Background
Ureterolithotomy refers to the open or laparoscopic surgical removal of a stone from the ureter. Today in the United States, ureterolithotomy is seldom performed given the advent and rise of minimally invasive procedures for fragmentation and removal. Minimally invasive options are now preferable and include extracorporeal shock wave lithotripsy (ESWL) and endoscopic techniques such as ureteroscopy (URS) with laser lithotripsy and stone basketing, and percutaneous nephrolithotomy (PCNL).
Despite this trend, there have been recent advances in ureterolithotomy involving laparoscopic and laparoendoscopic single-site surgery (LESS). Even robotic-assisted laparoscopic ureterolithotomy has been reported in the literature. [1] Open ureterolithotomy still has a role when the above, more sophisticated modalities are unavailable or when other therapies have failed. It can also be utilized in cases involving significant ureteral strictures that preclude endoscopic access.
History of the Procedure
In 1882, Bardenheuer removed a calculus from the upper ureter using an open surgical technique. This represents one of the earliest recorded documented cases of open ureterolithotomy.
In 1979, Wickham introduced laparoscopic ureterolithotomy via a retroperitoneal approach. Subsequently, in 1992, Raboy performed the first transperitoneal laparoscopic ureterolithotomy.
In the current age of Urology in developed nations, open ureterolithotomy has been all but entirely replaced by minimally invasive techniques of extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL). In fact, a recent study analyzing urologists’ practice patterns for management of upper urinary tract stones from 2003-2012 revealed an increase in the proportion of ureteroscopy from 40.9% to 59.6%. ESWL decreased from 54% to 36.3%. PCNL use remained stable around 4-5% and was more frequently performed by endourologists. The use of ureterolithotomy was not mentioned in that study.
Problem
Stone disease (urolithiasis) is common, affecting approximately 9% of American adults at some point during their lives. It is also very costly, accounting for $5.3 billion in direct and indirect costs annually.
Obstructing ureteral stones can cause severe pain, fever, urosepsis, and possibly even death if left untreated. They require treatment that often includes prompt and appropriate renal drainage and decompression (eg, ureteral stent placement or percutaneous nephrostomy tube placement) and subsequent definitive stone removal. Ureterolithotomy is used most commonly when minimally invasive therapies have failed.
Etiology
Most ureteral stones form in the kidney and migrate into the ureter. Many of these stones are passed spontaneously. Stones larger than 10 mm are unlikely to pass spontaneously. These larger stones and even some small stones may require surgical intervention at some point. During ureteral passage, stones most commonly become lodged in narrow areas of the ureter. The most common locations in which ureteral stones become lodged are in the upper (proximal) ureter at the ureteropelvic junction (UPJ), in the mid-ureter where the ureter crosses over the iliac vessels, and in the lower (distal) ureter at the ureterovesical junction (UVJ).
Epidemiology
United States data
Today in the United States, ureterolithotomy is seldom performed given the advent and rise of minimally invasive procedures for stone fragmentation and removal. It is considered an option if minimally invasive techniques of extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL) fail.
Relevant Anatomy
A ureter is 20-27 cm in length and 5-7 mm in diameter. The narrow portions of 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). This is crucial in the manifestations of calculus disease. These narrowings may result in ureteral stones becoming trapped and obstructing at these specific levels. These narrowings may also limit retrograde instrumentation performed for diagnostic or therapeutic purposes. For more information about the relevant anatomy, see Ureter Anatomy.
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.
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Laparoscopic ureterolithotomy. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
