Left Laparoscopic Ureterolithotomy With Transmesocolic Access To The Upper Ureteral Stone

Background and PurposeUreteral stone is one of the most common disease for urologist,and open surgery often following conservative treatment which is ineffective for the right upper ureteral calculi,the open surgery has a great success rate,but the large abdominal incision cause significant postoperative pain in patients and extend the recovery time.In recent years, with extracorporeal shock wave lithotripsy,ureteroscopic lithotripsy,percutaneous nephrolithotomy,most stones can be cured.The role of laparoscopic ureterolithotomy by the retroperitoneal approach is a well-established safe,minimally invasive,and very effective modality for treating large ureteral calculi,especially in the upper third of of the ureter.Although its role as a salvage procedure for failed extracorporeal shockwave lithotripsy and ureteroscopy is undisputed,in selected patients with large chronically impacted stones,laparoscopy may be considered the first line of treatment.As the technology matures,some scholars found that when dealing with the right kidney or upper ureteral lesion,only a small peritoneal incision is needed.Laparoscopic ureterolithotomy can be performed via a transperitoneal or a retroperitoneal approach.A transperitoneal route provides a wider working space,a better view and clearer anatomical landmarks as compared with a retroperitoneal approach.However,if the ureteral stone is in the left,the surgery required to free a wide range descending colon, in order to avoid this step,a direct transperitoneal approach to the left upper ureteral stone may be considered.This study describes the technique of left laparoscopic ureterolithotomy with transmesocolic access to the upper ureteral stone and assesses its clinical efficacy and with the traditional means of the left ureter through the abdominal incision the previous paragraph,compared to assess their clinical efficacy.MethodsFrom December 2007 to August 2009,we have 15 cases of left upper ureteral stone who underwent the left laparoscopic ureterolithotomy with transmesocolic access.Under general anesthesia,the patient is placed in the lateral decubitus position. Using a Veress needle,pneumoperitoneum up to 15 mm Hg is created.The first step is the detection of the dilated renal pelvis or left ureter protruding under the mesocolic fat.A mesocolic"window"is opened by carefully dissecting the mesocolon with the Harmonic Scalpel.Care must be taken to avoid injuring major vessels such as the inferior mesenteric vein and tributaries.The ureter was dissected and a longitudinal incision of the ureteral wall was then performed with a cold knife over the bulging of the stone which was subsequently extracted and removed.The ureterotomy was sutured with interrupted 4-0 suture.For each patient age,gender,body mass index(BMI),operative time,blood loss, time to resumption of oral intake,complications,hospital stay,postoperative symptom improvement and the results of B ultrasound and IVU were recorded.ResultsAll operations were successful in our 15 patients,There were no complications during or after surgery and no conversions to open surgery were needed.The mean operative time was 45.40±4.70 minutes,blood loss was 18.67±3.52.The mean time to resumption of oral intake was 18.67±2.02 hours.The mean time to resumption of oral intake was 30.67±2.36 hours.The mean hospital stay was 7.27±0.46 days and the mean follow-up was 12.1 months(range 4～23 months).The double-J tube was pulled out through cystoscopy 4～6 weeks later,after that no patient has low back pain and fever.IVU and dopple were performed in all patients postoperatively,never demonstrated ureteral stricture.No collecting system dilatation was detected on ultrasonography performed at follow-up and renal function all improved.6 cases take less than 1 year follow up after operation.In the traditional team,the mean operative time was 58.05±3.83 minutes,blood loss was38.50±5.40ml.The mean time to resumption of oral intake was 25.20±1.96hours. The mean time to resumption of oral intake was 31.90±1.58hours.The mean hospital stay was 7.40±0.60days and the mean follow-up was 12.6 months(range 5-22 months).The double-J tube was pulled out through cystoscopy 4～6 weeks later,1 patient complained of mild lumbar acid and recovered from removal of the double J tube.IVU and dopple were performed in all patients postoperatively,never demonstrated ureteral stricture.No collecting system dilatation was detected on ultrasonography performed at follow-up and renal function all improved.8 cases take less than 1 year follow up after operationConclusionsCompared with the traditional laparoscopic ureterolithotomy,the transmesocolic approach to a dilated renal pelvis or left ureter enables a shorter operative time,less blood loss and faster postoperative recovery for transperitoneal left laparoscopic ureterolithotomy without increasing morbidity,especially for slim patients or patients with a large dilated renal pelvis or left ureter.