Indications
1.Ureteral stones larger than 1cm in diameter, or irregular surface with polygonal shape.
2.Ureteral stenosis, or fixed stone position (due to multiple infection episodes causing heavy adhesions due to local inflammation).
3.Ureteral calculus combined with infection after treatment is ineffective, or combined with hydronephrosis, which seriously threatens kidney function.
4.Bilateral ureteral stone obstruction causing urinary closure
Preparation before surgery
On the day of surgery, abdominal plain film should be taken before surgery to determine the location of the stone and whether the stone has been expelled from the body.
Anesthesia method
Epidural or lumbar anesthesia.
Selection of surgical position
The position for upper ureteral stone extraction is the same as that for nephrectomy, while the position for middle and lower ureteral stone extraction is supine, with the patient’s side slightly elevated.
Ureteral exposure
Exposure of the upper ureter.
(1) Incision: from the tip of the 12th rib or slightly below, down to the upper anterior superior iliac spine.
(2) Incision of the musculature: the external oblique abdominal muscle, the internal oblique abdominal muscle and the transversus abdominis muscle are incised. When cutting the transversus abdominis muscle, care is taken to avoid injury to the subcostal nerve, blood vessels, inferior iliac abdominal nerve, and iliac inguinal nerve.
(3) Revealing the upper ureter (Figure 1): after entering the retroperitoneal space, the ureter is visible before the retroperitoneal lumbaris major muscle, and the internal spermatic cord artery and vein (or ovarian artery and vein) crosses the ureter, which should be protected to avoid injury.
Figure 2: Exposure of the middle ureter (schematic diagram)
Exposure of the middle ureter.
(1) Incision: two transverse fingers above the midpoint of the iliac crest superiorly, following the external oblique muscle stripe to the semilunar line of the external edge of the rectus abdominis muscle.
(2) Incision of the musculature: the external oblique abdominal muscle, internal oblique abdominal muscle and transverse abdominal muscle are incised to access the retroperitoneal space.
(3) Revealing the middle ureter (Figure 2): the peritoneum and abdominal contents are pulled inward; here the ureter is often mucosal with the peritoneum and easily pulled away with the peritoneum and not easily found. The intra-seminiferous (or intra-ovarian) vessels cross the iliac arteries and veins on the outer lower side of this segment of the ureter.
Figure 3: Revealing the arteries and veins under the abdominal wall (schematic diagram)
Exposure of the lower ureter.
(1) Incision: Starting about 2 cm medial to the anterior superior iliac spine superiorly, an arcuate incision is made downward toward the abdominal midline to 1 cm above the pubic symphysis.
(2) Incision of the muscle layer: the external oblique abdominal muscle was incised along the muscle stripe, the internal oblique abdominal muscle and transverse abdominal muscle were cut, and then the joint tendon was cut transversely, and the anterior sheath of the rectus abdominis muscle could be incised if necessary. After muscle incision, the inferior abdominal wall artery and vein can be seen in the lower corner of the incision (Figure 3), and damage should be avoided. They can also be ligated and cut if necessary to facilitate the surgery.
(3) Revealing the lower ureter (Figure 4): In the lower part of the ureter, there are uterine arteries and veins in women and vas deferens and internal spermatic arteries and veins across in men, which should be protected when separating.
Figure 4:Revealing the lower ureter (schematic diagram)
Define the stone site
If you touch the ureter with your finger, you can often feel a hard bulging mass, which is where the stone is embedded. If it is not clear at the moment, X-ray should be consulted at any time, and then bluntly separate the tissues around the segment of ureter.
Dissection of the ureter and removal of the stone
Use a gauze band to pull the ureter at the upper and lower ends of the stone to prevent it from slipping away. A gauze pad is placed around the ureter to prevent contamination by pus or urine spillage during the incision of the ureter. Then, the ureter at the stone is incised longitudinally (Figure 5) and the stone is removed with a curved hemostatic forceps or forceps (Figure 6).
Figure 5:Incision of the ureter (schematic diagram)
Probing the ureter
Aspirate the overflowing urine with a suction device. Use a ureteral catheter to insert up and down through the ureteral incision, up to the renal pelvis and down to the bladder, and probe the ureter for stones, strictures or other causes of obstruction.
Suture of the ureter
The ureter is intermittently sutured with 2 to 3 stitches using a small curved needle through 3-0 intestinal suture (overview image). The sutures may be passed only through the outer layer and the muscular layer and not through the mucosa to avoid recurrence of stones. The protective gauze pad around the incision is removed, the ureteral suture is covered with the surrounding adipose tissue, and the adipose tissue is fixed with 1 to 2 stitches of intestinal suture.
If the inflammation at the ureteral stone site is heavy, another small incision needs to be made at the upper end of the ureteral incision and a 4 to 5 gauge ureteral catheter is inserted to the renal pelvis as drainage, which is led from the original incision in the abdominal wall or another small incision made.
Figure 6: Stone removal (schematic)
Suture the incision
After checking the wound for bleeding and foreign body retention, cigarette drainage is placed next to the ureteral incision. The operating table is flattened and the muscle, subcutaneous tissue and skin are sutured layer by layer.
Precautions during surgery
1. Avoid squeezing hard when probing the stone location during surgery, which may cause the stone to slip away. Once it slips away, intraoperative plain films of the kidney, ureter and bladder should be taken to determine the hidden site of the stone.
2. The ureteral stone extraction site should be incised longitudinally and sutured transversely to avoid scar stenosis of the ureteral incision and hydronephrosis formation after surgery.
3. After the ureter is sutured, the corresponding drainage tube should be placed nearby to prevent local leakage, regardless of whether the support catheter is left in place or not.
Post-operative treatment
1. Pay attention to the wound bleeding and hematuria.
2. Encourage the patient to drink more water.
3.Continue to give anti-infection treatment.
4.If ureteral drainage is placed, it is usually removed 9 to 10 days after surgery. After removal, there is a small amount of urine leakage from the wound, which can mostly heal on its own after a few days, and a few can delay healing until 2 to 3 weeks later.
5.Cigarette drainage is usually removed 3 days after surgery. If there is leakage of urine and other conditions, the placement time can be extended appropriately.