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Ureterolithotomy for Juxtavesicular Stone
0022-5347/83/1295-0944$02.00/0 Vol. 129, May
THE JOURNAL OF UROLOGY
Copyright © 1983 by The Williams & Wilkins Co.
Printed in U.S.A.
URETEROLITHOTOMY FOR JUXTAVESICULAR STONE DAVID H. BARNHOUSE, MATTHEW MARSHALL, JR. AND STUART E. PRICE, JR. From West Penn and St. Margaret's Hospitals, Pittsburgh, Pennsylvania
ABSTRACT
Stones within the distal 8 cm. of the ureter often can be approached more readily through the posterior wall of the bladder than extravesically. The method and its indications are described. ient tissue anteriorly to increase the exposure with a minimum encumbrance of the field (fig. 1, A). We place 2 or 3 pairs of traction sutures deeply into the posterior bladder wall along the course of the ureter. Each pair member is at least 2 cm. from its partner. These sutures demarcate the incision and allow handling of the posterior wall without excessive trauma. The catheter is placed to demonstrate the orifice (fig. 1, B). The ureter is exposed by incising the posterior bladder wall between the marking sutures down into Waldeyer's space (fig. 2, A). Residents learning this technique have most of their difficulty here. Hunting for W aldeyer's space may be as difficult or as easy as in the Politano-Leadbetter ureteral reimplantation
Stones in the distal 8 cm. of ureter that have evaded basket extraction may be difficult to remove. They may be impacted where the ureter courses most posteriorly and the confines of the male pelvis may be frustrating. These distal 8 cm. are not only behind the bladder but are also behind the lateral vascular pedicle. Division of the superior vesical artery may be necessary for extravesical exposure and bleeding from these veins may be troublesome. These difficulties are accentuated in a secondary procedure. The transvesical approach described is certainly not original but we do not know whom to credit for its initial use. In the last 20 years there have been only 4 references to this method and 2 of these were not in English. 1-4 In the standard textbooks
FIG.I
there is only 1 brief mention of the method. 5 We have approached stones in the distal 8 cm. of the ureter transvesically for many years. There have been no complications uniquely attributable to this approach, and we have used it for primary and secondary procedures. Stones at 7 or 8 cm. may be reached either way but we prefer this method especially in a patient with a deep narrow pelvis. The suprapubic skin incision is transverse through the fascia, splitting the rectus muscle and exposing the bladder extraperitoneally. Exposure is improved by putting tension on Penrose drains through a lower midline stab wound. The bladder is incised distally in the midline and hemostasis is completed carefully. We place 1 or 2 sponges behind the bladder blade of a self-retaining retractor to flatten out the posterior bladder wall. The edges of the bladder incision are stitched to convenAccepted for publication October 15, 1982.
procedure. One problem with not fmding it is that handling the muscle excessively makes the field bloodier and decreases the visibility of the ureter. Once the space is found we free the ureter circumferentially and slip a plastic loop around it, which supports the ureter, and gives traction and visibility for later dissection. W aldeyer's space is cleared proximally and circumferentially, freeing up the ureter and using appropriate coagulation or clips for hemostasis. More and more of the ureter comes up into the field as the dissection progresses (fig. 2, B). Waldeyer's space is preserved largely even after a previous operation or despite periureteral inflammation from the stone. Usual efforts to prevent proximal migration of the stone may be used. The stone is removed through an appropriate ureterotomy. The stone in figure 2, C was about 6 cm. proximal to the orifice. We close the ureterotomy with 5-zero polyglycolic acid sutures. After the supporting loop is removed the ureter resumes its
944
URETEROLITHOTOMY FOR JUXTAVESICULAR STONE
945
Fm.2
Fm.3
normal position. The site of the stone removal is no longer visible since it has disappeared under the edge of the vesicotomy (fig. 3, A). The bladder muscle is closed with 3-zero and the mucosa is closed with 4-zero or 5-zero polyglycolic acid sutures. The original ureteral attachments to the trigonal muscle are not disturbed, which is the reason closing the muscle in front of the ureter has not been a problem (fig. 3, B). Reflux has not developed postoperatively in any patient. Since no other planes have been opened any urine leakage from the ureterotomy should track into the bladder. There have been no instances of stricture or ureteral compression seen on postoperative excretory urograms. We rarely use a ureteral catheter and we remove the Foley catheter in 3 to 5 days. Transvesical ureterolithotomy for distal ureteral stones is
certainly not foolproof but it may prove to be a welcome addition to the surgical armamentarium. REFERENCES
1. Ascoli, R.: L'ureterotomie transvesicale extra-meatique dans la
lithiase ureterale pre-murale. J. Urol. Nephrol., 69: 705, 1963. 2. Guzman, J. M., Solari, J. J. and Casal, J.: Ureter terminal: su abordiaje transtransvesical. Prensa Med. Argent., 55: 1564, 1968. 3. Maynard, J. F. and Landsteiner, E. K.: Pull-through ureterolithotomy. J. Urol., 107: 365, 1972. 4. Barnhouse, D. H., Johnson, S. H., III, Marshall, M., Jr. and Price, S. E., Jr.: Transvesical ureterolithotomy. J. Urol., 109: 585, 1973. 5. Boyarsky, S.: Surgery of the ureter. In: Urologic Surgery. Edited by J. F. Glenn and W. H. Boyce. New York: Harper & Row, Publishers, p. 140, 1969.
THE JOURNAL OF UROLOGY
Copyright © 1983 by The Williams & Wilkins Co.
Printed in U.S.A.
URETEROLITHOTOMY FOR JUXTAVESICULAR STONE DAVID H. BARNHOUSE, MATTHEW MARSHALL, JR. AND STUART E. PRICE, JR. From West Penn and St. Margaret's Hospitals, Pittsburgh, Pennsylvania
ABSTRACT
Stones within the distal 8 cm. of the ureter often can be approached more readily through the posterior wall of the bladder than extravesically. The method and its indications are described. ient tissue anteriorly to increase the exposure with a minimum encumbrance of the field (fig. 1, A). We place 2 or 3 pairs of traction sutures deeply into the posterior bladder wall along the course of the ureter. Each pair member is at least 2 cm. from its partner. These sutures demarcate the incision and allow handling of the posterior wall without excessive trauma. The catheter is placed to demonstrate the orifice (fig. 1, B). The ureter is exposed by incising the posterior bladder wall between the marking sutures down into Waldeyer's space (fig. 2, A). Residents learning this technique have most of their difficulty here. Hunting for W aldeyer's space may be as difficult or as easy as in the Politano-Leadbetter ureteral reimplantation
Stones in the distal 8 cm. of ureter that have evaded basket extraction may be difficult to remove. They may be impacted where the ureter courses most posteriorly and the confines of the male pelvis may be frustrating. These distal 8 cm. are not only behind the bladder but are also behind the lateral vascular pedicle. Division of the superior vesical artery may be necessary for extravesical exposure and bleeding from these veins may be troublesome. These difficulties are accentuated in a secondary procedure. The transvesical approach described is certainly not original but we do not know whom to credit for its initial use. In the last 20 years there have been only 4 references to this method and 2 of these were not in English. 1-4 In the standard textbooks
FIG.I
there is only 1 brief mention of the method. 5 We have approached stones in the distal 8 cm. of the ureter transvesically for many years. There have been no complications uniquely attributable to this approach, and we have used it for primary and secondary procedures. Stones at 7 or 8 cm. may be reached either way but we prefer this method especially in a patient with a deep narrow pelvis. The suprapubic skin incision is transverse through the fascia, splitting the rectus muscle and exposing the bladder extraperitoneally. Exposure is improved by putting tension on Penrose drains through a lower midline stab wound. The bladder is incised distally in the midline and hemostasis is completed carefully. We place 1 or 2 sponges behind the bladder blade of a self-retaining retractor to flatten out the posterior bladder wall. The edges of the bladder incision are stitched to convenAccepted for publication October 15, 1982.
procedure. One problem with not fmding it is that handling the muscle excessively makes the field bloodier and decreases the visibility of the ureter. Once the space is found we free the ureter circumferentially and slip a plastic loop around it, which supports the ureter, and gives traction and visibility for later dissection. W aldeyer's space is cleared proximally and circumferentially, freeing up the ureter and using appropriate coagulation or clips for hemostasis. More and more of the ureter comes up into the field as the dissection progresses (fig. 2, B). Waldeyer's space is preserved largely even after a previous operation or despite periureteral inflammation from the stone. Usual efforts to prevent proximal migration of the stone may be used. The stone is removed through an appropriate ureterotomy. The stone in figure 2, C was about 6 cm. proximal to the orifice. We close the ureterotomy with 5-zero polyglycolic acid sutures. After the supporting loop is removed the ureter resumes its
944
URETEROLITHOTOMY FOR JUXTAVESICULAR STONE
945
Fm.2
Fm.3
normal position. The site of the stone removal is no longer visible since it has disappeared under the edge of the vesicotomy (fig. 3, A). The bladder muscle is closed with 3-zero and the mucosa is closed with 4-zero or 5-zero polyglycolic acid sutures. The original ureteral attachments to the trigonal muscle are not disturbed, which is the reason closing the muscle in front of the ureter has not been a problem (fig. 3, B). Reflux has not developed postoperatively in any patient. Since no other planes have been opened any urine leakage from the ureterotomy should track into the bladder. There have been no instances of stricture or ureteral compression seen on postoperative excretory urograms. We rarely use a ureteral catheter and we remove the Foley catheter in 3 to 5 days. Transvesical ureterolithotomy for distal ureteral stones is
certainly not foolproof but it may prove to be a welcome addition to the surgical armamentarium. REFERENCES
1. Ascoli, R.: L'ureterotomie transvesicale extra-meatique dans la
lithiase ureterale pre-murale. J. Urol. Nephrol., 69: 705, 1963. 2. Guzman, J. M., Solari, J. J. and Casal, J.: Ureter terminal: su abordiaje transtransvesical. Prensa Med. Argent., 55: 1564, 1968. 3. Maynard, J. F. and Landsteiner, E. K.: Pull-through ureterolithotomy. J. Urol., 107: 365, 1972. 4. Barnhouse, D. H., Johnson, S. H., III, Marshall, M., Jr. and Price, S. E., Jr.: Transvesical ureterolithotomy. J. Urol., 109: 585, 1973. 5. Boyarsky, S.: Surgery of the ureter. In: Urologic Surgery. Edited by J. F. Glenn and W. H. Boyce. New York: Harper & Row, Publishers, p. 140, 1969.