Indications for ureterolithotomy are rare in the modern era of endourology. Current indications include stones with a low likelihood of treatment success using extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, or percutaneous techniques; secondary treatment for treatment failures after less invasive techniques; medically underserved areas or developing countries without access to ureteroscopic or lithotripsy equipment; and in patients who have a planned open or laparoscopic procedure for another condition in which simultaneous treatment of the stone is requested. Although traditionally described as an open procedure, ureterolithotomy can be performed with an open, laparoscopic, or robotic technique.
Preoperative Planning
It is imperative to know the location of the stone before performing ureterolithotomy because this will impact surgical approach. A recent computed tomography (CT) scan or kidneys–ureter–bladder (KUB) radiography study demonstrating the stone location is required before performing ureterolithotomy. If there is concern about a nonfunctioning kidney based on preoperative imaging, a dimercaptosuccinic acid (DMSA) scan is recommended to assess renal function. If the stone is present in association with a poorly functioning kidney, the patient may be better treated with a nephrectomy as opposed to a ureterolithotomy. A urine culture should be obtained before the procedure, and the patient should be treated with culture-specific antibiotics if a urinary tract infection is present.
Open Ureterolithotomy
The surgical approach for an open ureterolithotomy depends on the location of the stone. For all locations, an extraperitoneal approach can be performed. However, if the patient is undergoing a concomitant intraperitoneal surgery for another indication, a transperitoneal approach can be used.
Proximal ureter: For stones located proximal to the ureter crossing the iliac vessels, a supracostal, subcostal, or flank incision provides optimal exposure. Alternatively, a lumbotomy can be used for proximal stones. If needed, a midline extraperitoneal or intraperitoneal approach can also be used.
Distal ureter: For stones distal to the ureter, crossing the iliac vessels can be approached extraperitoneally via a low midline, Pfannenstiel, or Gibson incision.
Generally, the ureter can be accessed extraperitoneally. Care should be taken in the dissection of the ureter to preserve as much periureteral tissue as possible to minimize stone migration and ureteral devascularization. The stone can be located either by visualizing a bulge within the ureter or by gentle palpation. After the stone is identified, a vessel loop should be placed around the ureter both proximally and distally to the stone to prevent migration of the stone ( Fig. 38.1 ). The ureter is opened longitudinally over the stone with a scalpel and extended with Potts scissors if needed ( Fig. 38.2 ).
The stone is then loosened from the ureteral wall and removed intact. After removal of the stone, a 5-Fr feeding tube is placed proximally and distally to interrogate the ureter for remaining stone fragments ( Fig. 38.3 ). A stent can be placed at the discretion of the surgeon but is recommended to control any potential urinary leaks that could result in stricture.
The ureterotomy is closed longitudinally with interrupted absorbable sutures. The ureter can be wrapped with periureteral fat, and a drain is placed. The drain should be placed near the ureterotomy but not in direct contact. A Foley catheter is left in place. The Foley catheter can be removed on postoperative day 1, and the drain can be removed 24 hours later if output is low.
Laparoscopic Ureterolithotomy
If technically feasible, laparoscopic ureterolithotomy with or without robotic assistance is preferred to open ureterolithotomy because of decreased recovery time and lower morbidity. The surgical approach for laparoscopic ureterolithotomy depends on the location of the stone.
Proximal Ureter
The proximal ureter can be accessed by either transperitoneal or retroperitoneal approach with the patient in a flank position.
For a transperitoneal approach, the port placement is similar as for a laparoscopic pyeloplasty. Pneumoperitoneum is obtained through the umbilicus. A camera port is placed at the umbilicus. A second port is placed just lateral to the rectus muscle and below the costal margin, and the third port is placed in the same line as the second port approximately one hand breadth from the umbilical port ( Fig. 38.4 ). If performing robotically, a camera port is placed along the costal margin one hand breadth lateral from the second port, and the umbilical port is used by the assistant. The colon is then mobilized medially by incising the white line of Toldt, and the ureter is mobilized taking care to preserve the periureteral soft tissue.
