Open Surgery,Laparoscopic Surgery,or Transureteral Lithotripsy—Which Method? Comparison of Ureteral Stone Management Outcomes

Abstract

Background and Purpose:

The optimal treatment option for ureteral calculi is a controversial issue. In this study, we present our experience of 60 patients, divided into three groups, who were treated using open surgery, laparoscopic surgery, or transureteral lithotripsy (TUL).

Patients and Methods:

We enrolled 60 patients who had upper ureteral calculi >l0 mm in diameter from June 2008 to August 2009 in our center. In a prospective study, preoperative and postoperative data were evaluated, and for statistical analyses, the chi-square test, one-way analysis of variance, and post hoc test were used.

Results:

The mean operative time was 70, 191, and 162.5 minutes in the TUL, laparoscopic, and open groups, respectively. The mean hospital stay was 1.65, 4.2, and 4.35 days in the three groups, respectively. The stone-free rate was 90%, 95%, and 100% in the three groups, respectively. Flank pain was reported as 15%, 5%, and 15%, in the three groups, respectively. Hemoglobin decrease necessitating blood transfusion was not reported in the TUL and laparoscopic groups, but blood transfusion was reported in 15% in the open group. The lowest dose of analgesic was used in the TUL group. There was no damage to the ureter and adjacent organs and wound infection in the three groups.

Conclusion:

Our study showed that the complications after laparoscopic surgery were lower than in open surgery. We recommend laparoscopic surgery for upper ureteral stones >1 cm because of lower postoperative complications, shorter hospital stay, and shorter time to convalescence, and better cosmetic results.

Introduction

M anagement of urolithiasis, a very common disease, has changed drastically during recent years.¹ The optimal treatment option for ureteral calculi is a controversial issue. For proximal ureteral calculi, the options are extracorporeal shockwave lithotripsy (SWL), ureteroscopy, percutaneus nephrolithotomy (PCNL), and rarely, open or laparoscopic surgery.

Since the initial report by Clayman and colleagues² in 1991, laparoscopic surgery has been used for many types of urologic surgery involving ureterolithotomy. Transureteral lithotripsy (TUL) has been recommended as first-line therapy for patients in whom SWL fails.³

While most patients with renal and ureteral stones can be treated with less invasive techniques, open ureterolithotomy for the management of urinary calculi is almost abandoned today, but it still may be indicated in a small segment of the population with urinary stones for some cases of failure of first-line treatment modalities.⁴ Most upper or middle ureteral calculi are managed with SWL, PCNL, or ureteroscopy. Recently, the laparoscopic approach has gained as another minimally invasive alternative in patients with ureteral calculi.¹

In this study, we present our experience of 60 patients who were divided into three groups and treated using open surgery, laparoscopic surgery, or TUL.

Patients and Methods

We enrolled 60 patients who had upper ureteral calculi >l0 mm in diameter from June 2008 to August 2009 in our center. The patients were nonrandomly divided into three groups of 20 patients. The patients had stones >10 mm in the upper ureter with obstruction and hydronephrosis. The patients were not candidates for PCNL, and they were resistant to SWL. Our policy for large upper ureteral stone treatment was TUL, laparoscopic surgery, or open surgery. PCNL was indicated in patients with a ureteral stone before the lower border of the kidney.

In this study, the operative time, hospital stay, total dose of analgesic, complications (bleeding, fever, ileus, and stone migration, damage to ureter and adjacent organs), and return to full activity time were evaluated. We evaluated the stone-free rate by stone removal in the laparoscopic or open surgery groups and by kidneys-ureters-bladder radiography/ultrasonography in the TUL group. In the surgical approach in the laparoscopic group, the patient was in the lateral decubitus position for the transperitoneal procedure. A dorsal lumbotomy procedure was performed in the open group. TUL was performed using a semirigid ureteroscope with a pneumatic lithotripter.

In our educational center policies, we preferred to insert a J stent for 4 to 6 weeks in patients in the laparoscopic and open surgery groups for confidence of better healing. We inserted a ureteral stent in paients in the TUL group for 1 to 2 days.

We administered spinal anesthesia in the TUL group and general anesthesia in the laparoscopic and open surgery groups.

For statistical analysis, the chi-square test, one-way analysis of variance, and the post hoc test were used.

Results

In this study, 60 patients who had upper ureteral calculi >l0 mm in diameter were divided into three groups. In the TUL group, there were 12 males and 8 females with a mean age of 43 ± 14 years; in the laparoscopic group, there were 14 males and 6 females with a mean age of 41 ± 10 years; and in the open group, there were 13 males and 7 females with a mean age of 50 ± 18 years. The most common complaint was flank pain. In the TUL group, the mean operative time was 70 ± 23 minutes. The mean hospital stay was 1.65 days. In addition, the mean return to full activity time was 9 days. The stone-free rate was 90% in the TUL group. Flank pain was reported in three (15%) patients and fever in two (10%) patients. There was no hemoglobin change before and after operation in the TUL group. The lowest dose of analgesic was used in the TUL group (pethedin 22.5 ± 2.97 mg and acetaminophen 682.54 ± 617.5 mg) (Table 1).

Table 1.

Perioperative and Postoperative Results of Transureteral Lithotripsy, Laparoscopy, and Open Procedures

	Open	Laparoscopy	TUL	P value
Mean age (year)	50 ± 18	41 ± 10	43 ± 14
Mean operative time (min)	162.5 ± 45.57	190.7 ± 3 0.87	70/52 ± 22.35	TUL, open: <0/0001TUL, lap: <0/0001Open, Lap: <0/029
Mean hospital stay (day)	4.35 ± 1.46	4.2 ± 1.36	1.65 ± 0.87	TUL, Open: <0/0001TUL, lap: <0/0001Open, lap: <1/00
Mean return to full activity (day)	21.75 ± 7.96	14.6 ± 4.32	8.95 ± 2.16	TUL, open: <0/0001TUL, lap: <0/0001Open, lap: <0/0001
Total dose of morphine	4.61 ± 1.5	4.40 ± 1.37	0	TUL, open: <0/641TUL, lap: <0/641Open, lap: <1
Total dose of pethedin	55.25 ± 5.82	65 ± 6.09	22.5 ± 2.97	TUL, open: <0/058TUL, lap: <0/021Open, lap: <1
Total dose of acetaminophen	1503.3 ± 1025	606.71 ± 273.75	682.54 ± 617.5	TUL, open: <1TUL, lap: <0/029Open, l ap: <0/139

TUL = transureteral lithotripsy; lap = laparotomy.

In the laparoscopic ureterolithotomy group, the mean operative time was 191 ± 30 minutes. The mean hospital stay was 4.2 ± 1.36 days. The mean return to full activity time was 14.6 ± 4.32 days. The stone-free rate was 95% in the laparoscopic group. The mean analgesic dose was 4 ± 1.37 mg for morphine, and 65 ± 6 mg for pethedin and 606 ± 273.75 mg for acetaminophen (Table 1). The complications were fever (10%), ileus (10%), pain (5%), pulmonary edema (5%), and two other complications (15%). A coincidental complication was considered as a separate complication. There was no damage to the ureter and adjacent organs. Hemoglobin decrease necessitating blood transfusion was not reported in any patient (Table 2).

Table 2.

Minor Complications of Transureteral Lithotripsy, Laparoscopy, and Open Procedures

Complications	TUL (%)	Open (%)	Laparoscopy (%)	Total (%)
Without complication	75	30	55	53.3
Fever	10	10	10	10
Ileus	0	15	10	8.3
Pain	15	15	5	11.7
Two coincidental complications (Fever + ileus)	0	15	15	10
Bleeding	0	15	0	5
Pulmonary edema	0	0	5	1.7
Ureteral stricture (follow-up 7–21 months)	0	0	0	0

TUL = transureteral lithotripsy.

In the open ureterolithotomy group, the mean operative time was 162.5 ± 22.35 minutes. The mean hospital stay was 4.35 ± 1.46 days. The mean relative remission time was 21.75 ± 7.95 days. The stone-free rate was 100% in this group. The mean analgesic dose was 1.5 ± 4.61 mg (morphine), 55.25 ± 5.82 mg for pethedin, and 1503.3 ± 1025 mg for acetaminophen. The complications were fever (10%), ileus (15%), pain (15%) and two other complications (15%). There was no damage to the ureter and adjacent organs, and there was no hemoperitoneum and wound infection reported. In addition, hemoglobin decrease necessitating blood transfusion was reported in three (15%) patients (Tables 1 and 2).

Discussion

Since the introduction and development of percutaneous renal surgery, and because of significant achievements in SWL, refinements in ureteroscopy, and technical advancements in the available modalities of intracorporeal lithotripsy, the surgical management of urinary stone disease has dramatically changed.⁴ Today, the rate of open stone surgery has declined.^5,6 Laparoscopic surgery has low morbidity, less postoperative pain, a short convalescence period, and good cosmetic results.⁷ The first extraperitoneal ureterolithotomy was reported in 1979, and the first intraperitoneal laparoscopic ureterolithotomy was performed in 1992.^8,9

The treatment of choice, even for calculi >1 cm, should be SWL, ureteroscopy, or percutaneous removal. Open ureterolithotomy might be appropriate in complicated cases and as a salvage therapy. Evidence for laparoscopic ureterolithotomy was not available in the literature until 1997.¹⁰ The management of ureteral calculi >1 cm is controversial, although upper ureteral calculi <1 cm can be safely managed using semirigid ureteroscopy. Certainly, for ureteral stones necessitating multiple SWL sessions or more than one ureteroscopic intervention, removal by a single procedure may be a better choice. This study is still the first that has been compared three methods in the management of ureteral calculi >1 cm.

Skrepetis and coworkers¹¹ reported that the mean operative time in the laparoscopic group was 130 minutes, and in open ureterolithotomy it was 85 minutes. Several studies reported that operative times were 61 to 294 minutes in laparoscopic surgeries.^{1,7,12

–20} We achieved a mean operative time of 191 ± 3 0 minutes in the laparoscopic group, 70 ± 23 minutes in the TUL group, and 162.5 ± 22.35 minutes in the open ureterolithotomy group. Although our result in the laparoscopic group is similar to that of other reports, we believe it seems relatively long. We considered the operative period from anesthesia to sending the patients to the recovery room. Thus, the time spent for setup of instruments was a part of the operative time.

Mean blood loss in laparoscopic ureterolithotomy was 132.9 mL in the study by Micali and associates,¹² and in another study, mean estimated blood loss in open lithotripsy was reported to be 50 to 428 mL.^4,14 In our study, hemoglobin decrease necessitating blood transfusion was needed in no patient in the TUL and laparoscopic groups, and it was needed in three patients in the open surgery group. The smaller incision and sharp dissection with high quality visualization by laparoscope can decrease the oozing and bleeding from the tissue, thus decreasing blood loss in the laparoscopic group. The period of hospital stay ranged from 2 to 7 days (mean 4.6 d) in the study from Jeong and colleagues,¹⁴ and Micali and associates¹² reported that hospital stay was from 1 to 15 days (mean 4.5 d). The postoperative hospital stay was 3 days for the laparoscopic group and 6.4 to 8 days for the open ureterolithotomy group.^4,11

We achieved similar results: Average hospital stay was 4.2 ± 1.36 days in the laparoscopic group and 4.35 ± 1.46 days in the open surgery group and 1.65 ± 0.87 days in the TUL group. Although it is similar to that of other studies, we included the first cases of laparoscopic surgery in this study. After more experience with laparoscopic surgery, a urologist can decrease hospital stay for patients.

In the study by Jeong and coworkers,¹⁴ no significant intraoperative or postoperative complications were observed in laparoscopic surgery. Some studies reported that all of their laparoscopic procedures were accomplished successfully with minor postoperative complications.^4,11,12 In our study, similar to the other studies, no major complications, such as rupture of the ureter, urine leakage, or hemoperitoneum, occurred. Minor complications resolved with appropriate therapy. After laparoscopic ureterolithotomy, one patient showed symptoms of pulmonary edema from aspiration that was cured with medical management.

Simforoosh and associates¹ reported that 96.7% patients were stone free in the laparoscopic group.¹ In our study, the stone-free rate was 90% in the TUL and 95% in the laparoscopic group that was recommended to SWL, but the stone-free rate was 100% in the open surgery group. We believe that TUL is a minimally invasive surgery, but migration of upper ureteral stones after TUL is high.

Less postoperative convalescence and fewer complications (less blood loss and less postoperative pain) and better cosmetic outcome are advantages of laparoscopic procedures compared with open procedures. Similar to the other studies,^14,21 the mean time of convalescence was 21.75 days in the open surgery group, 14.6 days in the laparoscopic group, and 8.95 days in the TUL group, which are similar to results of other studies. They reported 12 days for laparoscopic and 22 days for open surgery groups.¹¹ We believe that laparoscopic cases recovered rapidly and needed fewer analgesics.

The study by Micali and colleagues¹² showed that the narcotic requirement was from 0 to 100 mg in the laparoscopic group; another published study showed that the analgesic requirement per patient was 1 day for laparoscopy and 4 days for an open surgery group.¹¹ In our study, among the three methods, the patients who underwent TUL had the lowest use of analgesics.

The optimal treatment options for proximal ureteral calculi are SWL, TUL, PCNL, and rarely open or laparoscopic surgery. Although Srivastava and coworkers²² recommended the percutaneous approach in the management of impacted upper ureteral calculi, according to our outcomes, TUL is the best method for management of ureteral stones, because of the lowest operative times, hospital stay, and returning to activity. Because of stone migration in this method, the stone-free rate in the TUL group is less than in the others.

The main disadvantage of the laparoscopic approach is that it is a technically demanding procedure that requires a long learning curve and an experienced surgeon to perform compared with an open procedure. Laparoscopy is not a replacement for SWL or ureteroscopic techniques, but it is an addition to the minimally invasive armamentarium when these techniques are unsuitable or fail.

Conclusion

This study demonstrated that hemoglobin decrease necessitating blood transfusion was not reported in the laparoscopic group, and bleeding in this method was less than in the open surgery group. Our study showed that the complications after laparoscopic surgery were lower than in the open surgery group. Thus, laparoscopic ureterolithotomy has been accepted as a standard minimally invasive treatment for upper ureteral stones >1 cm, and this method is an alternative method for open ureterolithotomy. We believe that most cases can be performed laparoscopically with experienced hands. We recommend laparoscopic surgery for upper ureteral stones >1 cm because of lower postoperative complications, shorter hospital stay, shorter time to convalescence, and better cosmetic results.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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