Evaluation of ureteral stent placement after retroperitoneal laparoscopic ureterolithotomy for upper ureteral stone: randomized controlled study

How safe and effective is stentless laparoscopic ureterolithotomy in elderly patients?

PURPOSE

With the improvement of minimally invasive urology procedures, open surgical interventions are less common to treat ureteral calculus. Laparoscopic ureterolithotomy (LU) indications are large multiple and/or impacted ureteral calculus that may not be treated with shock-wave lithotripsy or ureterorenoscopy approaches. The aim of our study was to investigate the feasibility and safety of stentless LU in elderly patients.

METHODS

Between October 2011 and December 2019, 38 geriatric patients underwent stentless transperitoneal LU for upper/mid ureteral calculi. The transperitoneal route was applied in all patients by two surgeons. No double J stent inserted in any patient. The data of all patients reviewed retrospectively.

RESULTS

The average age was 64.60 ± 3.70 years. The mean calculi size was 19.42 ± 1.41 mm. Ten patients had unsuccessful shock wave lithotripsy or ureterorenoscopy history. The calculi-free rate was 100%. Clavien grade 1 complications were seen in 11 (28.9%) cases. No major perioperative and postoperative complications were encountered. The average length of hospital stay was 3.24 ± 1.53 days.

CONCLUSION

The significant advances in medical technology and healthcare, lead a rising number of geriatric patients to take benefit of even complicated surgery. Although laparoscopy and its safety in the geriatric population pursues a challenge and the assessment of this procedure is hence obligatory, we think that stentless LU is safe, economical and less uncomfortable for elderly patients.

Combined Retroperitoneal and Transperitoneal Laparoscopic Procedures by a Single Surgeon: Boon to Economically and Medically Backward Areas

Introduction This study was done to evaluate our experience of combining a retroperitoneal laparoscopic urological operation with other transperitoneal laparoscopic operations. Materials and methods We present a retrospective study of a series of 20 cases of retroperitoneal laparoscopic urological surgeries combined with at least one transperitoneal laparoscopic procedures, performed by a senior minimally invasive surgeon, between March 2013 and August 2020. We have excluded three patients where either of the procedures required conversion to open surgery. We retrospectively reviewed all the data regarding the patient's demographics, combined surgical procedures done, operative time taken, blood loss, intraoperative and postoperative complications, and days of hospital stay. Results Total of 20 patients had undergone simultaneous retroperitoneal and transperitoneal laparoscopic procedures. A total of nine (45%) cases comprised a combination of retroperitoneal laparoscopic ureterolithotomy and laparoscopic cholecystectomy. Two patients had undergone a combination of three laparoscopic procedures in the same operation. The mean hospital stay was 3.6 days. Blood loss was minimal to moderate in all the patients, none needed any perioperative blood transfusion. No major complications were noted in any patients. Conclusion Combining a retroperitoneal laparoscopic urological procedure with another transperitoneal laparoscopic surgery is very much feasible. It becomes even easier and relevant provided both the procedures are performed by a single, experienced laparoscopic surgeon.

A new and easy technique of double-J stenting after retroperitoneal laparoscopic ureterolithotomy: A discussion of other techniques

Aim:

To summarize a new and easy technique of double-J stent (DJ stent) placement after retroperitoneal laparoscopic ureterolithotomy (RLU).

Materials and Methods:

RLU for upper and upper half of mid ureteric stones was performed successfully in 172 patients during the 8-year period between March 2011 and February 2019. In all the cases, a ureteric DJ stent was successfully placed by this new technique. A small-bore antral puncture needle is inserted into the retroperitoneal space to push down a DJ stent with a guidewire into the lower ureter. The tip of the antral puncture needle is manipulated to bring it near the ureterotomy site for easy insertion of the stent. The whole stent is pushed down leaving only the upper end in the ureterotomy area. Then, the guidewire is removed and the upper end is pushed up slowly into the renal pelvis.

Results:

DJ stents were successfully inserted by this technique in all the 172 cases. In most cases, the stent could be placed in <3 min (range between 2 and 8 min). In two patients, the upper end failed to fully coil in the renal pelvis, but as the stent was passed beyond the ureterotomy site, it served its purpose of an internal drain. None of our cases had any urinary leak. Stents were removed cystoscopically after 6–12 weeks.

Conclusion:

This technique provides an easy, fast, and safe antegrade method of inserting a DJ stent after RLU.

A giant ureteral stone in a 32-year-old man: a case report

Giant ureteral calculi are defined as stones greater than 5 cm in length or circumference. These giant calculi can cause blockage of the ureter, dilation of the kidney and also decreased kidney function if not treated in time. The patient in this report presented with complaints of bilateral episodic pain of the bilateral lumbar region. Kidney, ureter and bladder (KUB) X-ray test showed a large bilateral ureteral stone about 14 cm in length and 106 g weight in the left ureter and 3 cm longitudinal diameter in the right ureter and also a staghorn stone in the left upper collecting system. Thereafter, the ureteric calculi were managed successfully using the combination of open and endoscopic techniques.

The usefulness of flexible cystoscopy for preventing double-J stent malposition after laparoscopic ureterolithotomy

Background

The aim of this study was to evaluate the role of flexible cystoscopy in preventing malpositioning of the ureteral stent after laparoscopic ureterolithotomy in male patients.

Methods

From April 2009 to June 2015, 97 male patients with stones >1.8 cm in the upper ureter underwent intracorporeal double-J stenting of the ureter after laparoscopic ureterolithotomy performed by four different surgeons. In the last 50 patients who underwent laparoscopic ureterolithotomy flexible cystoscopy was performed through the urethral route to confirm the position of the double-J stent, while in the first 47 correct positioning of the stent was confirmed through postoperative KUB. The demographic data and perioperative outcomes were reviewed retrospectively. Penalized logistic regression analysis was used to evaluate the effects of flexible cystoscopy.

Results

Upward malpositioning of the ureteral stent was found in 9 of the 47 (19.1%) patients who underwent surgery without flexible cystoscopy. Among the 50 most recent patients who underwent surgery with flexible cystoscopy through the urethral route, upward malpositioning was observed in 10 (20%) patients. The factors preventing upward malpositioning of the double-J catheter in multivariate analysis were surgeon (p = 0.039) and use of flexible cystoscopy (p = 0.008).

Conclusion

Flexible cystoscopy is a simple, safe, quick, and effective method to identify and correct malpositioning of double-J stents, especially in male patients.

Trial registration

This study was registered with ClinicalTrials.gov Registry on May 11, 2017 (retrospective registration) with a trial registration number of NCT03150446.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-017-0232-4) contains supplementary material, which is available to authorized users.

Laparoscopic Ureterolithotomy

Background and Objective:

The present study retrospectively analyzed the data of 213 patients who underwent laparoscopic ureterolithotomy.

Methods:

We retrospectively analyzed the data of 213 patients, in whom we performed conventional laparoscopic ureterolithotomy from April 2006 and January 2015 based on the diagnosis of an upper or middle ureteral stone. Patients with large ureteral stones (>15 mm) or a history of failed shock-wave lithotripsy or ureteroscopy were included in the study. Although the retroperitoneal approach was preferred for 170 patients, the transperitoneal approach was used in the remaining 43 patients.

Results:

The mean patient age was 39.3 ± 12.0 years (range, 18–73). The study population was composed of 78 (26.7%) female and 135 (63.3%) male patients. The mean stone size was 19.7 ± 2.5 mm. The mean operative time was 80.9 ± 10.9 minutes, and the mean blood loss was 63.3 ± 12.7 mL. Intraoperative insertion of a double-J catheter was performed in 76 patients. The overall stone-free rate was 99%. No major complication was observed in any patient. However, conversion to open surgery was necessary in 1 patient.

Conclusion:

With high success and low complication rates, laparoscopic ureterolithotomy is an effective and reliable method that ensures quick recovery and may be the first treatment option for patients with large, impacted ureteral stones, as well as for those with a history of failed primary treatment.

Should we place ureteral stents in retroperitoneal laparoscopic ureterolithotomy?: Consideration of surgical techniques and complications

Purpose

There is some debate over the necessity of ureteral stenting after laparoscopic ureterolithotomy. We evaluated the need for ureteral stenting after retroperitoneal laparoscopic ureterolithotomy (RLU).

Materials and Methods

Between January 2009 and January 2013, 41 patients underwent RLU to remove upper ureteral stones. The retroperitoneal approach was used in all patients by a single surgeon. A double J (D-J) stent was placed in the first 17 patients after the procedure but not in any of the next 24 patients.

Results

The mean patient age, serum creatinine levels, and stone size were not significantly different between the two groups. The stone-free rate was 100%. The mean operative time was significantly shorter in the stentless group than in the stent group (59.48 minutes vs. 77.88 minutes, p<0.001). Parenteral analgesic use and anticholinergic medication use were observed in the stent group only. The blood loss, drain removal day, and hospital stay were not significantly different between the two groups. No other significant complications occurred during or after the operation in any patients.

Conclusions

RLU is a safe and effective treatment modality for large impacted ureteral stones. In this study, D-J stent placement was not necessary after RLU. In the future, large-scale studies of RLU without D-J stenting, especially on the frequency of the development of complications according to the surgical technique, may be needed.

Experience and learning curve of retroperitoneal laparoscopic ureterolithotomy

OBJECTIVE

This study was conducted to evaluate clinical experience and learning curve associated with laparoscopic ureterolithotomy performed for upper ureteral stones.

MATERIALS AND METHODS

The medical data of 50 patients who had undergone retroperitoneal laparoscopic ureterolithotomy between June 2010 and March 2013 were retrospectively analyzed. To assess the learning curve, patients were divided into two groups: Group A (the first 25 cases) and Group B (the last 25 cases). In Group A, double J stents were placed in 17 patients, whereas in Group B 15 patients received double J stents. In Group A, three ports were placed in nine patients and four ports in 16 patients. In Group B, three ports were placed in 20 patients and five patients had four ports. The patients were compared according to demographics, operative time, stone size, complications, hospital stay, and transfusion.

RESULTS

The mean age for Group A was 47.8 ± 14.13 (21-72) years and that for Group B was 44.2 ± 14.98 (22-78) years. Mean operative times were 106.4 ± 38 (55-210) minutes and 70.76 ± 30.4 (30-180) minutes for Groups A and B, respectively (p < 0.05). The mean hospital stay was 7.12 ± 4.47 (3-22) days and 4.04 ± 2.05 (2-12) days for Groups A and B, respectively (p < 0.05). The mean stone size was 20.12 ± 5.18 (12-30) mm and 19.44 ± 4.44 (13-28) mm for Groups A and B, respectively (p > 0.05).

CONCLUSION

In our study, as staff experience (in performing laparoscopic retroperitoneal ureterolithotomy) increased, operative time, length of hospital stay, and complication rates have correspondingly declined.

Ureteroscope-assisted double-J stenting following laparoscopic ureterolithotomy

The aim of this study was to examine the feasibility of ureteroscope-assisted double-J stenting following laparoscopic ureterolithotomy and to evaluate the effects of retrograde ureteroscopic access exerted on the sutured ureterotomy site. From January 2002 to December 2011, 30 patients with proximal ureteral stone underwent ureteroscopic double-J stenting of the ureter following retroperitoneal laparoscopic ureterolithotomy. Patient demographics and perioperative parameters, including the degree of hydronephrosis, urine leakage, and drainage time, were retrospectively reviewed. These data were compared with those of 30 consecutive patients who received open ureterolithotomy and intracorporeal ureteral double-J stenting. In addition, a PubMed search was conducted and the related literature on the placement of a ureteral stent was reviewed. Twenty-eight patients successfully underwent ureteral double-J stenting with ureteroscopic access. No malposition of the ureteral stent was identified in the ureteroscopic group, but two patients in the intracorporeal group required postoperative adjustment of the stent. Residual stone fragments were found during stent placement in three patients in the ureteroscopic group and holmium:yttrium-aluminum-garnet laser lithotripsy was immediately performed. There was no significant difference in postoperative outcomes or complication rates between the two groups. Ureteroscope-assisted ureteral double-J stenting is a simple and safe alternative allowing intraluminal navigation along the entire ureter, correct stent placement, and prompt treatment of residual stone fragments, without radiation exposure. In addition, ureteral disruption and urinary extravasation may not be concerns for ureteroscopic access with continuous normal saline irrigation.

Laparoscopic management in stone disease

PURPOSE OF REVIEW

While most renal and ureteral stones can be efficiently managed using endourologic techniques, the use of laparoscopy for the management of urolithiasis is increasing. The application of laparoscopy for stone removal will further reduce the need for open stone surgery.

RECENT FINDINGS

Laparoscopic ureterolithotomy, pyelolithotomy, and anatrophic nephrolithotomy are highly successful techniques with regard to their one-session, high stone-free rates. These procedures could be considered as the preferred approaches when endourologic procedures are not available or have failed. Laparoscopic stone surgery (LSS) in patients with urinary tract anomalies offers a reliable minimally invasive procedure as an alternative to a complex endourologic technique.

SUMMARY

Although laparoscopy still has a limited role in the urologist's armamentarium for the surgical management of urolithiasis, it can further reduce the need for open stone surgery in complex circumstances. LSS duplicates its open counterpart and offers a high one-session, stone-free rate in most patients with a lower morbidity and quicker convalescence. More comparative studies are needed to define the role and indications of LSS in relation to endourologic and open techniques, especially in complex circumstances.

A novel case of laparoscopic ureterolithotomy in a partial duplex ureteric collecting system: can open procedures still be justified in the minimally invasive era?

BACKGROUND

Impacted ureteric stones can pose a treatment challenge due to the high level of failure of ESWL and endourological approaches. Laparoscopic ureterolithotomy can provide a safe and successful alternative to these and open, invasive procedures.

METHODS

Interval laparoscopic ureterolithtomy was carried out following placement of a percutaneous nephrostomy. This was performed through an trans-peritoneal approach with the ureterotomy closed by intracorporeal suturing and placement of a JJ stent without the need for an abdominal wound drain.

CONCLUSION

Laparoscopic ureterolithotomy is a safe, minimally invasive method of managing large, impacted ureteric stones with minimal associated patient morbidity.

Transperitoneal versus retroperitoneal laparoscopic ureterolithotomy: a prospective randomized comparison study

PURPOSE

We compared laparoscopic transperitoneal and retroperitoneal ureterolithotomy approaches, and determined whether one technique is superior to the other.

MATERIALS AND METHODS

In this prospective randomized study from January 2009 to May 2012, 48 patients with proximal or mid ureteral stones underwent transperitoneal laparoscopic ureterolithotomy or retroperitoneal laparoscopic ureterolithotomy. The randomization occurred on a 1:1 basis. Groups 1 and 2 consisted of patients who underwent transperitoneal laparoscopic ureterolithotomy and retroperitoneal laparoscopic ureterolithotomy, respectively. Demographic and clinical characteristics as well as postoperative data were collected and analyzed. Statistical analysis was performed with SPSS® version 15.0 using the Fisher exact and Mann-Whitney U tests with p <0.05 considered statistically significant.

RESULTS

The difference in visual pain analog score and mean tramadol requirement on days 1 and 2 between the 2 groups was statistically significant, and was higher in group 1 (p <0.05). Postoperative hospital stay and paralytic ileus rates were significantly higher in group 1 (p <0.05). The differences in total operative time and intracorporeal suturing time between the 2 groups were not statistically significant. However, successful stone removal was equal in the 2 groups.

CONCLUSIONS

For proximal or mid ureteral large and impacted stones, transperitoneal laparoscopic ureterolithotomy is significantly associated with pain, greater tramadol requirement, ileus and longer hospital stay than retroperitoneal laparoscopic ureterolithotomy. However, successful stone removal remains the same in both groups.

Is it necessary to place a Double J catheter after laparoscopic ureterolithotomy? A four-year experience

PURPOSE

To assess the necessity of placing a ureteral stent after transperitoneal laparoscopic ureterolithotomy (TPLU).

PATIENTS AND METHODS

In the period from May 2006 to November 2010, 46 patients underwent TPLU. There were 13 females and 33 males. All patients had an impacted stone larger than 1.5 cm in the upper and middle parts of the ureter. TPLU was performed as either a primary therapy or as a salvage therapy in patients in whom another treatment had failed. The exclusion criteria were pregnancy, a body mass index more than 35, and patients with abnormal results on coagulative tests. In all cases, after removing the stone, the ureter was sutured. In the first 23 patients, no ureteral catheter was placed, but in the second 23 patients, a Double J catheter was inserted through the ureter.

RESULTS

In one case, the stone was pushed back. The stone-free rate was 97.8%. There were four cases of prolonged urinary leakage after the surgery. All of them were in the group in whose members the Double J catheter had not been placed. The problem was resolved in one patient spontaneously after 4 days, but for the other three patients, a Double J catheter was placed and the leakage was stopped in 24 hours. There was no case of urinary leakage in the second group of patients with a placed Double J catheter.

CONCLUSION

Placing a Double J catheter during surgery does not increase the time of operation and may play a role in prevention of urinary extravasation after laparoscopic ureterolithotomy.

Retroperitoneal laparoendoscopic single-site ureterolithotomy: a comparison with conventional laparoscopic surgery

BACKGROUND AND PURPOSE

Laparoendoscopic single-site (LESS) surgery through the retroperitoneal approach has been seldom reported. We aimed to compare the feasibility and outcomes of LESS and conventional laparoscopic surgery via the retroperitoneal approach in the management of large, impacted ureteral stones.

PATIENTS AND METHODS

From June 2010 to May 2011, LESS ureterolithotomy through the retroperitoneal approach was performed in 10 patients (the LESS group). Another 15 patients who underwent conventional retroperitoneal laparoscopic ureterolithotomy (the conventional laparoscopic group) by the same surgeon were involved and compared. The operative time, complications, and surgical outcomes were evaluated.

RESULTS

All the operations were completed successfully, without conversion to conventional laparoscopic or open surgeries. The operative time of the LESS group and of the conventional laparoscopic group were 132.7±16.3 and 128.1±20.1 minutes, respectively (P=0.782). The estimated blood loss were 30.7±5.9 vs 28.0±4.5 mL (P=0.620). Duration of analgesia postoperatively was 2.0±0.8 vs 3.5±0.5 days (P=0.005). All targeted stones were successfully extracted without major complications. Postoperative urine leakage was noted in one patient in each group. Cosmetic results were superior in the LESS group according to both the study nurse's and the patients' assessments (8.5 vs 5.3; P=0.012, and 8.3 vs 5.6; P=0.025, respectively). All patients showed no obstructions or stricture formations on postoperative follow-up.

CONCLUSIONS

In experienced hands, LESS for ureterolithotomy through the retroperitoneal approach is feasible and can acquire outcomes equal to those of conventional multiport laparoscopic surgery. Prospective long-term follow-up studies with a larger number of patients are needed to further evaluate its benefits.