You are in: eMedicine Specialties > Urology > Surgery UreterolithotomyArticle Last Updated: Sep 13, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Jeffrey M Donohoe, MD, Assistant Professor of Pediatric Urology, Department of Surgery, Division of Urology, Medical College of Georgia Jeffrey M Donohoe is a member of the following medical societies: American Academy of Pediatrics and American Urological Association Coauthor(s): James A Brown, MD, FACS, Associate Professor, Department of Surgery, Medical College of Georgia; Consulting Staff, Head of Urologic Oncology, Veterans Affairs Medical Center; Subbarao V Cherukuri, MD, Consulting Staff, Department of Urology, St Joseph Regional Health Center Editors: Michael Grasso, MD, Chairman, Department of Urology, Saint Vincent's Medical Center; Professor and Vice Chairman, Department of Urology, New York Medical College; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Martin I Resnick, MD †, Former Lester Persky Professor and Chair, Department of Urology, Former Professor, Department of Oncology, Case Western Reserve University School of Medicine; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio Author and Editor Disclosure Synonyms and related keywords: ureteral calculus removal by open surgery INTRODUCTIONSection 2 of 11
  Ureterolithotomy refers to the open surgical removal of a stone from the ureter. Open ureterolithotomy has become very rare within the last decade due to the advent of less invasive procedures such as extracorporeal shock wave lithotripsy [ESWL] treatment and ureteroscopic stone removal or fragmentation. Less invasive procedures for ureteral stones include ureteroscopic stone basket extraction under direct vision and destruction of the calculus by various means, including electrohydraulic lithotripsy (EHL), ultrasound, pneumatic contact lithotripsy (Lithoclast), as well as lasers such as the pulsed dye and holmium. However, open ureterolithotomy still has a role where such sophisticated modalities are lacking, when other therapies have failed, and in cases involving significant ureteral strictures requiring open surgical repair. History of the ProcedureIn 1882, Bardenheuer removed a calculus from the upper ureter using an open surgical technique. This represents one of the earliest recorded cases of ureterolithotomy. ProblemStones that result in complete obstruction of the ureter, causing severe pain, fever, and urosepsis, require treatment that includes prompt, appropriate drainage (eg, ureteral stent, percutaneous nephrostomy) and subsequent definitive stone removal. Open ureterolithotomy has finite indications and is employed most commonly when minimally invasive therapies have failed. FrequencyUreterolithotomy (open surgical removal of the stone from the ureter) is performed rarely at present; however, it continues to be considered when other modalities, such as ESWL, ureteroscopy with laser, EHL, or ultrasound, fail. EtiologyMost ureteral stones form in the kidney and migrate in to the ureter. Many stones are passed spontaneously. Stones larger than 10 mm are unlikely to be passed. Most urologists have noted that some small stones often require surgical intervention, perhaps due to irregular margins of the stone. Passage of stones commonly is stopped at the narrow areas of the ureter, in the proximal ureter at the ureteropelvic junction, in the mid ureter where the ureter crosses the iliac vessels, and in the lower ureter at the ureteropelvic junction. ClinicalUreteral stones often present as renal colic. Pain radiates in to the groin or testicle. Pain is either constant or intermittent. Pain varies from severe to a dull ache. Pain on the left side is much more common. Ureteral stones are more frequent in men. Urinalysis most often is positive for occult blood. Results on physical examination may be normal except for some costovertebral angle tenderness. INDICATIONSSection 3 of 11
Although open ureterolithotomy has become very rare within the last decade because of the advent of extracorporeal and intracorporeal lithotripsy, it still has a role where such sophisticated modalities are lacking, when other therapies have failed, and in cases involving significant ureteral strictures requiring open surgical repair. Conservative treatment is possible for stones smaller than 5 mm. Pain, infection, and associated anatomical abnormalities on occasion necessitate surgical intervention in smaller stones. First-line surgical intervention involves minimally invasive procedures. Depending on the location of the stone, experience of the urologist, and preference of the patient, either extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy and intracorporeal lithotripsy are instituted. With the miniaturization of scopes and use of sophisticated wires, dilators, access sheaths, and stents, even cases involving complicated stones (ie, stricture with impacted stone) can be approached with ureteroscopy. Even in cases in which patients present with sepsis and hydronephrosis due to an impacted stone, the preferred treatment is percutaneous drainage of the kidney with nephrostomy and delayed endoscopic treatment of the stone. However, in cases that involve failure or other extenuating circumstances, open ureterotomy can be performed. RELEVANT ANATOMYSection 4 of 11
A ureter is 20-27 cm in length and 5-7 mm in diameter. The narrow parts in the ureter are at the ureteropelvic junction, in the most cephalad part; in the middle, where the ureter crosses the iliac vessels; and in the most caudal part, at the ureterovesical junction (intramural part of ureter). In men, the vas deferens crosses the ureter at its lower one third anteriorly. In women, the round ligament crosses the ureter at its lower one third anteriorly. The ureter is adjacent to the gonadal vessels. Periureteral vessels, from the pelvic branch of the renal artery, provide the blood supply to the ureter in the upper one third. In the lower one third, the vesicle artery supplies blood. The middle third is supplied by the lumbar vessels; here the blood supply is precarious. During ureterolithotomy, stripping the ureter of its periureteral fat in the middle third has to be performed very carefully. The urine in the ureter progresses due to peristalsis, and the nerve plexus that runs along the ureter controls peristalsis. CONTRAINDICATIONSSection 5 of 11
This procedure is not contraindicated unless the patient is in poor general condition. Consider ureterolithotomy as a last resort. Consider noninvasive procedures, such as ESWL, and less invasive ureteroscopy first. WORKUPSection 6 of 11
Lab Studies
Imaging Studies
Other Tests
TREATMENTSection 7 of 11
Medical therapyConservative treatment is possible for stones smaller than 5 mm. Pain, infection, and associated anatomical abnormalities on occasion necessitate surgical intervention in smaller stones. Surgical therapy
Upper and middle ureterolithotomy
Lower ureterolithotomy
Intraoperative detailsStabilize the ureter between 2 umbilical tapes and perform a generous ureterotomy so that the stone can be removed easily. After removal of the stone(s), initially pass a number 8 red rubber catheter proximally and irrigate so that any remaining stone fragments can be flushed out. Then pass the catheter distally and flush the ureter of any fragments. Watertight closure of the ureterotomy is advisable, taking care not to constrict the ureter. Always drain the ureterotomy site with a Penrose drain or JP (vacuum) drain. Make sure the stone is sent for chemical analysis to determine the composition of the stone, which helps in stone prevention therapy and advice. Postoperative detailsMobilize the patient on the day of surgery from bedrest as soon as possible. Remove the drain after 5 days if the drainage is scanty. Remove the urethral Foley catheter after the second day. Follow-upAn IVP 3-6 months postoperatively is helpful in recognizing stricture or residual stones. Patients should be evaluated for chemical risk factors that lead to stone formation. This should include an analysis of the chemical composition of the stone and an evaluation of the patient's diet. Minimum metabolic studies for stone prevention analysis are essential for determining the underlying risk factors for new stone formation. A minimal study should include serum electrolytes, calcium, creatinine, bicarbonate, and uric acid together with a 24-hour urine collection with analysis of calcium, uric acid, citrate, oxalate, sodium, magnesium, and volume. Appropriate preventive measures then can be instituted. For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Kidney Stones and Intravenous Pyelogram. COMPLICATIONSSection 8 of 11
Early complications
Late complications
OUTCOME AND PROGNOSISSection 9 of 11
FUTURE AND CONTROVERSIESSection 10 of 11
Laparoscopic ureterolithotomy has been described as a means of treating complex, often particularly large, ureteral calculi that are not amenable to more standard minimally invasive therapies. REFERENCESSection 11 of 11
Article Last Updated: Sep 13, 2006 |
