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Laparoscopic management of urolithiasis

Authors

Abstract

The description of the laparoscopic management of urolithiasis covers all aspects of the surgical procedure used for the management of urolithiasis.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, opening of urinary tract, stent placement, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.

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Publication

2004-11

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E-publication

WeBSurg.com, Nov 2004;4(11).
URL: http://www.websurg.com/doi-ot02en299a.htm

Laparoscopic management of urolithiasis

1. Introduction

Urinary calculous disease affects 5% to 10% of the population (Curhan et al., 1994). Standard treatments include extracorporeal lithotripsy and endoscopic treatments such as percutaneous nephrolithotomy and ureteroscopy (Tiselius et al., 2001). Indications for conventional surgery are rare, and consist of treatment of complex calculi or failure of the treatments mentioned above.
The efficacy of extracorporeal shockwave lithotripsy (ESWL) is inversely proportional to the size of the calculi, while the morbidity of endoscopic treatments is proportional to the size of the calculi (Renner and Rassweiler, 1999).
The management of urinary calculi by retroperitoneoscopy was first described in 1979 (Wickham) and by laparoscopy in 1992 (Raboy et al.). The laparoscopic and retroperitoneoscopic approaches have been developed in India (Gaur et al., 1994; Goel and Hemal, 2001), notably for calculi in the renal pelvis and upper ureter. The benefits of this approach include low morbidity that is not related to the size of the calculi, and high efficacy, especially in the case of single stones. More teams (Feyaerts et al., 2001; Keeley et al., 1999; Ramakumar and Segura, 2000) are developing this approach for large, single calculi of the renal pelvis and ureter, as an initial treatment or after failure of ESWL or endoscopic treatments.
This chapter is limited to the description of laparoscopic treatments for calculi of the renal pelvis and ureter. Both the transperitoneal and retroperitoneal laparoscopic approaches will be described. These approaches are closely related to the approaches described in the WebSurg chapters on nephrectomies or treatments for ureteropelvic junction obstruction.

2. Anatomy

Upper urinary tract
1. Upper calyx
2. Middle calyx
3. Lower calyx
4. Renal pelvis
5. Upper ureter
6. Middle ureter
7. Lower ureter
Upper urinary tract calculi can be found in the upper, middle and lower calyces, renal pelvis or upper, middle and lower ureter. The calyces are contained in the renal sinus. They must be approached through the parenchyma, which is often difficult except when the parenchyma opposite the calyx is very thin. The major portion of the renal pelvis is usually found outside the renal sinus, which makes it easier to approach, as it is not necessary to go through the parenchyma.
The portion of the renal pelvis situated outside the renal sinus, and the upper and middle portions of the ureter, are retroperitoneal.

3. Renal pelvis

• Left side

• Anteriorly

1. Pancreas
2. Ligament of Treitz
3. Transverse colon
The anatomical relationships of the renal pelvis are:
- the main and accessory renal vessels;
- the body of the pancreas;
- the ligament of Treitz;
- the angle of Treitz (duodenojejunal flexure);
- the proximal loops of the jejunum;
- the left transverse colon and mesocolon.

• Posteriorly

1. Retropyelic arterial branch
2. Psoas major muscle
- the retropyelic arterial branch;
- the psoas major muscle;
- the transverse process of the first lumbar vertebra.

• Medially/Laterally

1. Gonadal vein
2. Aorta
3. Renal hilum
Medially:
- the gonadal vein;
- the aorta.
Laterally:
- the renal hilum;
- the lower pole of the kidney.

• Right side

• Anteriorly

1. Treitz fascia
2. Second portion of duodenum
3. Hepatic flexure
The anatomical relationships of the renal pelvis are:
- the main and accessory renal vessels;
- the Treitz fascia;
- the second portion of duodenum;
- the hepatic flexure.

• Posteriorly

1. Retropyelic arterial branch
2. Psoas major muscle
- the retropyelic arterial branch;
- the psoas major muscle;
- the space between the first 2 lumbar transverse processes.

• Medially/Laterally

1. Gonadal vein
2. Inferior vena cava
3. Renal hilum
Medially:
- the gonadal vein;
- the inferior vena cava.
Laterally:
- the renal hilum;
- the lower pole of the kidney.

4. Upper ureter

• Left

1. Ureter
2. Psoas major muscle
3. Gonadal vein
4. Aorta
5. Muscles of the lateral abdominal wall
6. Transverse colon
The anatomical relationships of the upper ureter are:
- posteriorly: the psoas major muscle;
- medially: the gonadal vein and the aorta;
- laterally: the muscles of the lateral abdominal wall;
- anteriorly: the descending colon and mesocolon.

• Right

1. Ureter
2. Psoas major muscle
3. Gonadal vein
4. Inferior vena cava
5. Muscles of the lateral abdominal wall
6. Second portion of duodenum
7. Ascending colon
The anatomical relationships of the upper ureter are:
- posteriorly: the psoas major muscle;
- medially: the gonadal vein and the inferior vena cava;
- laterally: the muscles of the lateral abdominal wall;
- anteriorly: the ascending colon and second portion of duodenum.

5. Middle ureter

• Left

1. Aorta and vena cava
2. Common iliac artery
3. Common iliac vein
4. Iliac muscle
5. Sigmoid mesocolon
The anatomical relationships of the middle ureter are:
- posteriorly: the common iliac vessels;
- medially: the aortic bifurcation and the confluence of the common iliac veins;
- laterally: the iliac wing covered by its muscles;
- anteriorly: the sigmoid mesocolon.

• Right

1. Common iliac vessels
2. Common iliac artery
3. Common iliac vein
4. Psoas iliac muscle
5. Posterior parietal peritoneum
The anatomical relationships of the middle ureter are:
- posteriorly: the common iliac vessels;
- medially: the aortic bifurcation and the confluence of the common iliac veins;
- laterally: the iliac wing covered by its muscles;
- anteriorly: the posterior parietal peritoneum and small bowel.

6. Indications

Accepted indications for laparoscopic treatment of calculi of the renal pelvis or proximal or middle ureter include:
- failure of treatment by extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrostomy or ureteroscopy, as an alternative to conventional surgery;
- primary treatment of large calculi of the renal pelvis or ureter.
Laparoscopic management is particularly indicated for single stones.
Caliceal stones are not indications for laparoscopic treatment, except in certain, specific cases (very wide calyces that are easily accessible via the renal pelvis).
Theoretically, access to the distal ureter is easier with a transperitoneal approach than with a retroperitoneal approach. However, laparoscopic treatment is rarely indicated for distal ureteral stones, because their treatment by extracorporeal lithotripsy or by ureteroscopy rarely fails.

Contraindications:
- contraindication to general anesthesia;
- untreated urinary infection;
- untreatable coagulation disorder.
Previous peritoneal surgery is not a contraindication, since a retroperitoneoscopic approach is always conceivable.

7. Preop period

The patient’s urine should be sterile. Coagulation disorders are treated. Usual imaging evaluation includes abdominal ultrasound, intravenous urography or abdominal CT scan.
Except when necessary, for severe urinary infection or stasis of urine above a ureteral stone, it is not mandatory to place a double-J ureteral stent before the operation. The presence of this stent does not help to identify the stone and it often hinders dissection because of the inflammatory changes that it causes.

Anesthetic workup
The anesthetic workup evaluates the respiratory and cardiac functions of the patient. Coagulation tests should be normal and urine should be sterile before the operation. The patient is informed of the risks of the procedure and of the possibility of conversion to open surgery. A previous history of laparotomy increases this risk of conversion due to resulting adhesions that can hinder the transperitoneal approach. A previous history of lumbotomy increases the risk of conversion for the retroperitoneal approach.

For the transperitoneal approach, the hair is shaved from the costal margin to the mid-thigh level. An antiseptic solution is swabbed on the skin of the abdomen. For the retroperitoneal approach, the same procedure is applied to the posterior abdominal wall.

8. Operating room set-up

• Patient

1. Transperitoneal approach
2. Retroperitoneal approach
- general anesthesia;
- strict left or right lateral decubitus, contralateral to the side to be operated on;
- the anterior abdominal wall is positioned at the edge of the table for the transperitoneal approach, the back is positioned at the edge of the table for the retroperitoneal approach;
- an optional cushion can be useful in case of conversion;
- the patient is maintained in place with 2 supports placed posteriorly at the level of the sacrum and the shoulders for the transperitoneal approach, and at the level of the pubis and the sternum in case of a retroperitoneal approach.
- adhesive strips are placed at shoulder and pubic level to secure the patient to the table and the supports;
- the arm against the table is positioned perpendicularly on an arm rest;
- the other arm is placed parallel to the first on another arm rest, or secured to the bar or arch placed above the patient;
- urinary catheter.

• Team

• Transperitoneal approach

1. Surgeon
2. Assistant
3. Scrub nurse
The surgeon stands in front of the patient, closer to the feet for a right stone and closer to the head for a left stone.
The assistant stands in front of the patient and on the surgeon’s right, for both right and left stones.
The scrub nurse stands in front of the patient, near the feet.

• Retroperitoneal approach

1. Surgeon
2. First assistant
3. Second assistant
4. Scrub nurse
The surgeon stands behind the patient, closer to the head than the assistant for a right or left stone.
The first assistant stands behind the patient on the surgeon’s left for a left stone and on the surgeon’s right for a right stone.
The second assistant stands in front of the patient.
The scrub nurse stands in front of the patient, near the feet.

• Equipment

1. The laparoscopic unit and monitor are placed behind the patient for a transperitoneal approach.
For the retroperitoneal approach, the video unit is placed in front of and near the patient’s head. Preferably, 2 monitors are installed, 1 on each side of the patient.
2. Insufflation system
3. Suction-irrigation device
4. Electrocautery (monopolar and bipolar coagulation)

9. Trocar placement

• Landmarks

• Transperitoneal approach

The landmarks are as follows:
- the umbilicus;
- the anterior and superior iliac spine;
- the costal margin.

• Retroperitoneal approach

The landmarks are as follows:
- the tip of the 12th rib;
- the iliac crest;
- the lumbar muscles.

• Transperitoneal approach

The size and position of the trocars are as follows:
A: 10-12 mm, on the lateral margin of the rectus abdominis muscle, at umbilical level or 2 to 3 cm superior to the umbilicus;
This first trocar can be placed in different ways depending on the surgeon’s preference. It can be placed either by laparotomy or by a direct transcutaneous approach after insufflation of the abdominal cavity with carbon dioxide using a Veress needle. The remaining trocars are then introduced under visual control owing to the camera introduced through trocar A.
B: 5 mm, 5 cm lateral to A;
Trocars A and B can be positioned more cephalad or caudad than the umbilicus depending on the location of the stone (pelvic or ureteral). As a rule, these trocars should be placed in line with the target.
C: 5 mm, 2 cm medial to the anterior superior iliac spine, and sometimes superior to it;
D: 5 mm, below the costal margin on the same line as C.
The position of the trocars is described for an approach to the proximal ureter or renal pelvis. For an approach to the middle ureter, the trocars are moved 2 to 3 cm inferiorly.

• Retroperitoneal approach

• Principles

1. AAL: anterior axillary line
2. MAL: mid-axillary line
3. PAL: posterior axillary line
Five trocars are used.

• Step 1

A small flank incision (about 2 cm) is made below the 12th rib, on the anterior border of the sacro-lumbar muscular mass that projects roughly onto the posterior axillary line.
Computerized tomographic studies have shown that this landmark is always found posterior to the peritoneal reflection (Chiu et al., 1995). No vascular structures are found nearby. Consequently, the surgeon can approach the retroperitoneal space in a zone of near-absolute security. After incision of the transversalis fascia, finger dissection is done in the posterior perirenal space. The renal fascia and the peritoneum are mobilized from the abdominal wall.

• Step 2

The secondary trocars are placed under digital control. The surgeon’s index finger is placed in a latex finger glove. The secondary trocars are as follows:
- trocar B, 5 or 10 mm, situated on the anterior axillary line, below the costal margin;
- trocar C, 5 mm, situated on the anterior axillary line, superior to the iliac crest;
- trocar D, 10 mm, disposable, situated on the middle axillary line, superior to the iliac crest;
- trocar E, 5 or 10 mm, situated on the posterior axillary line, superior to the iliac crest.
When the 4 secondary trocars have been inserted, a 12 mm optical trocar (trocar A) is introduced through the initial small flank incision. This optical trocar has:
1. a sponge sealing ring.

• Step 3

Insufflation is begun. Maximum CO2 pressure is set at 12 mm Hg. The 0° laparoscope is then introduced.

10. Instruments

• Instruments

1. Monopolar scissors
2. Ultrasonic scissors (depending on availability and the surgeon’s preference)
3. Bipolar forceps
4. Grasper
5. One or two needle holders
6. Retrieval bag
7. Suction-irrigation device
8. Double-J ureteral stent
9. Urinary catheter

• Instruments/trocars

• Transperitoneal approach 1

FOR A STONE IN THE RIGHT URINARY TRACT:

The surgeon holds the monopolar or ultrasonic scissors or a needle holder, introduced through trocar B, in the right hand. The grasper, bipolar forceps, or second needle holder, introduced through trocar C, is held in the surgeon’s left hand.
The assistant holds the laparoscope, introduced through trocar A, in the left hand, and a grasper or suction-irrigation device, introduced through trocar D, in the right hand.

• Transperitoneal approach 2

FOR A STONE IN THE LEFT URINARY TRACT:

The surgeon holds the monopolar or ultrasonic scissors or needle holder, introduced through trocar B, in the right hand. The grasper, bipolar forceps, or a second needle holder, introduced through trocar D, is held in the surgeon’s left hand.
The assistant holds the laparoscope, introduced through A, in the left hand, and a grasper or suction-irrigation device, introduced through trocar C, in the right hand.

• Retroperitoneal approach

The surgeon holds the monopolar or ultrasonic scissors or a needle holder, introduced through trocar A, in the right hand. The grasper, bipolar forceps, or second needle holder, introduced through trocar E, is held in the surgeon’s left hand.
The first assistant holds the laparoscope introduced through trocar D. The second assistant holds a grasper, introduced through trocar B, in the left hand, and the suction-irrigation device, introduced through trocar C, in the right hand.

11. Exposure

• Transperitoneal approach

• Colon mobilization

The mobilization of the colon should be kept to a minimum. For a stone in the right renal pelvis, it is often unnecessary, as the incision of the posterior parietal peritoneum above the hepatic flexure leads directly to the renal pelvis. For a ureteral stone, the colonic mobilization is limited to exposing about 2 cm of the ureter on either side of the stone. During this dissection, the genital vein is often visible before the ureter, and must not be mistaken for it.

• Approach/renal pelvis

For renal pelvic calculi, the anterior surface of the renal pelvis is dissected free from the fatty tissue surrounding it so that a pyelotomy can be performed. It is not necessary to completely free the ureteropelvic junction. The stone can usually be felt through the wall with the graspers.

• Approach/ureter

1. Loop superior to the stone
2. Bulge of ureter as induced by the stone
For ureteral calculi, the ureter is dissected 2 cm on either side of the stone that is identified by the bulge of the ureter or by palpation with the graspers. It is advisable to place a loop around the ureter, superior to the stone, to prevent it from moving cephalad during the dissection of the ureter.

• Retroperitoneal approach

1. Psoas muscle
2. Gerota’s fascia
3. Stone
The psoas muscle represents the first anatomical landmark. It has to be found. To do so, the assistant standing opposite the surgeon draws the renal fossa and the peritoneum towards him/her. This landmark should not be followed cephalad as it may lead to the renal vessels, which should be avoided. For renal pelvic calculi, Gerota’s fascia should be opened to gradually reach the inferior pole of the kidney and find either the ureter or the ureteropelvic junction, or the renal pelvis medially. The posterior surface of the renal pelvis should be freed sufficiently.
For ureteral calculi, dissection should not be followed cephalad, nor Gerota’s fascia should be opened. As the peritoneum is retracted medially, the ureter and/or the genital vein have to be identified. Their course runs parallel to the psoas muscle. It is advisable to place a loop around the ureter, superior to the stone, to prevent the ureter from moving cephalad during the dissection of the ureter. The stone is identified by the bulge of the ureter (that is often inflamed) or by palpation with the graspers.

12. Opening of urinary tract

• Opening of renal pelvis

The renal pelvis is incised vertically using the cutting mode of the monopolar scissors, taking care not to injure the ureteropelvic junction and calyces. This incision can also be done with a scalpel. Urine is suctioned. The stone is mobilized and extracted with a grasper. It is immediately placed in a retrieval bag, which is removed through the optical trocar. If the stone is too big, it is removed at the end of the procedure through the small flank incision.

• Opening of the ureter

1. Loop superior to the stone
2. Bulge of ureter as induced by the stone
The incision of the ureter is performed while keeping hold of the stone through the ureteral wall with a grasper. Either the cutting mode of the monopolar scissors or the scalpel is used. Urine is suctioned, and the stone is mobilized and extracted with a grasper. It is immediately placed in a retrieval bag, which is removed through the optical trocar. If the stone is too big, it is removed at the end of the procedure through the small flank incision.

13. Stent placement

• Double-J ureteral stent

• Renal pelvic stone

1. Bladder
2. Kidney
The double-J ureteral stent is introduced through the subcostal trocar D for the laparoscopic approach or through trocar B for the retroperitoneal approach. It is possible to first insert a flexible guidewire into the ureter and to slide the stent into place over the guidewire. It is also possible to take a closed tip stent mounted on the stiff end of a guidewire and to insert both elements together into the ureter with the help of 2 graspers or a needle holder, or both.
To avoid gas leakage during the passage of the stent or guidewire through the trocar, a plastic tip (usually used on the openings of a cystoscope) can be placed on the trocar opening. When the double-J stent is placed in the bladder, the guidewire is removed and the upper extremity of the stent is placed in the renal pelvis.

• Variation

If a ureteropelvic junction obstruction is associated with the lithiasis, a pyelic resection is performed as described in the WebSurg chapter “Laparoscopic intraperitoneal pyeloplasty”.

• Ureteral stone

1. Introducing stent (with guidewire) in the ureter incision
2. Removing guidewire
3. Introducing guidewire toward the opposite tip of the stent
4. Creating a loop for introduction of the stent toward the opposite side of ureter
Depending on the position of the stone, the surgeon introduces the guidewire and double-J stent either proximally or distally into the ureter, choosing the side of the ureter that will use the longest length of the stent. The guidewire is removed from the portion of the stent in place, reinserted through one of the stent’s lateral holes and directed toward the opposite tip. This tip is then introduced through the ureterotomy toward the opposite side of the ureter, creating a loop in the stent. The stent must be inserted until this loop disappears entirely. While the surgeon is doing this, it is important for the assistant to prevent the portion of the stent that was already introduced from slipping out of place. The guidewire is removed once the double-J stent has been positioned inside the ureter.
Variation:
In certain cases, the double-J stent cannot be placed through the ureterotomy. In these cases, the stent may be placed at the end of the procedure using endoscopy.

• Closure/urinary tract

• Pyelic closure

The pyelotomy is closed with a 4.0 absorbable monofilament running suture.

• Ureteral closure

The ureterotomy is closed with a 4.0 absorbable monofilament running suture. This closure is performed either longitudinally or transversally, to avoid subsequent stenosis.

14. End of procedure

Drainage is performed with either a suction drain or a Penrose-type drain placed in the paracolic gutter.
The trocars are removed under visual control. The aponeurosis of trocar wounds larger than 5 mm are closed with an absorbable suture. The skin is reapproximated with staples. A urinary catheter is left in place for 5 to 7 days.
The double-J ureteral stent is left in place for 3 weeks. It is removed during the postoperative visit.

15. Conclusion

Laparoscopic surgery or retroperitoneoscopy of renal pelvic or ureteral stones remains limited to rare cases when other conventional treatments fail (ureteroscopy, percutaneous nephrostomy or extracorporeal shockwave lithotripsy). It should only be performed by experienced laparoscopic surgical teams.
It is indicated for accessible stones that do not require a transparenchymal approach (renal pelvis outside of the renal sinus or in the upper and middle ureter). A transparenchymal approach considerably increases morbidity (especially bleeding). In these cases, the advantage of a laparoscopic treatment as compared to percutaneous nephrostomy or ESWL is no longer evident. The only laparoscopic procedures that have been described using a transparenchymal approach have involved stones found in calyceal diverticula that were opposite an atrophied parenchyma.
Laparoscopic surgery is ideal for single stones. Randomized controlled trials will be needed to confirm that its low rate of morbidity and ease of performance make it a good alternative to conventional techniques as a primary approach, especially in the case of large stones.

16. Reference

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