Is It Necessary to Place a Double J Catheter After Laparoscopic Ureterolithotomy? A Four-Year Experience

Abstract

Purpose:

To assess the necessity of placing a ureteral stent after transperitoneal laparoscopic ureterolithotomy (TPLU).

Patients and Methods:

In the period from May 2006 to November 2010, 46 patients underwent TPLU. There were 13 females and 33 males. All patients had an impacted stone larger than 1.5 cm in the upper and middle parts of the ureter. TPLU was performed as either a primary therapy or as a salvage therapy in patients in whom another treatment had failed. The exclusion criteria were pregnancy, a body mass index more than 35, and patients with abnormal results on coagulative tests. In all cases, after removing the stone, the ureter was sutured. In the first 23 patients, no ureteral catheter was placed, but in the second 23 patients, a Double J catheter was inserted through the ureter.

Results:

In one case, the stone was pushed back. The stone-free rate was 97.8%. There were four cases of prolonged urinary leakage after the surgery. All of them were in the group in whose members the Double J catheter had not been placed. The problem was resolved in one patient spontaneously after 4 days, but for the other three patients, a Double J catheter was placed and the leakage was stopped in 24 hours. There was no case of urinary leakage in the second group of patients with a placed Double J catheter.

Conclusion:

Placing a Double J catheter during surgery does not increase the time of operation and may play a role in prevention of urinary extravasation after laparoscopic ureterolithotomy.

Introduction

C urrently, upper and middle ureteral stones are managed by using extracorporeal shockwave lithotripsy (SWL), transureteral lithotripsy (TUL), or percutaneous lithotripsy. In certain circumstances, however, such as impacted stones, especially those located in the proximal ureter, sometimes multiple interventions are needed; in such cases, open surgery has the advantage of removing the stone almost within one procedure.¹ One of the most preferred noninvasive approaches that can be used as an alternative to open surgery is laparoscopic ureterolithotomy (LUL). The importance of this approach is more significant when the size of the stone and the anatomy of the ureter make other noninvasive and endoscopic techniques impractical.²

The best treatment modality for large proximal ureteral stones is still controversial.³ Among the available noninvasive modalities, transureteral laser lithotripsy seems to be the method of choice for large impacted ureteral stones. Nonetheless, because we did not have this modality in our center, we preferred to use transperitoneal laparoscopic ureterolithotomy (TPLU) for treatment of patients with large impacted ureteral stones.

Placing a Double J catheter after LUL is still controversial. In addition, using a Double J catheter can impose costs on patients, and it may cause some discomfort while removing it. In this study, two groups of patients were studied to compare efficacy and complications of placing a Double J catheter after LUL.

Patients and Methods

TPLU was performed for 46 patients from May 2006 until November 2010. The eligibility criteria for TPLU were large impacted stones in the proximal and middle parts of the ureter. TPLU was performed as a primary procedure for stones >15 mm or as a salvage treatment in patients in whom previous attempts such as SWL and TUL had failed. All procedures were performed by a single surgeon in our center who was experienced in laparoscopy. Exclusion criteria were obese patients with a body mass index >35, pregnant patients, and patients with abnormal results on coagulative tests.

Surgical procedure

General anesthesia with endotracheal intubation was used in all patients. After placing the patient in a semilateral position, the abdomen was insufflated up to 15 mm Hg with CO₂ through an umbilical incision. A 10-mm trocar was inserted using an open access technique. A zero degree laparoscope was inserted, and under laparoscopic vision, two operating trocars were placed in the contralateral and ipsilateral sides of the stone. The surgeon was at the contralateral side, and an assistant was at the ipsilateral side. The retroperitoneal attachments to the descending colon were dissected to move the colon medially. The ureter was exposed as it crossed the psoas muscle and iliac veins. After localization of the stone, an incision was made longitudinally on the ureter by hook electrode. The stone was removed by a grasper.

A Double J catheter was not placed in any of the first 23 patients, but after observing urinary leakage in 4 patients, it was placed for each of 23 remaining patients and was removed 4 weeks after the procedure. The incision was sutured by 4-0 polyglactin with interrupted sutures. A vacuum drain was placed through the incision of the ipsilateral trocar. Operative time was calculated from the beginning of insertion of the trocars to the end of drain placement.

Postoperative fever was considered as body temperature of ≥38°C on two consecutive measurements, at least 6 hours apart, excluding the first day after surgery. Ileus persistent for more than 3 days after surgery was mentioned as postoperative adynamic ileus. Prolonged urinary leakage was considered as urine leakage longer than 7 days. The follow-up program consisted of radiography of the kidneys, ureters, and bladder (KUB) and sonography at 1 month and sonography 1 year after removal of the catheter. All data were analyzed by the SPSS 16.0 program using the Fisher exact test. P value less than 0.05 were considered significant.

Results

The mean age of patients was 41.5±8.3 years. Thirteen (28.2%) patients were female and 33 (71.7%) others were male. Thirty-one (67.3%) patients had upper and 15 (32.7%) had middle ureter stones. The stones and their sizes were confirmed by sonography or KUB radiography or CT scan. Demographic and clinical characteristics of patients in each group are compared in Table 1. TPLU was successful for all patients except one in the first group; the stone was pushed back into the renal pelvis. This patient was sent for SWL and became stone free after two sessions of SWL. The stone-free rate after laparoscopy in our series was 97.8%. There was no conversion to open surgery. The mean operative time was 92.5±16.2 minutes (63–128 min) for the first group, and 97.6±17.3 minutes (70–132 min) for the second group (P=0.48).

Table 1.

Demographic and Clinical Characteristics of Patients

	Group 1 (without Double J) n=23	Group 2 (with Double J) n=23	P value
Mean age±SD	43.2±6.8	39.8±6.5	0.2
Sex (%)
Female	8 (34.7)	5 (21.7)	0.3
Male	15 (65.3)	18 (78.3)
History of intervention (%)
TUL	3 (13)	3 (13)	0.9
SWL	8 (34.7)	6 (26.1)
Position of the stone (%)
Upper	14 (60.8)	17 (73.9)	0.3
Middle	9 (39.2)	6 (26.1)
Mean stone diameter±SD	15.9±1.2	16.6±1.8	0.1
BMI±SD	26.7±3.3	27.1±2.8	0.5

SD=standard deviation; TUL=transureteral lithotripsy; SWL=shockwave lithotripsy; BMI=body mass index.

The incision of the ureter was sutured for all patients. There were four cases of urinary leakage in the first group of patients in whom a Double J catheter was not placed (17.4%). In the second group of patients in whom a catheter was placed, drainage was not more than 50 mL per 24 hours, and the drain was removed 24 hours after the surgery. There were four cases of prolonged urinary leakage in the first group. In one patient, the problem resolved spontaneously after 4 days, but for the other three patients, after 1 week of leakage, a Double J catheter was placed and drainage was stopped in 24 hours.

Gonadal vessel injury occurred in three patients, two of whom were in the first group and one was in the second group; all were immediately controlled by endoclips. Blood transfusion was not needed in any of the patients. Patients were all ambulatory the next day after the procedure, and oral diet was started at the same time and was well tolerated. There was no case of postoperative ileus. There were no major complications, such as bleeding, sepsis, intestinal injury, and cardiac or respiratory complications. Patients' intraoperative and postoperative data are compared in Table 2.

Table 2.

Patient Intraoperative and Postoperative Data

	First group (without Double J) n=23	Second group (with Double J) n=23	P value
Mean operative time (min)	92.5±16.2	97.6±17.3	0.4
Stone-free status	22 (95.6%)	23 (100%)	1
Complication
Gonadal vessel injury	2 (8.6%)	1 (4.3%)	1
Intestinal injury	0	0	_
Need for transfusion	0	0	_
Postoperative fever	0	0	_
Postoperative adynamic ileus	0	0	_
Prolonged urinary leakage	4 (17.4%)	0	0.05

min=minutes.

One month later, after removing the catheter, all patients were studied again, and there was no remnant stone or hydronephrosis. In the 1-year follow-up period, three patients in the first group and two patients in the second group were lost. The remaining ones had no stone or hydronephrosis in an ultrasonography study.

Discussion

The management of urinary stones has been revolutionized in the last decades. A variety of minimally invasive treatments, such as SWL, TUL, and laparoscopy, has blurred the role of open surgery. Nevertheless, there are some stones that could not be managed by such methods, and open surgery is indicated for them.

Since 1979 in which the first LUL was performed, its popularity has been increasing steadily. Laparoscopic surgery is significantly developed today, and the indications for open surgery in those with renal stones have decreased significantly over the past 20 years. Open surgery is indicated for patients who are not treatable with minimally invasive procedures. Because of accumulated experience in laparoscopy, however, this approach has increasingly begun to replace open surgery.⁴ There are some obvious advantages in laparoscopy over open surgery, such as shorter hospital stay, cosmetic appearance, and convalescent period.^5,6

Laparoscopic surgery is performed via transperitoneal or exteraperitoneal approaches. Wider working space, better view, and clear anatomic landmarks are advantages of transperitoneal laparoscopy over retroperitoneal approach.⁷ The European Association of Urology guidelines on urolithiasis have mentioned the following items as indications for laparoscopic surgery in ureteral stones: Large impacted stones, multiple ureteral stones, in cases of concurrent conditions necessitaing surgery, and when other non-invasive or low-invasive procedures have failed.⁴ In a study to compare transperitoneal and exteraperitoneal approaches, Kongchareonsombat and associates⁸ found out that estimated blood loss and mean operative time were almost the same in these approaches, but the duration of retaining drain was significantly shorter in the retroperitoneal approach.

Comparing laparoscopy and TUL, LUL seems a more proper approach for large and impacted stones. In these kinds of stones, there might be some degree of ureteral dilatation behind the impaction that could let the stone be pushed back easily during TUL. Ko and colleagues⁹ compared TUL with LUL in two groups, each consisting of 32 patients. Stone clearance was significantly higher in the laparoscopy group. They concluded that LUL can be performed as a first-line procedure in impacted ureteral stones. In a study by Leonardo and coworkers,¹⁰ LUL was performed for 33 patients with previously failed TUL or SWL. The mean stone size was 34 mm, and the stone-free rate was 100%.

In our study, TPLU was performed as both a primary and salvage method for impacted ureteral stones. The use of LUL either as primary or after other failed treatments has been experienced in other series, too.^11

–14 Lopes Neto and colleagues³ compared postoperative outcomes of SWL and LUL and TUL. They concluded that LUL is associated with a higher success rate and lower number of surgical procedures to make the patient stone free.

The need for suturing the ureter seems controversial among the authors. Kijvikai and Patcharatrakul¹⁵ emphasized that suturing the ureter is essential in LUL, while Bellman and Smith¹⁶ mentioned that closure of the incision is unnecessary when the incision is small and the preoperative urine is sterile. El-Moula and coworkers¹⁷ performed a series of 74 cases of LUL. They placed ureteral sutures for all cases and used a ureteral stent for 5 days. They encountered only one case of prolonged urinary leakage, which stopped spontaneously after 11 days. Kijvikai and Patcharatraku¹⁴ reported long time impaction and chronically inflamed tissue as possible causes of leakage even after proper suturing. Gaur and associates¹⁸ performed LUL in 101 patients and placed urethral stents for 47 cases. They encountered 20 cases of prolonged urinary leakage, all of whom were in the stentless group. They have suggested that in cases with long time impaction and chronic inflammation, only a stent is needed to be placed and the ureter should not be sutured. Hammady and colleagues¹⁹ randomized 104 patients with upper ureteral stones >1 cm into two groups and placed ureteral stents in one group. They did not found any significant difference in drainage time between the two groups. They concluded that LUL without placing a ureteral stent is a safe and cost effective procedure and reduces auxiliary procedures and patient discomfort.

At the beginning of our series, we sutured all incisions on the ureter and did not place a Double J catheter. Four patients among the first 23 patients had prolonged urinary drainage. With the exception of one case with spontaneous resolution, for the other three cases, a Double J catheter was placed and almost immediately the urinary extravasation resolved. Then we decided to continue our series using a ureteral catheter to prevent urinary leakage. There was no significant leakage in the rest of the patients. We found a weakly significant statistical difference for urinary leakage between the two groups, and it seems that a controlled randomized trial with larger sample size can be helpful.

Conclusion

LUL is a safe and cost effective minimally invasive procedure to remove large and impacted ureteral stones that cannot be properly managed by other minimal invasive techniques. This technique can be used as first-line treatment for impacted ureteral stones or as a salvage procedure when SWL or TUL has failed. We believe placing a Double J catheter during the surgery does not increase the time of operation and may play a role in prevention of urinary extravasation after LUL.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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