu JG, Wang DJ, Zhan HI, Situ J. Comparative study on ureteroscopic lithotripsy and laparoscopic ureterolithotomy for treatment of unilateral upper ureteral stones. Acta Cir Bras. 2012;27:266-70.
  8. Keeley FX, Gialas I, Pillai M, Chrisofos M, Tolley DA. Laparoscopic ureterolithotomy: the Edinburgh experience. BJU Int. 1999;84:765-9.
  9. Nouira Y, Kallel Y, Binous MY, Dahmoul H, Horchani A. Laparoscopic retroperitoneal ureterolithotomy initial experience and review of literature. J. Endourol. 2004;18:557-61.
  10. Kijvikai K, Patcharatrakul S. Laparoscopic ureterolithotomy: Its role and some controversial technical considerations. Int J Urol. 2006;13: 206-10.
  11. Skrepetis K, Doumas K, Siafakas I, Lykourinas M. Laparoscopic versus open ureterolithotomy. A comparative study. Eur Urol. 2001;40:32-6.
  12. Gaur DD, Trivedi S, Prabhudesai MR, Madhusudhana HR, Gopichand M. Laparoscopic ureterolithotomy: technical considerations long term follow-up. BJU Int. 2002;89:339-43.

Written by:
Goksel Bayar, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Departments of Urology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey

Comparison of laparoscopic and open ureterolithotomy in impacted and very large ureteral stones - Abstract

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