Ureterolithotomy

Ureterolithotomy

Ureterolithotomy is removal of a large stone in the ureter that has become stuck within the tube that takes urine from the kidney to the bladder. 

Signs of Ureterolithotomy

Your doctor may recommend this surgery if:

• The stone is too large (usually >11.5 cm) to pass on its own. 
• Stone has a long history of being affected in the ureter.
• Acute infection or obstruction has ensued.
• Recurrent ureteroscopy/ESWL has been unsuccessful.
• Deformity of the anatomy does not allow endoscopic treatment.

Types of Ureterolithotomy

Open Ureterolithotomy

• Conventional flank or abdominal incision.
• To be used only when all other methods are not feasible.

Laparoscopic Ureterolithotomy

• Small incisions and keyhole surgery.
• Faster healing, less pain, less scarring.

Robotic-Assisted Ureterolithomy

• Just like laparoscopy but with the precision of robots. 
• Improved visualization and suturing.

Ureterolithotomy surgery

Ureterolithotomy is an operation to extract a stone from the ureter, a channel that links a kidney to the urinary bladder. It is excised when big, affected or hard stones cannot be moved out using endoscopic procedures.

Preparation before Surgery

• Total medical assessment
• Blood tests, urine tests and imaging
• IV antibiotics as prophylaxis.
• General anaesthetics are given 
• Most cases involve passing a urinary catheter.

The Surgical Procedure

The process may be open, laparoscopic or robotic. The below is an operating procedure recommended for use (some prefer laparoscope nowadays):

Step 1: Positioning

• Based on the site of the stones the patient is placed either in the lateral decubitus (lying on the side) or supine position. 
• The abdominal area is cleaved and covered.

Step 2: Placement of Laparoscopic Ports 

• Keyhole incisions of small size are created (3-4).
• A camera (laparoscope) and instruments are inserted.

Step 3: Exposure of the Ureter 

• The surgeon manipulates the bowel and tissues along with it softly.

The ureter can be characterized by:

• Peristaltic movement
• Connection to adjacent buildings.
• Palpation of the stone

Step 4: Localization of the Stone.

• The stone is experienced as a hard and compact region (bulge) of the ureter.
• The surrounding tissues are dissected away to expose the exact site.

Step 5: Ureterotomy (Incision into the Ureter) 

• Fine instruments are used to make a small longitudinal cut over the stone.
• Precautions are observed not to harm blood circulation.

Step 6: Stone Extraction

The stone is lifted out with:

• Graspers, or
• A stone basket
• Stone is subjected as whole (not fragmented).

Step 7: Inspection

• The ureter is also examined whether it has any leftover stones.
• Saline is flushed into the lumen (inside of ureter).

Step 8: DJ Stent Placement

A Double J (DJ) ureteric stent is placed to:

• Keep the ureter open
• Prevent blockage
• Aid healing
• Stent remains for 4–6 weeks.

Step 9: Closure of Ureter

• Ureterotomy cut is stitched by using fine absorbable suture.
• To make sure that it is closed with watertight, leak test might be performed with saline.

Step 10: Completion

• Instruments are removed.
• Staples or sutures are used to close incisions.
• Temporary drain can be installed (not obligatory).

Care after Surgery

• Suffering management and IV antibiotics.
• Catheter removed in 1–2 days
• Promote urine flushing fluids.
• It should not be overloaded in the first 4 to 6 weeks.
• Stent removed later in OPD

Open ureterolithotomy procedure

Open ureterolithotomy is used in case of large impacted multiple inaccessible stones that cannot be removed using endoscopic/laparoscopic techniques.

Preparation before Surgery

• Full blood analysis: CBC, renal examination, coagulation analysis
• Imaging: CT KUB, ultrasound, or X-ray in order to find the stone.
• Antibiotics: This is used as a preventive measure before infection.
• Fasting: 6–8 hours preoperative.
• Consent: Process, risk and recovery explained.
• Anaesthesia: General anaesthesia is preferable.

Patient Positioning 

• Flank/lateral position: With upper/mid ureter stones.
• Supine position: In lower ureter stones.
• There is cleaning and draping of surgical site.

Incision

• Upper ureter: Flank (lumbotomy) incision and 11th, or 12th rib.
• Mid ureter: Oblique incision of the flank.
• Lower ureter: Lower abdomen incision.
• The skin, subcutaneous fat and muscle are incised in layers. 

Ureter Exposure

• Access to the ureter is done by opening the retroperitoneal space.
• Fat and tissue surrounding is dissected carefully.
• The stay sutures are used to identify and isolate the ureter to prevent damage.

Stone Localization

• Stone is sensationed as a hard and non-portable substance in the ureter.
• Clearance of tissue of ureter done to reveal site of a stone.

Ureterotomy (Perturbation of the Ureter)

• Minor longitudinal incision is done over the stone.
• Prevents trauma to blood vessels of the ureters.
• Removal of stone is done with the help of forceps or stone hook.

Irrigation and Inspection

• Saline is used to flush out the ureter to clear the debris.
• Check for residual stones
• Viable urine flow.

DJ Stent Placement 

Double J stent is inserted to:

• Prevent obstruction
• Facilitate healing
• Allow urine drainage

Closure

• Incision of ureterotomy stitches with fine absorbable sutures.
• Muscle and fascia layers were kept closed.
• Skin sewn up or stapled.
• Near ureter, drain can be put to test leakage (option)

Care after Surgery

• Hospital stay: 3–5 days
• Pain management: First IV analgesics.
• Catheter care: Urinary catheter is typically discharged 1-2 days.
• Fluids: Promote high fluid consumption to urinate.
• Activity: Do not lift heavy objects during 4-6 weeks.
• Stent removal: 4-6 weeks in OPD.

Ureterolithotomy recovery

The recovery is determined by the nature of the surgery open or the minimally invasiveness (laparoscopic/robotic), the overall health of the patient, and the occurrence of complications.

Post-Operative Period

• Patient kept in rec room till anesthetized.
• Observed vital signs, urine checked and wound checked.
• IV fluids were maintained first.
• IV/oral analgesia of the pain.
• The antibiotics can be used up to 1-2 days.

Hospital Stay

• Open ureterolithotomy: 3 to 5 days in hospital
• Laparoscopic/robotic ureterolithotomy: Hospital stay of 1 to 3 days.

Early Recovery (Week 1 and Week 2) 

• Mild pain or discomfort is incidental. 
• DJ stent can result in burning soreness or frequency or minor back pain.
• Walking should be encouraged to avoid blood clots and encourage healing.
• Fluids: Drink plenty of fluids to keep your urine flowing and help prevent infection.
• Don’t strain trying to lift heavy. 

Mid-Term Recovery (2–6 Weeks)

• Incision repaired and sutures/staples normally dissolved or excised.
• During around 4-6 weeks, stent removal (assuming that it was placed) occurs.
• The urination should also resume normally.
• Diet: Keep your body hydrated and adhere to diet recommendations to halt stones.

Long-term Recovery Phase

• The typical convalescence was 4 to 6 weeks (3 to 6 weeks with laparoscopic surgery) 
• Minor scar can persist, normally disappearing in months.
• The follow up imaging can be undertaken to make sure no leftover stones.
• Recurrence may be averted by lifestyle change.

Ureterolithotomy complications

Ureterolithotomy is usually a safe and effective procedure, but, as any other surgery, it is associated with certain risks. The complications may be early (during or immediately after surgery) and late (weeks to months after surgery).

Early Complications    

• Bleeding
• Infection
• Urinary Leakage
• Pain
• Stent-related Issues

Late Complications

• Ureteral Stricture
• Recurrence of Stones
• Adhesions
• Chronic Pain
• Rare Organ Injury

Best hospital for ureterolithotomy India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Ureterolithotomy involves surgery to dissolve large impacted or complex ureteric stones that are not possible or have not been successful using less invasive methods (such as ureteroscopy or ESWL). It may be conducted in the form of open, laparoscopic or robotic surgery where the minimally invasive approaches have quicker recovery, reduced pain, and minimized scars. It is performed by attentively exposing the ureter, ureterotomy above the stone, removal of the stone, and repair of the ureter, and in most cases, temporary stents are placed. Recovery time varies based on the surgical techniques used, but generally includes a hospital stay of 1-5 days and a return to normal activities in 4-6 weeks. The success rate of the operation is high and it clears the obstruction effectively and prevents complications like infection and damage to the kidney. Good post-operative care, hydration, and follow-up are necessary to help ensure people heal and avoid stone recurrence. 

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FAQ

Is the procedure painful?

• The first pain is mild or moderate.
• Pain management is typically effective with drugs.
• Minimally invasive surgery is less painful as compared to open surgery.

Will I need a stent?

• A majority of patients are fitted with a Double J (DJ) stent to aid the healing process of the ureter and stabilize the flow of urine.
• Stent is normally taken out in 4-6 weeks.

Can I prevent future stones?

• Keep hydrated and take lots of fluid.
• Adhere to nutrition (low salt, low protein, balanced protein)
• Manage underlying medical or metabolic disorders that cause stones.

What is the success rate of ureterolithotomy?

• High success rate: 95-100% of removal of stones.
• Especially useful on large and or affected stones