Ureterolithotomy
Can be done open, laparoscopic or robotic.
For very large ureteric stones.
Pre-op:
- Stented if needed acutely – or stent prior to incision to allow palpation of the ureter
- Up to date imaging to confirm location of stone and plan approach
- Medically optimised
- Sterile urine / treated infection
Incision:
- Flank or subcostal incision for proximal ureter or mid ureter
- Lower midline or Gibson for distal ureter
- Extraperitoneal approach with distal and proximal dissection
Ureterotomy
- Sharp longitudinal incision with knife then Potts on to stone between 2 x stay sutures or loops above and below
- Remove stone with Rampley’s or Randall forceps
Stent and closure
- Place stent – can use wire in side holes for second shorter end
- Close watertight closure with 4-0 PDS
- Drain
Can have II available if can’t find the stone, or pass a flexible scope to look up and down the ureter.
Ongoing leak – consider and exclude distal obstruction (although should be OK with stent in).
Preservation of peri-ureteric tissue during dissection important to prevent ischaemia and allow closure to heal and prevent stricture.
Re: drain – leave within vicinity but not adjacent to ureterotomy. Remove catheter first day prior to removing drain a la pyeloplasty.
Pyelolithotomy
Pre-op:
- Up to date imaging – the renal pelvis should be extra-renal – also ensure no ureteric obstruction
- May be done at time of pyeloplasty
- Urine culture and treat infection
- Medically optimise
Technique:
- Flank incision and extraperitoneal approach
- Open Gerota’s and expose renal pelvis and ureter +/- sling vessels
- U-shaped incision with points towards lower and upper calyces – therefore if incision tears it tears into calyces and not down into PUJ
- Remove stones with Randall or Rampley forceps
- Can use a flexible cystoscope or pyeloscopy to inspect all calyces
- Pass stent into bladder (consider filling bladder as IDC in situ will make bladder empty)
- Close renal pelvis with 4-0 PDS watertight over stent
- Drain
Anatrophic nephrolithotomy
Pre-op:
- Ensure adequate renal function, consider MAG3
- Medically optimised
- Up to date imaging
- Consider arterial phase and renogram
- Urine culture and treat any infection
- Group and hold
Technique:
- Extraperitoneal flank incision
- Expose lateral convex kidney and hilum
- Sling vessels and ureter
- Dissect and identify artery branching to segmentals – clamp on posterior segmental artery
- Give IV methylene blue 10 mL – delineates anterior and posterior circulations – can score Brodel line with diathermy
- Ice slush (+/- 12.5 g mannitol) and clamp main renal artery now to keep methylene blue in anterior circulation of kidney
- Incision along capsule at Brodel line (as short as necessary)
- Blunt dissection through parenchyma onto calyces with stone
- Consider flexible scope to inspect all calyces
- Stent
- Close collecting system with 4-0 PDS
- Release arterial clamps and oversew bleeders
- Close the capsule a la partial nephrectomy renorrhaphy – sliding clips
- Drain