BJU International (2002), 89, 339±343
Laparoscopic ureterolithotomy: technical considerations
and long-term follow-up
D . D . G A U R , S . T R IV E D I , M . R . P R A B HU D E S A I , H . R . M A D HU S U D H AN A and M . G O P I C H AN D
Department of Urology, Bombay Hospital Institute of Medical Sciences, Bombay, India
Objective To analyse the technical details and the long-
term results of laparoscopic ureterolithotomy.
Patients and methods Laparoscopic ureterolithotomy
was undertaken in 101 patients between 1991 and
2001; in only one patient with retroperitoneal
®brous adhesions was the procedure transperitoneal,
being retroperitoneal in all the others, using Gaur's
balloon retroperitoneoscopy. The mean (range) stone
size was 16 (10±47) mm, and the stones were in the
upper ureter in 75, mid-ureter in 11 and lower ureter
in 15 patients. Nine patients had more than one
stone, the maximum being six, in a megaureter.
Most were impacted for >2 months, the maximum
being 240 months.
Results Laparoscopic ureterolithotomy was successful in
93 patients, with the eight failures being mostly early
in the series. The mean operative duration was 79 min
(66 min when the ureter was left open and 92 min
when it was sutured). The overall mean duration of
Introduction
Following the historic report of laparoscopic uretero-
lithotomy (LU) by Wickham in 1979 via the retro-
peritoneal approach, there was little therapeutic
laparoscopic urological activity for some time [1]. Only
after Clayman et al. [2] reported the ®rst transperitoneal
laparoscopic nephrectomy in 1991 and Gaur [2]
described an innovative balloon dissection technique of
retroperitoneoscopy did laparoscopic urology become
established as a minimally invasive therapeutic method.
Although urolithiasis is fairly common there have been
few reports of LU [4 ±19], as there are few indications
for its use, with most patients being treatable by existing
minimally invasive methods, e.g. ESWL and uretero-
scopy. In this report we analyse the technical details and
long-term results of LU undertaken by our group.
Accepted for publication 1 December 2001
# 2002 BJU International
urinary leakage was 5.5 days, which was reduced
to 3.2 days by stenting and suturing the ureter. The
mean (range) blood loss was 25 (5±100) mL. The
overall complication rate was high (31%) because of
prolonged urinary leakage in 20 patients. No patient
required morphine for pain relief and the mean for oral
analgesic use was 2.5 days. The mean hospital stay was
3.5 days and that for resuming work 14 (7±28) days.
Conclusions Laparoscopic ureterolithotomy by the retro-
peritoneal approach is a safe and reliable minimally
invasive procedure. Although its role as a salvage pro-
cedure for failed extracorporeal shock wave lithotripsy
and ureteroscopy is undisputed, in selected patients
with large chronically impacted ureteric stones
and particularly with solitary kidneys, it may be
considered the ®rst-line treatment.
Keywords laparoscopy, retroperitoneoscopy, uretero-
lithotomy, complications, stone extraction, balloon
dissection
Patients and methods
In all, 101 LUs were undertaken between 1991 and
2001; because of postoperative retroperitoneal ®brosis
only one was transperitoneal, the remainder being retro-
peritoneal using the technique described by Gaur [15].
The stones were acutely impacted in four patients,
for >2 months in 69 and for >4 months in 28;
the maximum duration of impaction in a patient with
azotaemia was 240 months. The laparoscopic approach
was used as a salvage procedure for failed ESWL or
ureteroscopy in 37 patients. LU was used as a primary
procedure in 23 patients who had a stone of o15 mm
impacted for >4 months, in one who had a previous
ureteric re-implantation and in four who had stones
impacted in a solitary functioning kidney. In the
remaining 36 patients with chronically impacted ureteric
stones, LU was selected for socio-economic reasons, as the
patient wanted this to be the only visit to the hospital.
The mean (range) age of the patients was 36.6
(4 ±73) years and the male to female ratio was 21 : 4.
The patients were of average Asian build except for
339
340 D.D. GAUR et al.
14 who were obese. The mean (range) stone size was
16 (10 ± 47) mm; nine patients had more than one stone,
the maximum being six in a megaureter. Fifty-three
stones were on the right side and 48 on the left; they
were in the upper ureter in 75, mid-ureter in 11 and
lower ureter in 15 patients. General endotracheal
anaesthesia was used in all except three patients in
whom an epidural or unilateral spinal anaesthetic
was used.
The retroperitoneal lumbar approach was used in 84
and the iliac approach in 16 patients [20]. The primary
retroperitoneal access was by the closed percutaneous
technique in 62 and by the mini-open technique in 38
patients [20]. The balloon dissection technique was used
for all retroperitoneal procedures and the ports were
placed as described previously [15]; three ports were used
was in 68, four in 29 and two in four patients.
The ureter was incised with an endoknife in 65 and by
diathermy in 28 patients. The stones were delivered from
the ureter by leverage in 59, by angling the ureter in 20,
with a grasper in nine and by compression in ®ve
patients. They were extracted from the abdomen with
a 10-mm cup forceps in most patients, but in three
a sponge forceps was used and in one the stone was
hooked out with a ®nger. In 48 patients the ureter was
neither stented nor sutured, but six of these already
had a percutaneous nephrostomy placed earlier. In the
remaining 45 successful cases, the ureter was sutured in
36, stented in 18 and both sutured and stented in nine.
Results
LU was successful in 93 patients; it failed in eight, mostly
early in the series, and these were converted into a mini-
open procedure through a 5±7 cm long incision. The
reasons for failure were inability to locate the stone
in two, severe ®brosis in three, poor pneumoretro-
peritoneum in two and accidental ureteric avulsion in
one patient. Nevertheless, the basic reason for failure
in six patients was retroperitoneal ®brous reaction.
The ureter was identi®ed as soon as the laparoscope
was inserted in 71 patients, by its pathology, anatomical
relationship or peristaltic activity. Of the remaining 30,
in 24 it could be identi®ed only after a long laparoscopic
search. However, in six patients, the ureter could not be
identi®ed laparoscopically and required digital palpation
[21,22].
The mean operative duration was 79 min, being
66 min when the ureter was left open and 92 min
when it was sutured. All successful patients were
ambulatory and accepted oral foods the same evening.
Those in whom the ureter was left open were discharged
on the following day with the drain. However, those who
had their ureter stented or sutured were kept in the
hospital until the drain was removed. The overall mean
urinary leakage was for 5.5 days; it was 7.1 days when
the ureter was left open, 5 days when it was only stented,
4.4 days when it was only sutured and 3.2 days when
it was both stented and sutured. Cutting the ureter
with endoknife or diathermy made no difference to the
duration of leakage. There was prolonged (>7 days)
leakage of urine in 20 patients, although in 14 of these
the ureter was neither stented nor sutured, whereas six
had their ureters sutured. The mean (range) blood loss
was 25 (5±100) mL; no patient required morphine for
pain relief and the mean use of oral analgesics was for
2.5 days. The mean hospital stay was 3.5 days and
the mean for resuming work 14 (7±28) days.
All stones were removed in one session and there were
no residual stones in any patient. The parietal perito-
neum was torn in ®ve patients but this was of no con-
sequence. The overall complication rate was 31%
(Table 1). There was only one major complication, an
avulsion of the ureter while dissecting it for an impacted
lower ureteric calculus. The bleeding occurred in a
patient with dense ®brosis that required a mini-open
conversion, but no transfusion was given.
Discussion
Recent series from various centres (Table 2) [12,15±19]
show that of the total of 119 LUs previously reported, 66
were retroperitoneal and 53 transperitoneal. However,
we prefer the retroperitoneal approach with our re®ned
technique and the present series of 101, with only one
transperitoneal LU, shows that the former approach can
be used for stones situated anywhere in the ureter.
There is no doubt that the main indication for LU is as a
salvage procedure for failed ureteroscopy and ESWL, as
an alternative to an open procedure. However, this was
applicable to only 37 of the present patients. In 24 of the
28 patients where the laparoscopic approach was used as
a primary procedure, the chances of failure with existing
minimally invasive procedures was considered to be high
because the stones were large, severely impacted or there
Table 1 The complications of LU in 101 patients
Complication Number
Bleeding 1
Gross subcutaneous emphysema 2
High fever 2
Ureteric avulsion 1
Hypercarbia (monitored in 76 patients) 1
Ureteric stricture (follow-up in 75 patients) 3
Prolonged urinary leakage 20
Total 30
# 2002 BJU International 89, 339±343
 LAPAROSCOPIC URETEROLITHOTOMY 341

Table 2 A comparison of the results of LU with previous studies

Study

Variable [19] [17] [18] [16] [12] [15] Present

No. of procedures 10 21 14 24 9 41 101

Access:
transperitoneal 10 21 14 0 8 0 1
retroperitoneal 0 0 0 24 1 41 100
Mean:
stone size, mm 10 ± 27 ± 13.2 ± 16
operative time, min 181 90 105 61 158 98 79
Hospital stay, days 5±23 ± 1± 4 3.6 5.2 1± 4 3.5
Success, % 100 90 100 100 100 90 92
Complications, %:
early ± ± 21 ± 11 7.3 7
late ± ± ± ± ± ± 4

was a ureteric anomaly. In four patients with acutely
obstructed solitary functioning kidneys, laparoscopy was
used as a primary procedure, as it gave a better chance of
success in one session.
In the remaining 36 patients who had impacted stones
for >2 months the laparoscopic approach was used for
socio-economic reasons; these patients lived outside the
city and wanted their stones removed in one economical
procedure. Despite the need for general anaesthesia
and longer hospitalization, LU can be less expensive
in developing countries than ESWL and ureteroscopy;
laparoscopic procedures are free in India, to support
the government's family planning programme, and thus
ESWL and ureteroscopy procedures are more expensive.
Although retroperitoneal LU is simple, identifying the
ureter can sometimes be dif®cult, time-consuming and
frustrating. In 30 of the 100 retroperitoneal procedures,
>30 min was lost looking for the ureter, with success in
only 24. In the remaining six patients the ureter had to
be located digitally [23]. The key to early identi®cation of
the ureter is gaining access to the retroperitoneal space
deep to the transverse fascia, which can be done dur-
ing the laparoscopic exploration; however, we prefer to
use the balloon for this dissection by placing it deep to the
transverse fascia. Nevertheless, this may not be possible
every time because of chronic in¯ammatory reaction.
A laparoscopic search for the ureter can be initiated
anywhere in the lumbar region, but we prefer the iliac
crossing, because the iliac artery can be identi®ed easily
on either side and there is less chance of damage to
the lumbar vessels at this level. However, if the retro-
peritoneal space deep to the transverse fascia has already
been dissected by the balloon, there should be no problem
in identifying the ureter arched above the great vessels.
The gonadal vein crosses the ureter to become medial in
the upper part of the lumbar retroperitoneal space and
the formation of this ureterovenous angle can also
sometimes help in ureteric identi®cation [24]. Placing a
stent in the ureter beforehand was not much help in
®nding the ureter, as the stent could be felt only when
the ureter was visible.
The lumbar retroperitoneal approach provides more
working space and is our preferred approach for ureteric
stones above the ischial spine. Because the space is
truncated, the iliac approach should be used for stones
below this level and for stones at a higher level only if the
patient has an operative scar in the lumbar region.
However, for stones below the ischial spine in children,
we prefer the lumbar approach, as in these patients it is
dif®cult to obtain a workable space in the iliac retro-
peritoneal region. The procedure is easy with three
ports, although sometimes a fourth port is needed for
retraction.
Ureteric stones below S2 are more dif®cult to remove
even in open surgery and it is not surprising that in one
such case there was an accidental avulsion of the ureter.
Stones in the upper ureter are more easily removed
but there is a risk of their migration into the dilated
pelvicalyceal system during dissection of the ureter,
which happened in two of the present patients. To pre-
vent this the proximal ureter should ®rst be dissected
from above downwards and if possible held with an
endo-Babcock until the stone has been removed.
Even after many procedures making an accurate
incision over the ureter can sometimes be dif®cult.
During an open procedure the ureter is ®xed between the
®ngers before making an incision, but during LU such
ureteric ®xation is impossible with any of the available
instruments. Moreover, there can be problems if the
endoknife approaches the ureter almost at a right angle.

# 2002 BJU International 89, 339±343

342 D.D. GAUR et al.
Making an incision from inside out with a curved endo-
knife can simplify the incision. Cutting the ureter with
diathermy is much easier, as it can be incised with no
proper ureteric ®xation and the accompanying haemo-
stasis helps to make an accurate incision. There was no
problem with ureteric healing in the 28 patients where
diathermy was used.
Another problem during LU is delivering the stone
from the ureter; if the stone is impacted but not adherent,
it might move up during removal. In this event the stone
can be squeezed from the ureter with a 5-mm spatula or a
Fallopian tube-holding forceps. A grasper should be used
to extract the stone from the ureter only when the stone
is hard, otherwise grasping the stone can create problems
if it breaks and small pieces migrate into the dilated
proximal ureter. The best way to extract a stone impacted
in the ureter is to lever it out, as there is less chance
of breakage.
The easiest way of extracting a stone from the
abdomen is by grasping it with a 10-mm cup forceps;
if this is not available, a sponge-holding forceps passed
directly through the abdominal incision (made airtight
by packing it with gauze) can be used. A stone lost in
the retroperitoneal space can create problems and the
simplest way to locate and remove it is by using the
index ®nger.
Of the present failures in eight patients only two were
caused by inexperience, as precautions were not taken
and the stones migrated into the dilated pelvicalyceal
system. In the remaining six patients where the stones
could not be removed laparoscopically, extensive retro-
peritoneal ®brosis was mainly responsible. Such patients
might be identi®able by a detailed history and physical
examination, and warned that a mini-open conversion
may be necessary [25]. Considering the complete success
rate of the three transperitoneal series reported to
date (Table 2), it seems that a transperitoneal laparo-
scopic approach would have been more suitable in these
patients.
Although stenting was always helpful in reducing
urinary leakage the same was not true for suturing; six
of the 20 patients with urinary leakage of >7 days had
their ureters sutured. This was possibly because the
suturing was poor, but the main reason was that these
ureters were chronically in¯amed, oedematous and
friable after infection and prolonged impaction. The
urine in some of these patients was even purulent.
Therefore, under such circumstances, the ureter should
only be stented and not sutured.
The mean stone size, operative duration, hospital stay,
success rate and early complication rate are comparable
with those of other series, if the prolonged urinary
leakage in 20 patients is not considered a complication
(Table 2). Although there were no major complications
in some series, in the present there was one ureteric
avulsion requiring open conversion. Three of the 75
patients followed up to 10 years developed ureteric
strictures at the impaction site within a year but no more
strictures were noted thereafter. One patient presenting
within 3 months was treated by retrograde JJ stenting
while the other two required antegrade dilatation and
stenting. Infection and the severity of stone impaction
were mainly responsible for this complication as these
ureters were oedematous and the stones badly impacted.
The size of the stone also appeared to be related to the
incidence of stricture formation. As all the three affected
patients had stones of f15 mm, and there was no
stricture in those with stones of >20 mm, those with
small impacted stones appear to be at greater risk
of stricture formation. The high stricture rate of 24%
reported previously [26] after ureteroscopic, open sur-
gical or laparoscopic treatment of patients with stones
impacted in the ureter for >2 months is dif®cult to
explain, as in the present series the stones were impacted
for prolonged periods in most.
References
1 Wickham JEA ed. The surgical treatment of renal lithiasis.
In Urinary Calculus Disease. New York: Churchill
Livingstone, 1979: 145±98
2 Clayman RV, Kavoussi LR, Soper NJ et al. Laparoscopic
nephrectomy: initial case report. J Urol 1991; 146: 278±81
3 Gaur DD. Laparoscopic operative retroperitoneoscopy. Use
of a new device. J Urol 1992; 148: 1137±9
4 Raboy A, Ferzli GS, Ioffreda R, Albert PS. Laparoscopic
ureterolithotomy. Urology 1992; 39: 223±5
5 Gaur DD. Retroperitoneal laparoscopic ureterolithotomy.
World J Urol 1993; 11: 175±7
6 Wuernschimmel E, Lipsky H. Laparoscopic treatment of
an upper ureteral stone. J Laparoendosc Surg 1993; 3: 301±7
7 Gangal HT, Gangal PH, Gangal MH. An attempt at a
percutaneous retroperitoneoscopic approach to uretero-
lithotomy. Surg Endosc 1993; 7: 455±8
8 Escovar Diaz P, Rey Pacheco M, Lopez Escalante JR et al.
Laparoscopic ureterolithotomy. Arch Esp Urol 1993; 46:
633±7
9 Low RK, Moran ME. Laparoscopic use of the ureteral
illuminator. Urology 1993; 42: 455±7
10 Bellman GC, Smith AD. Special considerations in the
technique of laparoscopic ureterolithotomy. J Urol 1994;
151: 146±9
11 Gaur DD, Agarwal DK, Purohit KC, Darshane AS,
Shah BC. Retroperitoneal laparoscopic ureterolithotomy
for multiple upper mid ureteral calculi. J Urol 1994; 151:
1001±2
12 Harewood LM, Webb DR, Pope AJ. Laparoscopic uretero-
lithotomy, the results of an initial series, and an evalua-
tion of its role in the management of ureteric calculi. Br J
Urol 1994; 74: 170±6
# 2002 BJU International 89, 339±343

13 Fahlenkamp D, Schonberger B, Liebetruth L, Lindeke A,
Loening SA. Laparoscopic laser ureterolithotomy. J Urol
1994; 152: 1549±51
14 Henkel TO, Rassweiler J, Alken P. Ureteral laparoscopic
surgery. Ann Urol (Paris) 1995; 29: 61±72
15 Gaur DD ed. Retroperitoneal laparoscopic ureteral
surgery. In Retroperitoneal Laparoscopic Urology. Chapt 13.
New Delhi: Oxford University Press, 1997: 106±32
16 Sinha R, Sharma N. Retroperitoneal laparoscopic manage-
ment of urolithiasis. J Laparoendosc Adv Surg Tech A 1997;
7: 95±8
17 Turk I, Deger S, Roigas J, Fahlenkamp D, Schonberger B,
Loening SA. Laparoscopic ureterolithotomy. Tech Urol
1998; 4: 29±34
18 Keeley FX, Gialas I, Pillai M, Chrisofos M, Tolley DA.
Laparoscopic ureterolithotomy: the Edinburgh experience.
BJU Int 1999; 84: 765±9
19 Nualyong C, Taweemonkongsap T. Laparoscopic uretero-
lithotomy for upper ureteric calculi. J Medical Assoc Thailand
1999; 2: 1028±33
20 Gaur DD ed. Retroperitoneal access techniques. In
Retroperitoneal Laparoscopic Urology. Chapt 6. New Delhi:
Oxford University Press, 1997: 31± 47
21 Gaur DD ed. Lost in space. In Retroperitoneal Laparoscopic
Urology. Chapt 12. New Delhi: Oxford University Press,
1997: 96±105
22 Gaur DD. Laparoscopic ureterolithotomy. In Smith AD
ed. Controversies in Endourology. Chapt 22. Philadelphia:
WB Saunders Co., 1995: 353±60
# 2002 BJU International 89, 339±343
LAPAROSCOPIC URETEROLITHOTOMY 343
23 Gaur DD ed. Retroperitoneal laparoscopic pyelolitho-
tomy. In Retroperitoneal Laparoscopic Urology. Chapt 18.
New Delhi: Oxford University Press, 1997: 174 ±84
24 Gaur DD ed. Preliminary retroperitoneoscopy. In
Retroperitoneal Laparoscopic Urology. Chapt 8. New Delhi:
Oxford University Press, 1997: 56±60
25 Repassy D, Frang D, Jako GJ. Minimal and direct
access ureterolithotomy. Acta Chir Hung 1995±96;
35: 361±8
26 Roberts WW, Cadeddu JA, Micali S, Kavoussi LR, Moore RG.
Ureteral stricture formation after removal of impacted
calculi. J Urol 1998; 159: 723±6
Authors
D.D. Gaur, MS, FRCS, Associate Professor.
S. Trivedi, MS, Senior Resident.
M.R. Prabhudesai, MS, Senior Resident.
H.R. Madhusudhana, MS, FRCS, Senior Resident.
M. Gopichand, MS, Senior Resident.
Correspondence: D.D. Gaur, Department of Urology, Bombay
Hospital Institute of Medical Sciences, 19 Marine Lines,
Bombay 400 020, India.
e-mail: ddgaur@vsnl.com
Abbreviations: LU, laparoscopic ureterolithotomy.