Identifying Ureteral Stone During Transperitoneal Laparoscopic Transperitoneal Laparoscopic Ureterolithotomy

Background and Purpose:Urolithiasis is one of China's most common diseases of urology,Ureteric stones have a percentage of 32～54%in urinary calculi.Ureteral stones with a diameter＞7 mm have a little chance of spontaneous clearance.If observation and medical therapy fail or have a low probability of success,stones have to be removed actively.Today there are different therapeutic approaches for ureteral stones:1.Shock-wave lithotripsy 2. Ureteroscopy.3.percutaneous antegrade ureteroscopy 4.laparoscopic stone removal 5.Open surgery.For most cases with very large,impacted,and/or multiple ureteral, stones in which SWL and URS have either failed or are unlikely to succeed, laparoscopic ureterolithotomy is a better alternative than open surgery if expertise in laparoscopic techniques is available.The first retroperitoneal laparoscopic ureterolithotomy was reported by Wickham in 1979.and the first transperitoneal laparoscopic ureterolithotomy fulfilled successfully by Raboy in 1994.While in 1996,Jianguo Chen reported the first laparoscopic ureterolithotomy in Chinese. Laparoscopic ureterolithotomy has been wildly used since 1990s.How to seeking ureteral stone is one of the vital skills for operating successfully.It's also one of the difficulties,especially in obese patients.If the stone can not be found exactly,it will be resulted in:overtime operation,increased probability of being converted to open surgery and neibouring organic or vascular injury.The beginners are often not managed in seeking ureteral stone.Thus,in this paper,we decide to evaluate the method of seeking ureteral stone during transperitoneal laparoscopic ureterolithotomy.Data and Methods:1.Clincal DataThe cases were collected from January 2004 to March 2008,a total of 98 cases done by transperitoneal laparoscopic ureterolithotomy,a detailed record of clincal data, operative experience and the video of the operation.The methods or skills of seeking ureteral stone during operation,were analyzed and summarized.2.Mothod of treatmentAfter general anaesthesia was achieved,patients were positioned at a 90-degree angle to the operating table.When artificial pneumoperitoneum using carbon dioxide was established,a transperitoneal approach was then performed using three to four trocars. Incision beside umbilicus was made for the primary 10mm port site.Incision at aterioraxillary line off the umbilicus and incision at medioclavicular line on the costal margin were made for another 10 mm and 5mm trocars,repectively.An additional trocar was used at postaxillary line on the costal margin,when needed.Ureteric stone was exposed and managed by five processes:approximate location,anatomise and dissection,muscular tract,local apophysis,hard-sense.Ureteric incision where the stone stay was performed by the scalpel.After the stone was taked out,then a D-J tube was put.Methylenc blue was infused to the bladder to ensure that the D-J tube was right in place.Interupted suture was performed to the ureter using 4-0 absorbable suture.Drainage tube was put and finally the incisions of lateral abbdmen was sewed up. For mid ureter stones,patients were positioned at a 45-degree angle to the operating table.The two 10mm trocar port sites and operative process were same as the fore-descriptions.Another 5mm trocar port site was at the midpoint between the umbilicus and pubic symphysis.Seeking ureteral stone should be started from the second ureteric straitness.Results:Among all the cases,93 cases were successfully completed,operation time was 40-110min,70min average.Operative time could be shorted by the proficiency of manipulation.5 patients could not go along with the five part procedures.The reasons for laparoscopic ureterolithotomy failure:Severe conglutination of the celiac and ureter or bleeding(2 cases),Moving of the ureteral stone(3 cases).2 cases were converted to transperitoneal laparoscopic pyelolithotomy,1 case were converted to D-J tube drainage only and the stone was successfully removed by postoperative percutaneous nephrolithotomy.All of the cases were finally successfully removed of calculi.There were no residual ureteric calculi and no neighboring vessel or enteric injury.Hospital stay ranged from 3 to 7(mean 5.1) days.Conlusions:Ureteral stone can be seeked exactly by five processes:approximate location,anatomise and dissection,muscular tract,local apophysis,hard-sense.The probability of being converted to open surgery and the risk of the neighboring vessel or enteric injury can be reduced..It will be the manipulative criterion of laparoscopic ureterolithotomy.