Lumbotomy Ureterolithotomy

1. A z i s A i m a d u d d i n A I
LUMBOTOMY – PROXIMAL
URETEROLITHOTOMY

2. Definition
• Manual of urologic surgery, Jackson E. Fowler. 2012
Lumbotomy : Surgical approach to
provide direct extraperitoneal acces to
the kidney and proximal ureter
• Hinmann Atlas of Urologic Surgery. 2012
Proximal ureterolithtotomy : Open
surgery procedure performed for the
removal of proximal ureteral stones

3. Anatomy
( Campbell-Walsh Urology, 9 ed, 2010)

4. Anatomy
Anatomy of ureter, physiologic narrowing of ureter, radiographic
ureteral segmentation and ureteral blood supply ( Campbell-Walsh
Urology, 9 ed. 2010)

5. Indication
• Nephrolithotomy
• Pyelolithotomy- extended
pyelolithotomy
• Bivalve nephrolithotomy
• Pyeloplasty
• Nephrectomy-partial
nephrectomy
• Ureterolithotomy proximal
Lumbotomy :
all procedure
to access
kidney and
proximal
ureter by
extraperitoneal
approach by
open surgery
such as
(Manual of urologic surgery, Jackson E. Fowler. 2012)

6. Indication for open surgery in
ureteral stone
Large impacted stones
Multiple ureteral stones
When other non-invasive or low-
invasive procedures have failed
(EAU guideline, 2013)

7. contraindiations
patients who are
medically unfit for an
open surgery or who
harbor an active
infection
EAU guideline, 2013

8. Preparation
Surgical cap, mask, sterile gawn,
sterile hand gloves
Sterile gauze, povidone iodin 10%Disinfection clamp, doek clamp

9. Preparation
Surgical blade no 23, 11, scalpel handle
Electronic cauter
Sharp spreader
Langenback
Ring clamp
Kocher
Suction

10. Preparation
Pean/mosquito
clamp
Spreader
ScissorsPinset Needle holder
Stone forceps Right angle
Metzenbaum
Tieman bebcock

11. Preparation
Yarn + surgical needle
Redon Drain
NGTFoley cath + urobag Nelaton catheter
DJ stent

12. Procedure
Placement the
Imaging
Read the patient
safety check list
Patient in
general
anesthesia
Insert urethral
catheter
(Hinmann Atlas of Urologic Surgery)

13. The patient is placed in
the dorsolateral position.

14. • Disinfect operation fields using
Povidone Iodine 10%
• Narrowing the operation field

15. • Incise skin starting from
ICS XI towards the
umbilicus approximately
15 cm
• Structures are incised:
skin, subcutaneous fat,
External oblique m.,
Internal oblique m.,
Transverse abdominis m.
until internal abdomen
fascia
• Open the lumbodorsal
muscle fascia slightly to
the posterior in the
posterior axillary line.

16. • Separate the
peritoneum with
steel deppers
toward the
medial
• After the
peritoneum
clearly
separated, the
incision
widened.
• Attach spreader

17. Insert a self-
retaining
retractor.
Enter Gerota's
fascia bluntly to
displace part of
the perirenal fat
posteriorly , and
expose the
ureter.

18. Procedure
(Hinmann Atlas of Urologic Surgery)
After Insert a
self-retaining
retractor. Enter
Gerota's fascia
bluntly to
displace part
of the
perirenal fat
posteriorly ,
and expose
the ureter

19. Procedure
• Find the ureter by opening
the fascia gerota , infront of
M. ileopsoas
• Use nelathon catheter
(no.8 fr) to teugel the
ureter
• Identify the ureteral stone
• Incise the ureter with blade
no.11, upon the urteral
stone.
• Remove the ureteral stone (Hinmann Atlas of Urologic Surgery)

20. Procedure
• Evaluate fluid/urine that
coming out from the
ureter
• Sondage to the distal
and proximal of ureter
• If sondage can be done
well, do spoeling, and
also DJ stent insersion if
needed
• Stitch the ureter with
polyglactin 4-0
• Wash operation field
with PZ (Hinmann Atlas of Urologic Surgery)

21. Procedure
• Evaluate bleeding
• Put redon drain in
retroperitoneal
• Close operation
field layer by layer
• Close the wound
by tulle and gauze

22. • Bleeding (2-6%), injured peritoneal
cavity and intra abdominal organ (2%);
axillary nerve palsy (1%)
During
operation
• Wound infection (10-15%);
haematuria (9-15%); urosepsis
(10%); leakage of urine-urinoma
(1-5%)
Early
postoperative
• ureteral stricture (15-20%),
fistule (5%)
Late post
operative
Complication
(Hinman’s atlas of urologic surgery)

23. Post operative care
KUB post
operatively
Remove urethral
catheter 1 or 2 day
post operatively
Remove drain if
production is
minimal
Release the
stitches 10-14 days
postoperative

24. Thank you