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ORIGINAL ARTICLE
Year : 2022 | Volume
: 33
| Issue : 1 | Page : 9-13
Comparative study of transperitoneal laparoscopic versus retroperitoneoscopic ureterolithotomy techniques
Sunil Mhaske, Vilas Sabale, Vikram Satav, Sonu Sharma, Shashikant Asabe, Hareesh Belagalli
Department of Urology, Dr. D. Y. Patilmedical College, Pune, Maharashtra, India
Correspondence Address:
Dr. Shashikant Asabe
Department of Urology, Dr. D. Y. Patilmedical College, Pune, Maharashtra
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_83_20
Purpose: This study evaluated the effectiveness and safety of transperitoneal laparoscopic ureterolithotomy (TPLU) and retroperitoneal laparoscopic ureterolithotomy (RPLU) in the surgical management of ureterolithiasis. Materials and Methods: The current prospective study was conducted at the Department of Urology, Dr. D. Y. Patil Medical College. The complete patient medical history including patient's age, sex, stone (size, number, and laterality), and past history of stone surgeries were evaluated. Based on the treatment method, the patients were divided into TPLU and RPLU group. Both the procedures were evaluated for parameters including operative technique, operating time, hospital stay, intra- and postoperative complications, conversion rate, success rate, and surgical ergonomics. Results: A total of 50 patients were included (TPLU, n = 25; and RPLU, n = 25). The average age was 43.6 years in the TPLU and 46.7 years in the RPLU group. The average size of calculi was >15 mm in both the groups. The operation time and blood loss were relatively higher in the TPLU group than RPLU group. The complete stone clearance was observed in both the groups. The pain in loin area and burning micturition were the most common complaints reported by the patients from both the groups. One patient from RPLU group was converted to open surgery. The calculi size in TPLU group was positively correlated with operative time (r = 0.535, P = 0.006), blood loss (r = 0.440, P = 0.028), and hospital stay (r = 0.430, P = 0.032). Conclusion: TPLU and RPLU are feasible techniques for the management of large ureteric stones that are not amenable to ureteroscopy or extracorporeal shockwave therapy.
Keywords: Large ureteric stones, open surgery, operating time, success rate
Stone formation is one of the most frequent disorders of the urinary system. Nephrolithiasis rates are increasing rapidly in India and worldwide, with a prevalence rate of 12% in Indians. An estimated 12% of the population is expected to have urinary stones, of which 50% may result in kidney loss or renal damage.[1],[2] Ignorance of these risks may lead to progression to chronic kidney diseases and loss of kidney function.[3]
Various treatment methods for ureterolithiasis have evolved over the past few decades and continue to advance, reducing morbidity and improving recovery. The open surgery trend has declined with the adoption of minimally invasive procedures. Several factors, including stone characteristics, clinical, anatomical, and technical aspects, are considered to select the most appropriate treatment approach. Common approaches to ureterolithiasis include conservative and medical expulsive and active therapies such as extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy techniques, and intracorporeal lithotripsy, ureteroscopy (URS), or retrograde intrarenal surgery.[4],[5]
ESWL and URS with lithotripsy are first-line interventions for patients with ureterolithiasis requiring surgical management.[5] URS is the treatment of choice for lower and midureteric stones with a success rate of 75%, 94.6%, and 86.4% for upper, middle, and lower ureteric stones, respectively. Laparoscopic ureterolithotomy (LU) is more effective than open surgery in terms of the need for analgesia, convalescence, and hospital stay, with good cosmesis.[6] Thus, retroperitoneal LU (RPLU) and transperitoneal LU (TPLU) are the best substitutes for open surgery for difficult, large, and impacted stones.
Studies comparing laparoscopy, ESWL, and semirigid URS procedures show the highest success rates for laparoscopy without supplementary procedures, making it cost effective.[7] An extensive literature search revealed limited studies comparing the safety and efficacy of TPLU and RPLU in ureterolithiasis management. This study compared TPLU and RPLU in terms of efficacy, complications, surgical ergonomics, advantages, and disadvantages. We also evaluated stone characteristics, hospital stay, conversion rate, and success rates.
MethodsThis prospective study was conducted at the Department of Urology, Dr. D. Y. Patil Medical College, Pune, from August 2017 to January 2020. Patients with ureteric calculus were evaluated as per the pro forma containing complete patient medical history, including patient's age, sex, stone (size, number, and laterality), and history of stone surgeries. All ureteric calculus patients were included in this study, whereas patients unfit for surgery were excluded.
Institutional Ethical Committee approval was obtained before study commencement and conducted in accordance with the Declaration of Helsinki. All patients were given a patient information sheet that provided a complete description of the study before their enrollment. All participants provided written informed consent after the research team explained the merits and demerits of all techniques.
Patient preparation
The patient was placed in a supine position for general anesthesia and endotracheal intubation, then positioned in the lithotomy position for cystoscopy, and an open tip ureteric catheter was implanted using fluoroscopy. The umbilicus was placed on the table bridge, and the patient was turned to a modified lateral decubitus position with padding of the axilla and buttocks. The same surgical team conducted both procedures.
Based on the treatment method, the patients were divided into the following groups:
Transperitoneal laparoscopic ureterolithotomy
Pneumoperitoneum was created by inserting a Veress needle inserted at the subumbilical crease. The needle was removed, a 10-mm camera port (port I) was inserted, and the peritoneal cavity was inspected for trauma and adhesion. Working 12-mm (Port II) and 5-mm (Port III) ports were inserted under telescope vision a handbreadth superior and inferior to the camera port. The working 5-mm port was occasionally used for liver retraction in right-sided cases. The stones were located and extracted through a visceral ureterotomy. The stone was extracted using a sac through the 10-mm port, and then a small drain was inserted through the other 5-mm port. A 6F DJ stent was inserted, and the ureterotomy was closed with 4/0 vicryl sutures. For lower ureteric calculi, we preferred to stent endoscopically before or after LU.
Retroperitoneal laparoscopic ureterolithotomy
A 10-mm transverse incision is made at the tip of the 12th rib. Blunt dissection was performed to create a retroperitoneal working space. A 10-mm trocar was inserted, and carbon dioxide insufflation was performed. The second and third trocars were inserted at the midclavicular and posterior axillary lines under laparoscopic control. Opening of Gerota's fascia facilitated the identification of the ureter and tracing to the level of the stone. Ureterotomy was made using a knife and endoshears, followed by stone extraction through one of the ports.
Postoperative care
Nasogastric tube and intravenous fluid were given until the recovery of bowel sounds. An intravenous broad-spectrum antibiotic and pain killer were administered. Once the drain output reached <30 mL in 24 h, the drainage tube was removed, and the patients were discharged. The DJ stent was removed 4 weeks postoperation.
Outcomes
Both procedures were evaluated for operative technique, vascular injury, stone clearance, operating time, hospital stay, intra- and postoperative complications, conversion rate, success rate, and surgical ergonomics.
Statistical analysis
Statistical analysis was performed using SPSS version 23.0. (Armonk, NY, USA, IBM Corp.) Descriptive statistics in terms of frequency (%) for qualitative variables and range (minimum, maximum), mean, and standard deviation for quantitative variables were calculated. A P < 0.05 was considered statistically significant.
Ethical
Application for ethics committee approval was submitted on 07/02/2018 with ref number: IESC/C-3/18 from r. D. Y. Patil Medical College Hospital's institutional ethics subcommittee. Institution name: Dr. D. Y. Patil Medical College Hospital and Research Center, Pimpari, Pune: 411018.
Approval number: IESC/PGS/03/18.
Approval date: 31/01/2018.
ResultsDemographics
The demographic characteristics of both groups are shown in [Table 1]. There were fifty patients in the study, 25 in each group. The average age was 43.6 years in the TPLU group and 46.7 years in the RPLU group. The number of males was higher in each group (80.0% vs. 20.0%). The mean calculus size was comparable between groups (P = 0.302). The average calculus was 20.5 mm in the TPLU group and 19.8 mm in the RPLU group.
Preoperative characteristics
Pain in the loin area and burning micturition were the most common complaints reported by the patients in both groups. There was no significant difference in complication rates (P = 0.552). The overall duration of complaints was similar for each type of complaint. The median (range) duration of pain observed in the right loin area was higher in the RPLU group (150.0 [5.0–729.0] days) (P = 0.552). One patient (4.0%) from the TPLU group experienced one episode of lithuria. One patient from the RPLU group was converted to open surgery [Table 2].
Intra- and postoperative characteristics
The operation time was significantly longer in the TPLU group than in the RPLU group (65.4 vs. 55.8 min, [P = 0.006]). Mean blood loss was significantly higher in patients from the TPLU group than in patients from the RPLU group (P = 0.047). The average blood loss was 61.0 mL in the TPLU group and 56.4 mL in the RPLU group. Complete clearance was observed in both groups. The mean hospital stay was slightly lower in the RPLU group (4.0 days vs. 4.4 days).
The incidence of pre- and postoperative fever is shown in [Figure 1]. Postoperative fever incidence was slightly higher with TPLU than RPLU, but there was no statistically significant difference between groups in pre- and postoperative fever symptoms. The calculus size in the TPLU group was positively correlated with operative time (r = 0.535, P = 0.006), blood loss (r = 0.440, P = 0.028), and hospital stay (r = 0.430, P = 0.032). Blood loss in the TPLU group was positively correlated with oral analgesic intake time (r = 0.598, P = 0.001) and hospital stay (r = 0.424, P = 0.027) [Table 3].
Figure 1: Comparison of incidence of pre- and post-operative fever. RPLU: Retroperitoneoscopic ureterolithotomy, TPLU: Transperitoneal laparoscopic ureterolithotomy Discussion This study compared the feasibility and safety of TPLU versus RPLU in the management of ureterolithiasis. Demographics and stone characteristics were homogenous, and there was no statistically significant difference in age, sex, calculus size, and hospital stay. RPLU had a lower overall complication rate and shorter operating time than TPLU, and complete clearance was observed in both groups. This study showed a shorter convalescence period, less oral and intravenous analgesic requirements, and early mobilization. The choice of laparoscopic access in TPLU or RPLU depends on the surgeon's experience and familiarity with the procedures. Overall, both approaches were safe and efficient.
Previous studies have reported a higher prevalence of male patients over female patients,[8],[9] and this study was consistent with these findings.
ESWL has been identified as a better intervention for upper ureteral stones with a stone size <10 mm; however, its efficacy declines when the stone size is >12 mm, reducing the stone-free rate. URS has been proposed as an effective treatment modality for the treatment of larger stones (≥15 mm) than ESWL, with higher stone clearance (>86%).[10] Kumar et al. prospectively compared the efficacy of URS and ESWL for larger proximal ureteral stones (>2 cm). The URS had a higher stone-free rate, comparable operating time, reduced conversion rate, and lower complication rate than ESWL.[11] Consistent with previous studies, the current study demonstrated that LU by TPLU or RPLU provides a high stone-free rate and a low conversion rate.
Previous studies have indicated that most surgeons prefer TPLU over RPLU due to larger working space, greater visibility, and a lower risk of becoming disoriented and causing unintentional injury. However, the RPLU technique provides direct access to the calculus, limiting the need for visceral mobilization and patient repositioning.[12],[13],[14] In addition, visceral intra-abdominal organ dissection in the transperitoneal approach can cause postoperative adhesion and major blood loss.[15],[16] Maurice et al. suggested that the TPLU approach is superior in terms of operative time, hospital stay, intra- and postoperative complications, and the earliest resumption of normal activity versus RPLU.[17] A recently published comparative study provided some evidence that there was no significant difference in operative time, hospital stay, changes in hemoglobin level, and complication rates.[18] A meta-analysis revealed that RPLU could achieve better perioperative outcomes than the TPLU approach. RPLU produced better outcomes related to operation time, postoperative length of hospital stay, and blood loss than TPLU.[19] In this study, operating time and estimated blood loss were lower in the RPLU group than in the TPLU group. The approach selected depends on personal preference.
A previous meta-analysis suggested that the stone-free rate of LU is 100%, and the rate of conversion to open surgery was low.[20] Abat et al. conducted a retrospective study that included fifty patients who underwent either TPLU or RPLU. Stone migration was managed using a flexible cystoscope. The results indicated successful surgery without indications for open surgery.[21] This outcome is consistent with the results of this study. Surgeons with less LU experience performed the dissections more carefully and slowly and may cause postoperative complications that convert laparoscopic techniques to open surgery. It has alluded that the high conversion rate reported in the literature reflects the need for a trained surgeon to reduce postoperative complications.
Postoperative intravenous or oral analgesia is commonly used after LU to treat pain.[22] A prior study suggested a longer duration of epidural analgesia intake in RPLU than in TPLU (179.07 vs. 189.0 min).[23] However, in this study, the average time required for oral and intravenous analgesic intake was longer in the TPLU group than in the RPLU group. A recently published study reported ureteral strictures in two patients from the TPLU group.[24] The current study found no ureteric stricture complication in either group.
The main limitations of this study were the nonrandomized design and small sample size.
ConclusionTPLU and RPLU are feasible techniques for managing large ureteric stones unamenable to URS or ESWL. The RPLU method was associated with less blood loss and time to oral intake, intravenous analgesic use, and hospital stay than TPLU. However, TPLU is superior to RPLU for lower ureteric calculus with better ergonomics. We conclude that LU by TPLU or RPLU is the procedure of choice for stones >15 mm in size.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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