Original Paper
Urologia Internationalis
Received: September 9, 2013 Accepted after revision: February 7, 2014 Published online: August 8, 2014
Urol Int DOI: 10.1159/000360425
Our Experience with Retroperitoneal Laparoendoscopic Single-Site Ureterolithotomy Zhonghua Wu Youming Xu Jianhua Yu Jin Liu Jiushun Chen Shaoliang Wang Kan Chen Department of Urology, Hubei Provincial Corps Hospital, Chinese People’s Armed Police Forces, Wuhan, China
Abstract Aim: To report our experience with retroperitoneal laparoendoscopic single-site (LESS) ureterolithotomy for the management of large proximal ureteral stones. Patients and Methods: From July 2011 to April 2012, 20 patients underwent retroperitoneal LESS ureterolithotomy. The indications for the operation were impacted upper ureteral stones larger than 15 mm. A reusable elastic single-port device with 3 working channels was inserted through the 2.5-cm incision at the midpoint between the costal arch and iliac crest on the mid-axillary line. A rigid 10-mm 30° extra-long laparoscope was introduced for monitoring, and a combination of lengthened pre-bent and conventional laparoscopic instruments was used for handling. The surgical procedure was similar to conventional retroperitoneal laparoscopic ureterolithotomy. Results: Retroperitoneal LESS ureterolithotomy was completed in all of the patients. The mean stone size was 18.8 mm (range 16–28). The mean operative
© 2014 S. Karger AG, Basel 0042–1138/14/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin
time was 108 min (range 75–140). Significant bleeding was not observed, and no major intraoperative complications occurred in any of the patients. The mean hospital stay was 4.4 days (range 3–7). Conclusions: Retroperitoneal LESS ureterolithotomy, using a reusable elastic single-port device, is technically feasible and safe, and the combination of conventional and pre-bent laparoscopic instruments represents an attractive option for retroperitoneal LESS. © 2014 S. Karger AG, Basel
Introduction
In cases of large impacted proximal ureteral stones for which shock wave lithotripsy, ureteroscopy and percutaneous antegrade ureteroscopy have either failed or are unlikely to succeed, laparoscopic ureterolithotomy is a minimally invasive alternative to open surgery [1, 2]. Both transperitoneal and retroperitoneal access to the ureter have been reported [3–6]. However, conventional laparoscopy continues to be associated with tissue trauma due to the number of incisions and ports that are used. To minimize access-related complications and to improve Jianhua Yu Department of Urology, Hubei Provincial Corps Hospital Chinese People’s Armed Police Forces, Minzhu Road 475, Wu Chang District 430061 Wuhan, Hubei (China) E-Mail lenovo888 @ 163.com
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Key Words Laparoscopy · Ureteral stone · Laparoendoscopic single-site ureterolithotomy
Color version available online
the cosmetic results, laparoendoscopic single-site (LESS) surgery has been developed [7, 8]. Many LESS ureterolithotomies have been performed using the transperitoneal approach [9–11]. However, only a few cases of retroperitoneal LESS ureterolithotomy have been reported [12–14]. In this retrospective study, we report our experience and evaluate the feasibility and safety of retroperitoneal LESS ureterolithotomy for the management of large, proximal ureteral stones. Patients and Methods
Urol Int DOI: 10.1159/000360425
Fig. 2. Appearance of instrument cooperation during the surgery.
double-J stent was closed at the distal end and open at the proximal end. A guidewire was extracorporeally inserted through the open end into the stent. Subsequently, the stent, with its closed end nearly straight, was introduced through 1 working channel. The stent was inserted antegrade into the ureter and bladder through the ureteral incision site (fig. 3c). After the guidewire was withdrawn, the proximal end of the stent was placed in the renal pelvis through the incision site. The ureteral incision was closed with 2 or 3 interrupted sutures using a 3-0 Vicryl suture (fig. 3d). Two curve graspers were used to make a knot (fig. 3e). A 20-Fr drain was placed in the retroperitoneum, and the incision was closed (fig. 3f). The retroperitoneal drain was removed after 24 h without fluid drainage (drain ≤20 ml). The double-J stent was removed after 4–6 weeks, and IVU or ultrasonography was performed every 3 or 6 months postoperatively.
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2
Fig. 1. The single-port device, a rigid 10-mm 30° extra-long laparoscope and lengthened pre-bent instruments used in LESS ureterolithotomy.
Color version available online
We retrospectively reviewed the medical records of 20 patients who underwent retroperitoneal LESS ureterolithotomy between July 2011 and April 2012. The indications for the operation were impacted upper ureteral stones larger than 15 mm. The mean age and the mean body mass index were 40.6 years (range 22–61) and 23.2 kg/m2 (range 17.2–27.6), respectively, and 12 men and 8 women were included in the study. The stones were localized to the left side in 11 patients and to the right in 9. All of the stones were radiopaque and therefore easily seen on plain abdominal film. In 3 of these patients, earlier treatments with extracorporeal shock wave lithotripsy had failed. None of the patients had undergone previous renal or ureter surgery. Ultrasonography and intravenous urography (IVU) were used preoperatively to evaluate the urinary system. Under general anesthesia, the patient was placed in the lateral decubitus position, with the side ipsilateral to the stone facing up. A 2.5-cm incision was made at the midpoint between the costal arch and iliac crest on the mid-axillary line. The muscular layer and lumbodorsal fascia were bluntly divided, and the peritoneum was pushed forward with the index finger. The retroperitoneal space was entered and further developed by inflating a homemade glove balloon (500–600 ml of air was injected to maintain the balloon dilation for 3–5 min). A single-port device (Kangyou Medical Equipment Co., Ltd., Hangzhou, China) (fig. 1) was placed in the incision. This reusable elastic single-port device consists of a distraction component and a valve component. The distraction component, in the shape of a trumpet at both ends, can be deployed through a 2.5-cm fascial incision. The valve component has 3 ports, 2 5-mm ports and 1 10-mm port, which, in turn, can be attached to the distraction component for specimen removal. In addition, the valve component contains 2 openings and tubes for insufflation and exsufflation. After a pneumoperitoneum was created by carbon dioxide at a pressure of 15 mm Hg, a rigid 10-mm 30° extra-long laparoscope (Hawk Optical Electronic Instruments Co., Ltd., Hangzhou, China) (fig. 1) was inserted for monitoring. During the procedure, a conventional laparoscopic instrument was held in the dominant hand, and a pre-bent instrument was held in the nondominant hand (fig. 2). The pre-bent instruments were 5 cm longer than conventional instruments (fig. 1). The surgical procedure was similar to conventional retroperitoneal laparoscopic ureterolithotomy. The ureter was located, dissected and traced to the stone, which was identified as a bulge. The ureter was incised longitudinally over the stone (fig. 3a), and the stone was removed using laparoscopic forceps (fig. 3b). A 6-Fr
Color version available online
b
c
d
e
f
Results
Retroperitoneal LESS ureterolithotomy was completed in all of the patients without conversion to open surgery or placement of additional ports. The patients’ demographics, intraoperative and postoperative data are presented in table 1. The mean stone size was 18.8 mm (range 16–28). The mean operative time was 108 min (range 75–140). Significant bleeding was not observed in any of the patients, and no blood transfusions were necessary. There were no major intraoperative complications such as injury to adjacent organs and major vessels. The postoperative period was uneventful in all of the patients, and the mean hospital stay was 4.4 days (range 3–7). Postoperative analgesic requirements were minimal, and all of the patients were active and eating norLaparoendoscopic Single-Site Ureterolithotomy
Table 1. Patient demographics, intraoperative and postoperative data
Parameter Sex Male Female Age, years Body mass index, kg/m2 Mean stone size, mm Stone side Left Right Operative time, min Estimated blood loss, ml Hospital stay after surgery, days Follow-up, months
Value 12 8 40.6 (22 – 61) 23.2 (17.2 – 27.6) 18.8 (16 – 28) 11 9 108 (75 – 140) 35.5 (20 – 60) 4.4 (3 – 7) 9.5 (7 – 12)
Ranges are provided in parentheses.
Urol Int DOI: 10.1159/000360425
3
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Fig. 3. a The ureter was incised longitudinally over the stone. b The stone was removed using laparoscopic forceps. c The 6-Fr double-J stent was inserted antegrade into the ureter through the ureteral incision site. d The ureteral incision was closed with interrupted sutures. e Two curved graspers were used to make a knot. f A 20Fr drain was placed in the retroperitoneum, and the incision was closed.
a
Discussion
Trocar-related morbidity and improved cosmetic outcomes associated with laparoscopic surgery have resulted in increased reports of LESS surgery [15, 16]. Early clinical series have demonstrated the safety and feasibility of a broad range of LESS urologic procedures [15]. The majority of these procedures have been performed using the transperitoneal approach because it offers a larger working space and a hidden umbilical incision; experience with retroperitoneal LESS remains limited [17]. In the relatively small retroperitoneal space, the LESS procedure is not easy. However, the retroperitoneal approach offers several advantages over the transperitoneal approach, such as preventing urine leakage in the peritoneal cavity, avoiding intraperitoneal organ injury, decreasing the risk of postoperative ileus and eliminating peritoneal irritation by insufflated CO2, thereby potentially enhancing patient recovery. In addition, the retroperitoneal LESS approach provides direct and rapid access to the target without intruding in the peritoneal cavity. Although the disadvantages of the retroperitoneal approach include the inability to hide the wound in the umbilicus, a small posterior port site scar is usually acceptable to patients. For LESS ureterolithotomy, the transperitoneal approach is typically employed [9–11]. Retroperitoneal LESS ureterolithotomy has proven to be feasible in treating ureteral stones in select patients; however, this procedure has rarely been reported, with limited case numbers. Ryu et al. [12] reported 14 successful cases of retroperitoneal LESS surgery using a homemade single-port device, with only 2 patients undergoing ureterolithotomy. A study by Micali et al. [13] included 11 patients who were treated by LESS surgery, 3 of whom underwent retroperitoneal LESS ureterolithotomy using TriPort and a 5-mm flexible laparoscope. Wen et al. [14] reported their initial experience with retroperitoneal LESS ureterolithotomy in 10 patients, and the authors retrospectively compared the surgical outcomes with conventional laparoscopic ureterolithotomy. Wen et al. applied a homemade single-port device, a flexible laparoscope and flex4
Urol Int DOI: 10.1159/000360425
ible instruments for LESS, and the authors used double laparoscopic clips to fix the two ends of the suture threads in the ureters instead of the difficult knot-tying approach. In the present study, we performed 20 cases of retroperitoneal LESS ureterolithotomy using a single-port device, a laparoscope and instruments that differed from those in the aforementioned studies. Because the camera and the instruments are inserted in parallel through the same site and in close proximity, the major challenges of LESS include the lack of triangulation, clashing and poor range of motion. Conventional laparoscopes have a large extracorporeal profile, with a light cable exiting at 90°. This configuration leads to the clashing of the instruments with the camera during LESS. In our series, we used a 10-mm 30° extra-long laparoscope, in which the light cable is placed 45° to the lens. The additional length removes the camera head and light cord from the operative field, which can prevent clashing of the camera with the instruments and reduce interference between the surgeon and the camera holder. In addition, a 10-mm 30° laparoscope is essential because it allows for variable perspective with little shift in the location, which can reduce its interaction with the instruments. Although clashing of instruments can be overcome using flexible (articulating) instruments, these instruments are difficult to use [16, 18]. We also used flexible instruments during our initial retroperitoneal LESS approaches. We found that these instruments were suitable for transperitoneal access; in the retroperitoneal approach, the working space was smaller, and the distance from the port site to the retroperitoneal organ was shorter, so flexible instruments did not fit in the retroperitoneal space. Pre-bent instruments have been developed for the purpose of providing triangulation, minimizing instrument clashing and providing better force application at the instrument tip during dissection [19]. Stolzenburg et al. [18] compared the efficacy of pre-bent instruments with flexible instruments in vitro and in vivo with respect to time requirements, maneuverability and ease of handling. Pre-bent instruments proved to be less time consuming to use and provided better maneuverability. Therefore, we replaced flexible instruments with pre-bent instruments. During the LESS procedure, we used a conventional laparoscopic instrument in the dominant hand for the major handling and a pre-bent instrument in the nondominant hand to fix the tissue. We did not need to cross our hands with the right-hand instrument used on the left-hand side or vice versa. We found that this setting eased handling difficulties and limited the clashing of instruments. Additionally, pre-bent instruments were lonWu/Xu/Yu/Liu/Chen/Wang/Chen
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mally by the 2nd day. The mean follow-up was 9.5 months (range 7–12). Satisfactory drainage with decreased kidney dilation was documented in all patients by ultrasonography or IVU during the postoperative follow-up. The length of the LESS scar in each case was approximately 2.5 cm.
References
Laparoendoscopic Single-Site Ureterolithotomy
modalities for upper ureteral stones. However, the efficacy of shock wave lithotripsy decreases significantly with impacted stones larger than 10 mm. Positive results and few complications have been reported with flexible ureteroscopy using a holmium laser, but the procedure is expensive and unavailable to many centers. Compared with percutaneous antegrade ureteroscopy, laparoscopic ureterolithotomy has had a higher success rate in patients with large stones. Basiri et al. [20] compared 3 surgical options for the management of urinary stones in the upper ureter: retrograde ureteroscopic lithotripsy, percutaneous nephrolithotripsy and laparoscopic ureterolithotomy; the authors reported stone-free rates of 56, 64 and 88% at discharge and 76, 86 and 90% after 3 weeks for the 3 procedures, respectively. In our series, all of the patients were discharged stone free, and had no stone recurrence throughout the follow-up period. Furthermore, all of the procedures were free of complications. These data indicate the efficacy and safety of retroperitoneal LESS ureterolithotomy. Our study has several limitations, one of which is the lack of a comparison group; thus, a prospective randomized study is needed. In addition, scar satisfaction was not evaluated with a validated questionnaire, body mass index did not exceed 28 kg/m2, and the number of patients was relatively small.
Conclusion
In our experience, retroperitoneal LESS ureterolithotomy using a reusable elastic single-port device is technically feasible and safe, representing a reproducible alternative to conventional retroperitoneoscopy for select patients. In addition, the combination of conventional and pre-bent laparoscopic instruments might represent an attractive option for retroperitoneal LESS.
1 Preminger GM, Tiselius HG, Assimos DG, Alken P, Buck AC, Gallucci M, Knoll T, Lingeman JE, Nakada SY, Pearle MS, Sarica K, Turk C, Wolf JS Jr: Guideline for the management of ureteral calculi. Eur Urol 2007; 52: 1610–1631. 2 Hruza M, Schulze M, Teber D, Gozen AS, Rassweiler JJ: Laparoscopic techniques for removal of renal and ureteral calculi. J Endourol 2009;23:1713–1718.
Urol Int DOI: 10.1159/000360425
3 Bove P, Micali S, Miano R, Mirabile G, De Stafani S, Botteri E, Giampaolo B, Vespasiani G: Laparoscopic ureterolithotomy: a comparison between the transperitoneal and the retroperitoneal approach during the learning curve. J Endourol 2009;23:953–957. 4 Huri E, Basok EK, Ugurlu O, Gurbuz C, Akgul T, Ozgok Y, Bedir S: Experiences in laparoscopic removal of upper ureteral stones: multicenter analysis of cases, based on the TurkUroLap Group. J Endourol 2010; 24: 1279–1282.
5
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ger than conventional instruments, which provided more space for the movement of the instruments outside of the port. We believe that these features might render the combination of conventional and pre-bent instruments an appealing option for retroperitoneal LESS. The main obstacle in retroperitoneal LESS cases is knot-tying. When making a knot, we replaced the needle holder with a curved grasper in the dominant hand, which offset the shafts adequately to accomplish a satisfactory degree of triangulation because the curved grasper had a longer and more curved tip. Additionally, the nondominant grasper was used to grip the tip of the needle to maintain the half circle of the curved needle. The dominant grasper was rotated clockwise around to the butt of the needle, which allowed multiple loops to be made for knotting with a minimal excursion range. In our series, the mean operative time was 108 min, which was shorter than the 110.4–176.7 min reported for LESS ureterolithotomy [9, 10, 13, 14]. The reduction in the mean operative time could be attributed to the aforementioned techniques and tricks, proper patient selection or surgical experience. The mean hospital stay was 4.4 days in the present series, longer than the 2.5–3.8 days previously reported [9, 10, 14]. This long stay might be explained by the availability of national health insurance in our country and by the preference of some patients to remain in the hospital until their skin sutures were removed. The costs of disposable single-port devices and flexible instruments have significantly limited the availability of LESS technology. Our LESS platform may be cost-effective because we used a reusable single-port device and prebent instruments. With the currently described LESS technique, further expenses for the flexible laparoscope and flexible instruments were rarely necessary. Currently, shock wave lithotripsy, retrograde ureteroscopy, percutaneous antegrade ureteroscopy and laparoscopic ureterolithotomy are accepted as treatment
6
Urol Int DOI: 10.1159/000360425
10 Lee JY, Han JH, Kim TH, Yoo TK, Park SY, Lee SW: Laparoendoscopic single-site ureterolithotomy for upper ureteral stone disease: the first 30 cases in a multicenter study. J Endourol 2011;25:1293–1298. 11 Rane A, Rao P: Single-port-access nephrectomy and other laparoscopic urologic procedures using a novel laparoscopic port (Rport). Urology 2008;72:260–263. 12 Ryu DS, Park WJ, Oh TH: Retroperitoneal laparoendoscopic single-site surgery in urology: initial experience. J Endourol 2009; 23: 1857–1862. 13 Micali S, Isgro G, De Stefani S, Pini G, Sighinolfi MC, Bianchi G: Retroperitoneal laparoendoscopic single-site surgery: preliminary experience in kidney and ureteral indications. Eur Urol 2011;59:164–167. 14 Wen X, Liu X, Huang H, Wu J, Huang W, Cai S, Li X, Ye C, Zhu B, Cai Y, Gao X: Retroperitoneal laparoendoscopic single-site ureterolithotomy: a comparison with conventional laparoscopic surgery. J Endourol 2012; 26: 366–371. 15 Greco F, Cindolo L, Autorino R, Micali S, Stein RJ, Bianchi G, Fanizza C, Schips L, Fornara P, Kaouk J: Laparoendoscopic single-site upper urinary tract surgery: assessment of postoperative complications and analysis of risk factors. Eur Urol 2012;61:510–516. 16 Autorino R, Cadeddu JA, Desai MM, Gettman M, Gill IS, Kavoussi LR, Lima E, Montorsi F, Richstone L, Stolzenburg JU, Kaouk JH: Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature. Eur Urol 2011;59:26–45.
17 Kaouk JH, Autorino R, Kim FJ, Han DH, Lee SW, Yinghao S, Cadeddu JA, Derweesh IH, Richstone L, Cindolo L, Branco A, Greco F, Allaf M, Sotelo R, Liatsikos E, Stolzenburg JU, Rane A, White WM, Han WK, Haber GP, White MA, Molina WR, Jeong BC, Lee JY, Linhui W, Best S, Stroup SP, Rais-Bahrami S, Schips L, Fornara P, Pierorazio P, Giedelman C, Lee JW, Stein RJ, Rha KH: Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1,076 cases. Eur Urol 2011;60:998–1005. 18 Stolzenburg JU, Kallidonis P, Oh MA, Ghulam N, Do M, Haefner T, Dietel A, Till H, Sakellaropoulos G, Liatsikos EN: Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting. J Endourol 2010; 24:239–245. 19 Raman JD, Cadeddu JA, Rao P, Rane A: Single-incision laparoscopic surgery: initial urological experience and comparison with natural-orifice transluminal endoscopic surgery. BJU Int 2008;101:1493–1496. 20 Basiri A, Simforoosh N, Ziaee A, Shayaninasab H, Moghaddam SM, Zare S: Retrograde, antegrade, and laparoscopic approaches for the management of large, proximal ureteral stones: a randomized clinical trial. J Endourol 2008;22:2677–2680.
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5 El-Feel A, Abouel-Fettouh H, Abdel-Hakim AM: Laparoscopic transperitoneal ureterolithotomy. J Endourol 2007;21:50–54. 6 Nouira Y, Kallel Y, Binous MY, Dahmoul H, Horchani A: Laparoscopic retroperitoneal ureterolithotomy: initial experience and review of literature. J Endourol 2004; 18: 557– 561. 7 Gill IS, Advincula AP, Aron M, Caddedu J, Canes D, Curcillo PG 2nd, Desai MM, Evanko JC, Falcone T, Fazio V, Gettman M, Gumbs AA, Haber GP, Kaouk JH, Kim F, King SA, Ponsky J, Remzi F, Rivas H, Rosemurgy A, Ross S, Schauer P, Sotelo R, Speranza J, Sweeney J, Teixeira J: Consensus statement of the consortium for laparoendoscopic single-site surgery. Surg Endosc 2010;24:762–768. 8 Greco F, Hoda MR, Mohammed N, Springer C, Fischer K, Fornara P: Laparoendoscopic single-site and conventional laparoscopic radical nephrectomy result in equivalent surgical trauma: preliminary results of a singlecentre retrospective controlled study. Eur Urol 2012;61:1048–1053. 9 Choi KH, Yang SC, Lee JW, Rha KH, Han WK: Laparoendoscopic single-site surgery for ureterolithotomy: focus on intracorporeal stenting and suturing. Urology 2010; 76: 1283–1287.
Urologia Internationalis
Received: September 9, 2013 Accepted after revision: February 7, 2014 Published online: August 8, 2014
Urol Int DOI: 10.1159/000360425
Our Experience with Retroperitoneal Laparoendoscopic Single-Site Ureterolithotomy Zhonghua Wu Youming Xu Jianhua Yu Jin Liu Jiushun Chen Shaoliang Wang Kan Chen Department of Urology, Hubei Provincial Corps Hospital, Chinese People’s Armed Police Forces, Wuhan, China
Abstract Aim: To report our experience with retroperitoneal laparoendoscopic single-site (LESS) ureterolithotomy for the management of large proximal ureteral stones. Patients and Methods: From July 2011 to April 2012, 20 patients underwent retroperitoneal LESS ureterolithotomy. The indications for the operation were impacted upper ureteral stones larger than 15 mm. A reusable elastic single-port device with 3 working channels was inserted through the 2.5-cm incision at the midpoint between the costal arch and iliac crest on the mid-axillary line. A rigid 10-mm 30° extra-long laparoscope was introduced for monitoring, and a combination of lengthened pre-bent and conventional laparoscopic instruments was used for handling. The surgical procedure was similar to conventional retroperitoneal laparoscopic ureterolithotomy. Results: Retroperitoneal LESS ureterolithotomy was completed in all of the patients. The mean stone size was 18.8 mm (range 16–28). The mean operative
© 2014 S. Karger AG, Basel 0042–1138/14/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin
time was 108 min (range 75–140). Significant bleeding was not observed, and no major intraoperative complications occurred in any of the patients. The mean hospital stay was 4.4 days (range 3–7). Conclusions: Retroperitoneal LESS ureterolithotomy, using a reusable elastic single-port device, is technically feasible and safe, and the combination of conventional and pre-bent laparoscopic instruments represents an attractive option for retroperitoneal LESS. © 2014 S. Karger AG, Basel
Introduction
In cases of large impacted proximal ureteral stones for which shock wave lithotripsy, ureteroscopy and percutaneous antegrade ureteroscopy have either failed or are unlikely to succeed, laparoscopic ureterolithotomy is a minimally invasive alternative to open surgery [1, 2]. Both transperitoneal and retroperitoneal access to the ureter have been reported [3–6]. However, conventional laparoscopy continues to be associated with tissue trauma due to the number of incisions and ports that are used. To minimize access-related complications and to improve Jianhua Yu Department of Urology, Hubei Provincial Corps Hospital Chinese People’s Armed Police Forces, Minzhu Road 475, Wu Chang District 430061 Wuhan, Hubei (China) E-Mail lenovo888 @ 163.com
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Key Words Laparoscopy · Ureteral stone · Laparoendoscopic single-site ureterolithotomy
Color version available online
the cosmetic results, laparoendoscopic single-site (LESS) surgery has been developed [7, 8]. Many LESS ureterolithotomies have been performed using the transperitoneal approach [9–11]. However, only a few cases of retroperitoneal LESS ureterolithotomy have been reported [12–14]. In this retrospective study, we report our experience and evaluate the feasibility and safety of retroperitoneal LESS ureterolithotomy for the management of large, proximal ureteral stones. Patients and Methods
Urol Int DOI: 10.1159/000360425
Fig. 2. Appearance of instrument cooperation during the surgery.
double-J stent was closed at the distal end and open at the proximal end. A guidewire was extracorporeally inserted through the open end into the stent. Subsequently, the stent, with its closed end nearly straight, was introduced through 1 working channel. The stent was inserted antegrade into the ureter and bladder through the ureteral incision site (fig. 3c). After the guidewire was withdrawn, the proximal end of the stent was placed in the renal pelvis through the incision site. The ureteral incision was closed with 2 or 3 interrupted sutures using a 3-0 Vicryl suture (fig. 3d). Two curve graspers were used to make a knot (fig. 3e). A 20-Fr drain was placed in the retroperitoneum, and the incision was closed (fig. 3f). The retroperitoneal drain was removed after 24 h without fluid drainage (drain ≤20 ml). The double-J stent was removed after 4–6 weeks, and IVU or ultrasonography was performed every 3 or 6 months postoperatively.
Wu/Xu/Yu/Liu/Chen/Wang/Chen
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2
Fig. 1. The single-port device, a rigid 10-mm 30° extra-long laparoscope and lengthened pre-bent instruments used in LESS ureterolithotomy.
Color version available online
We retrospectively reviewed the medical records of 20 patients who underwent retroperitoneal LESS ureterolithotomy between July 2011 and April 2012. The indications for the operation were impacted upper ureteral stones larger than 15 mm. The mean age and the mean body mass index were 40.6 years (range 22–61) and 23.2 kg/m2 (range 17.2–27.6), respectively, and 12 men and 8 women were included in the study. The stones were localized to the left side in 11 patients and to the right in 9. All of the stones were radiopaque and therefore easily seen on plain abdominal film. In 3 of these patients, earlier treatments with extracorporeal shock wave lithotripsy had failed. None of the patients had undergone previous renal or ureter surgery. Ultrasonography and intravenous urography (IVU) were used preoperatively to evaluate the urinary system. Under general anesthesia, the patient was placed in the lateral decubitus position, with the side ipsilateral to the stone facing up. A 2.5-cm incision was made at the midpoint between the costal arch and iliac crest on the mid-axillary line. The muscular layer and lumbodorsal fascia were bluntly divided, and the peritoneum was pushed forward with the index finger. The retroperitoneal space was entered and further developed by inflating a homemade glove balloon (500–600 ml of air was injected to maintain the balloon dilation for 3–5 min). A single-port device (Kangyou Medical Equipment Co., Ltd., Hangzhou, China) (fig. 1) was placed in the incision. This reusable elastic single-port device consists of a distraction component and a valve component. The distraction component, in the shape of a trumpet at both ends, can be deployed through a 2.5-cm fascial incision. The valve component has 3 ports, 2 5-mm ports and 1 10-mm port, which, in turn, can be attached to the distraction component for specimen removal. In addition, the valve component contains 2 openings and tubes for insufflation and exsufflation. After a pneumoperitoneum was created by carbon dioxide at a pressure of 15 mm Hg, a rigid 10-mm 30° extra-long laparoscope (Hawk Optical Electronic Instruments Co., Ltd., Hangzhou, China) (fig. 1) was inserted for monitoring. During the procedure, a conventional laparoscopic instrument was held in the dominant hand, and a pre-bent instrument was held in the nondominant hand (fig. 2). The pre-bent instruments were 5 cm longer than conventional instruments (fig. 1). The surgical procedure was similar to conventional retroperitoneal laparoscopic ureterolithotomy. The ureter was located, dissected and traced to the stone, which was identified as a bulge. The ureter was incised longitudinally over the stone (fig. 3a), and the stone was removed using laparoscopic forceps (fig. 3b). A 6-Fr
Color version available online
b
c
d
e
f
Results
Retroperitoneal LESS ureterolithotomy was completed in all of the patients without conversion to open surgery or placement of additional ports. The patients’ demographics, intraoperative and postoperative data are presented in table 1. The mean stone size was 18.8 mm (range 16–28). The mean operative time was 108 min (range 75–140). Significant bleeding was not observed in any of the patients, and no blood transfusions were necessary. There were no major intraoperative complications such as injury to adjacent organs and major vessels. The postoperative period was uneventful in all of the patients, and the mean hospital stay was 4.4 days (range 3–7). Postoperative analgesic requirements were minimal, and all of the patients were active and eating norLaparoendoscopic Single-Site Ureterolithotomy
Table 1. Patient demographics, intraoperative and postoperative data
Parameter Sex Male Female Age, years Body mass index, kg/m2 Mean stone size, mm Stone side Left Right Operative time, min Estimated blood loss, ml Hospital stay after surgery, days Follow-up, months
Value 12 8 40.6 (22 – 61) 23.2 (17.2 – 27.6) 18.8 (16 – 28) 11 9 108 (75 – 140) 35.5 (20 – 60) 4.4 (3 – 7) 9.5 (7 – 12)
Ranges are provided in parentheses.
Urol Int DOI: 10.1159/000360425
3
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Fig. 3. a The ureter was incised longitudinally over the stone. b The stone was removed using laparoscopic forceps. c The 6-Fr double-J stent was inserted antegrade into the ureter through the ureteral incision site. d The ureteral incision was closed with interrupted sutures. e Two curved graspers were used to make a knot. f A 20Fr drain was placed in the retroperitoneum, and the incision was closed.
a
Discussion
Trocar-related morbidity and improved cosmetic outcomes associated with laparoscopic surgery have resulted in increased reports of LESS surgery [15, 16]. Early clinical series have demonstrated the safety and feasibility of a broad range of LESS urologic procedures [15]. The majority of these procedures have been performed using the transperitoneal approach because it offers a larger working space and a hidden umbilical incision; experience with retroperitoneal LESS remains limited [17]. In the relatively small retroperitoneal space, the LESS procedure is not easy. However, the retroperitoneal approach offers several advantages over the transperitoneal approach, such as preventing urine leakage in the peritoneal cavity, avoiding intraperitoneal organ injury, decreasing the risk of postoperative ileus and eliminating peritoneal irritation by insufflated CO2, thereby potentially enhancing patient recovery. In addition, the retroperitoneal LESS approach provides direct and rapid access to the target without intruding in the peritoneal cavity. Although the disadvantages of the retroperitoneal approach include the inability to hide the wound in the umbilicus, a small posterior port site scar is usually acceptable to patients. For LESS ureterolithotomy, the transperitoneal approach is typically employed [9–11]. Retroperitoneal LESS ureterolithotomy has proven to be feasible in treating ureteral stones in select patients; however, this procedure has rarely been reported, with limited case numbers. Ryu et al. [12] reported 14 successful cases of retroperitoneal LESS surgery using a homemade single-port device, with only 2 patients undergoing ureterolithotomy. A study by Micali et al. [13] included 11 patients who were treated by LESS surgery, 3 of whom underwent retroperitoneal LESS ureterolithotomy using TriPort and a 5-mm flexible laparoscope. Wen et al. [14] reported their initial experience with retroperitoneal LESS ureterolithotomy in 10 patients, and the authors retrospectively compared the surgical outcomes with conventional laparoscopic ureterolithotomy. Wen et al. applied a homemade single-port device, a flexible laparoscope and flex4
Urol Int DOI: 10.1159/000360425
ible instruments for LESS, and the authors used double laparoscopic clips to fix the two ends of the suture threads in the ureters instead of the difficult knot-tying approach. In the present study, we performed 20 cases of retroperitoneal LESS ureterolithotomy using a single-port device, a laparoscope and instruments that differed from those in the aforementioned studies. Because the camera and the instruments are inserted in parallel through the same site and in close proximity, the major challenges of LESS include the lack of triangulation, clashing and poor range of motion. Conventional laparoscopes have a large extracorporeal profile, with a light cable exiting at 90°. This configuration leads to the clashing of the instruments with the camera during LESS. In our series, we used a 10-mm 30° extra-long laparoscope, in which the light cable is placed 45° to the lens. The additional length removes the camera head and light cord from the operative field, which can prevent clashing of the camera with the instruments and reduce interference between the surgeon and the camera holder. In addition, a 10-mm 30° laparoscope is essential because it allows for variable perspective with little shift in the location, which can reduce its interaction with the instruments. Although clashing of instruments can be overcome using flexible (articulating) instruments, these instruments are difficult to use [16, 18]. We also used flexible instruments during our initial retroperitoneal LESS approaches. We found that these instruments were suitable for transperitoneal access; in the retroperitoneal approach, the working space was smaller, and the distance from the port site to the retroperitoneal organ was shorter, so flexible instruments did not fit in the retroperitoneal space. Pre-bent instruments have been developed for the purpose of providing triangulation, minimizing instrument clashing and providing better force application at the instrument tip during dissection [19]. Stolzenburg et al. [18] compared the efficacy of pre-bent instruments with flexible instruments in vitro and in vivo with respect to time requirements, maneuverability and ease of handling. Pre-bent instruments proved to be less time consuming to use and provided better maneuverability. Therefore, we replaced flexible instruments with pre-bent instruments. During the LESS procedure, we used a conventional laparoscopic instrument in the dominant hand for the major handling and a pre-bent instrument in the nondominant hand to fix the tissue. We did not need to cross our hands with the right-hand instrument used on the left-hand side or vice versa. We found that this setting eased handling difficulties and limited the clashing of instruments. Additionally, pre-bent instruments were lonWu/Xu/Yu/Liu/Chen/Wang/Chen
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mally by the 2nd day. The mean follow-up was 9.5 months (range 7–12). Satisfactory drainage with decreased kidney dilation was documented in all patients by ultrasonography or IVU during the postoperative follow-up. The length of the LESS scar in each case was approximately 2.5 cm.
References
Laparoendoscopic Single-Site Ureterolithotomy
modalities for upper ureteral stones. However, the efficacy of shock wave lithotripsy decreases significantly with impacted stones larger than 10 mm. Positive results and few complications have been reported with flexible ureteroscopy using a holmium laser, but the procedure is expensive and unavailable to many centers. Compared with percutaneous antegrade ureteroscopy, laparoscopic ureterolithotomy has had a higher success rate in patients with large stones. Basiri et al. [20] compared 3 surgical options for the management of urinary stones in the upper ureter: retrograde ureteroscopic lithotripsy, percutaneous nephrolithotripsy and laparoscopic ureterolithotomy; the authors reported stone-free rates of 56, 64 and 88% at discharge and 76, 86 and 90% after 3 weeks for the 3 procedures, respectively. In our series, all of the patients were discharged stone free, and had no stone recurrence throughout the follow-up period. Furthermore, all of the procedures were free of complications. These data indicate the efficacy and safety of retroperitoneal LESS ureterolithotomy. Our study has several limitations, one of which is the lack of a comparison group; thus, a prospective randomized study is needed. In addition, scar satisfaction was not evaluated with a validated questionnaire, body mass index did not exceed 28 kg/m2, and the number of patients was relatively small.
Conclusion
In our experience, retroperitoneal LESS ureterolithotomy using a reusable elastic single-port device is technically feasible and safe, representing a reproducible alternative to conventional retroperitoneoscopy for select patients. In addition, the combination of conventional and pre-bent laparoscopic instruments might represent an attractive option for retroperitoneal LESS.
1 Preminger GM, Tiselius HG, Assimos DG, Alken P, Buck AC, Gallucci M, Knoll T, Lingeman JE, Nakada SY, Pearle MS, Sarica K, Turk C, Wolf JS Jr: Guideline for the management of ureteral calculi. Eur Urol 2007; 52: 1610–1631. 2 Hruza M, Schulze M, Teber D, Gozen AS, Rassweiler JJ: Laparoscopic techniques for removal of renal and ureteral calculi. J Endourol 2009;23:1713–1718.
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3 Bove P, Micali S, Miano R, Mirabile G, De Stafani S, Botteri E, Giampaolo B, Vespasiani G: Laparoscopic ureterolithotomy: a comparison between the transperitoneal and the retroperitoneal approach during the learning curve. J Endourol 2009;23:953–957. 4 Huri E, Basok EK, Ugurlu O, Gurbuz C, Akgul T, Ozgok Y, Bedir S: Experiences in laparoscopic removal of upper ureteral stones: multicenter analysis of cases, based on the TurkUroLap Group. J Endourol 2010; 24: 1279–1282.
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ger than conventional instruments, which provided more space for the movement of the instruments outside of the port. We believe that these features might render the combination of conventional and pre-bent instruments an appealing option for retroperitoneal LESS. The main obstacle in retroperitoneal LESS cases is knot-tying. When making a knot, we replaced the needle holder with a curved grasper in the dominant hand, which offset the shafts adequately to accomplish a satisfactory degree of triangulation because the curved grasper had a longer and more curved tip. Additionally, the nondominant grasper was used to grip the tip of the needle to maintain the half circle of the curved needle. The dominant grasper was rotated clockwise around to the butt of the needle, which allowed multiple loops to be made for knotting with a minimal excursion range. In our series, the mean operative time was 108 min, which was shorter than the 110.4–176.7 min reported for LESS ureterolithotomy [9, 10, 13, 14]. The reduction in the mean operative time could be attributed to the aforementioned techniques and tricks, proper patient selection or surgical experience. The mean hospital stay was 4.4 days in the present series, longer than the 2.5–3.8 days previously reported [9, 10, 14]. This long stay might be explained by the availability of national health insurance in our country and by the preference of some patients to remain in the hospital until their skin sutures were removed. The costs of disposable single-port devices and flexible instruments have significantly limited the availability of LESS technology. Our LESS platform may be cost-effective because we used a reusable single-port device and prebent instruments. With the currently described LESS technique, further expenses for the flexible laparoscope and flexible instruments were rarely necessary. Currently, shock wave lithotripsy, retrograde ureteroscopy, percutaneous antegrade ureteroscopy and laparoscopic ureterolithotomy are accepted as treatment
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17 Kaouk JH, Autorino R, Kim FJ, Han DH, Lee SW, Yinghao S, Cadeddu JA, Derweesh IH, Richstone L, Cindolo L, Branco A, Greco F, Allaf M, Sotelo R, Liatsikos E, Stolzenburg JU, Rane A, White WM, Han WK, Haber GP, White MA, Molina WR, Jeong BC, Lee JY, Linhui W, Best S, Stroup SP, Rais-Bahrami S, Schips L, Fornara P, Pierorazio P, Giedelman C, Lee JW, Stein RJ, Rha KH: Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1,076 cases. Eur Urol 2011;60:998–1005. 18 Stolzenburg JU, Kallidonis P, Oh MA, Ghulam N, Do M, Haefner T, Dietel A, Till H, Sakellaropoulos G, Liatsikos EN: Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting. J Endourol 2010; 24:239–245. 19 Raman JD, Cadeddu JA, Rao P, Rane A: Single-incision laparoscopic surgery: initial urological experience and comparison with natural-orifice transluminal endoscopic surgery. BJU Int 2008;101:1493–1496. 20 Basiri A, Simforoosh N, Ziaee A, Shayaninasab H, Moghaddam SM, Zare S: Retrograde, antegrade, and laparoscopic approaches for the management of large, proximal ureteral stones: a randomized clinical trial. J Endourol 2008;22:2677–2680.
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