Pyelolithotomy and Ureterolithotomy

Indications and Contraindications

With the use of shock wave lithotripsy (SWL) and advances in endoscopic technology and instrumentation, open surgery, once the mainstay treatment for ureteral stones, is now uncommon. Currently, open surgery is reserved for impacted stones for which these techniques have failed or in situations in which endoscopic equipment and SWL are unavailable. In the rare instance in which multiple minimally invasive treatments may be required, patients may opt for open surgery if it will ensure a single treatment session. In addition, open surgery may be indicated in the management of urolithiasis associated with anatomic abnormalities such as primary obstructive megaureter and ureteropelvic junction obstruction (UPJO). It also has a small role in the management of large staghorn calculi in patients with morbid obesity or unfavorable collecting system anatomy. Laparoscopic or robotic-assisted pyelolithotomy or ureterolithotomy is an alternative to open treatment and has exactly the same indications. From the first laparoscopic ureterolithotomy reported in 1992 to early reports of robotic-assisted pyelolithotomy in the mid-2000s, these techniques have been shown to be safe and effective. Most reports have been limited to case series with relatively small numbers compared with more conventional options, but this is a reflection of the number of patients (<5%) for whom endoscopic management of urolithiasis fails.

Patient Preoperative Evaluation and Preparation

Noncontrast computed tomography (CT) provides detailed information about stone size and position, renal pelvis anatomy, and proximity of adjacent organs and blood vessels. If CT is unavailable, kidney, ureter, and bladder x-ray studies in combination with intravenous pyelography will identify stone location, suggest stone consistency, and detail renal calyceal and ureteral anatomy. If a ureteral stricture is suspected, retrograde pyelogram (or antegrade if a percutaneous nephrostomy is in place) can be performed. Midstream urine culture should be performed for all patients before surgery, and culture-specific antibiotics should be given if infection is present.

Laparoscopic Surgery ( )

Operating Room Configuration and Patient Positioning

The operating room is configured for ready instrument accessibility and visualization of the procedure by the entire surgical team ( Fig. 31-1 ). For the transperitoneal approach, the patient is placed in a lateral position for proximal and midureteral stones. For stones located in the distal ureter, the patient is positioned supine with slight contralateral rotation. For the retroperitoneal approach, the patient is placed in the flank position.

Trocar Placement

Transperitoneal Approach

For midureteral and proximal ureteral stones, three trocars are placed in line: a 10/12-mm umbilical port for the laparoscopic camera, a 10/12-mm port in the midline between the umbilicus and the pubis, and a 5-mm port in the midline between the xiphoid and the camera port ( Fig. 31-2 ). An alternate option for instrument ports is to place them ipsilateral to the stone on the midclavicular line (one subcostal and one lower quadrant). A fourth trocar can be placed on the ipsilateral anterior axillary line, forming a diamond-shaped configuration with the other three ports, if necessary. For distal ureteral stones, use four trocars: one umbilical, one ipsilateral to the stone supraumbilically at the midclavicular line, and two contralateral on the midclavicular line (one in the lower quadrant and the other in line with the umbilicus). If necessary, a fifth trocar can be placed in the suprapubic area.

Retroperitoneal Approach

A small incision is made at the tip of the 12th rib to allow balloon dissection of the retroperitoneal space. If the stone is distal, reposition the balloon dissector so that dissection proceeds more distally. Place the first port through this incision. Place two or three more ports with a combination of manual guidance and direct vision. Place one 5- to 10-mm trocar at the superior edge of the iliac crest, and place another 10-mm port one palm breadth superior to the previous one and over a line that passes over the standard subcostal incision. Place the last 5-mm port on the same vertical line as previously, but one palm breadth cranial ( Fig. 31-3 ).