Transperitoneal, Laparoscopic Ureterolithotomy : :

Rabea Gomaa Sayed Omar

Laparoscopy is a procedure which allows visual inspection of the peritoneal cavity, (abdominal and pelvic) and offers the facility of performing many surgical procedures.Laparoscopic applications in Urology started recently and rapidly evoluted in few years, and some laparoscopic urological procedures proved to be feasible, safe and minimally invasive alternative to open surgery.The first documented use of laparoscopy in urology was to diagnose cryptorchid testis in 1976, followed by retroperitoneal laparoscopic ureterolithotomy in 1979, laparoscopic varix ligation in 1988 and laparoscopic nephrectomy in 1991. Since that time, most of the urologic surgical procedures are considered to be ideal for laparoscopy.All patients included in the study underwent transperitoneal laparoscopic ureterolithotomy in Urology Department, Benha Faculty of Medicine between March 2004 to december 2005.This study included 20 patients (15 male and 5 females) of which 16 cases had stone upper 1/3 ureter and 4 cases had stone middle 1/3 ureter. The mean age 37.6 (range 20-65 y).Laparoscopic ureterolithotomy was successful in 17 cases (85%). There were 3 operative failures (15%). In one patient, failure to identify the ureter, in another case the stone was migrated distally to the pelvic part of the ureter and we used ureteroscopy through one of the laparoscopic ports and through the ureterotomy under guidance of laparoscopy to grasp the stone by ureteroscopic forceps but the stone was difficult to extract due to its large size (22 mm). and the third case, mechanical error (Insufflator stopped working suddenly) and all these 3 cases were converted to open ureterolithotomy.The mean operative time was 165.5 min. (range 110-250 min), the estimated blood loss was <100 ml and non required blood transfusion. The mean stone size was 23.5 (range 15-30mm). The oral feeding started in the 1st post-operative day in all cases, the mean post-operative parenteral analgesia was 176.3 (range 75-300 mg) diclofenac sodium, the average hospital stay was 2.5 (range 2-3) day and the mean time to return to the normal activity was 16.95 (10-30) days.Laparoscopic ureterolithotomy has definite advantages; particularly in offering reduced post-operative pain resulting in early ambulation and discharge from hospital and early return to normal activity.In addition, from a cosmotic point of view, the small incision made for the laparoscopic ports will be barely discernable in few months after surgery.While operative time for completing laparoscopic procedures was lengthy. It will be shorter with improvement of skills and experience of the surgeons and production of better instruments.In conclusion, percutaneous surgery, ureteroscopy and ESWL have made open stone surgery a rarity in many hospitals. Nevertheless, for some large ureteric stones, ureterolithotomy, which can now be performed laparoscopically, may be the most effective treatment. The laparoscopic approach, a natural extension of the minimally invasive philosophy, may provide ureterolithotomy with a role in the modern management of stone disease. In cases of stone migration which may occur intraoperatively, we can use ureteroscopy through one of the laparoscopic ports and through the ureterotomy under guidance of laparoscopy to grasp the stone by ureteroscopic forceps.