1. Open ureterolithotomy is indicated for stones with a low likelihood of success with less invasive techniques or in areas without access to ureteroscopy or lithotripsy. 2. The procedure involves making an extraperitoneal or transperitoneal incision to access the ureter, dissecting and opening the ureter longitudinally over the stone, removing the stone, and closing the ureterotomy with sutures. 3. Postoperatively, patients are monitored for vital signs and urine output, given antibiotics and analgesics, and the drain is removed if output is low after 24 hours.

1. OPEN
URETEROLITHOTOMY
Eko Indra P

2. Indication
• Stones with a low likelihood of treatment success using
ESWL & URS
• Secondary treatment for treatment failure after less
invasive techniques
• Developing countries without access to URS or lithotripsy
equipment

3. Open Ureterolithotomy
• Depends on the location of the stone.
• For all locations, an extraperitoneal approach can be
performed.
• If undergoing a concomitant intraperitoneal surgery for
another indication, a transperitoneal approach can be
used

4. APPROACH
o Proximal ureter (crossing the illac vessels)
• Supracostal, subcostal provide optimal exposure.
• Midline extraperitoneal or intraperitoneal
o Distal ureter
• Extraperitoneal via a low midline
• Pfannenstiel incision
• Gibson incision

5. • Place the patient in the classical flank position, with the
dependent 12th rib directly over the kidney lift
• Fix the patient in position with broad tape extending from the
table top anteriorly, over the hip, and to the table top
posteriorly, placed after the table has been flexed

6. Start the incision at the lateral border
of the sacrospinalis muscle, 1 cm
below the lower edge of the 12th rib.
Follow the lower border of the rib
anteriorly, curving the incision
caudally as it crosses the anterior
abdominal wall to avoid the subcostal
nerve

7. Incise and digitally split the transversus
abdominis to expose the retroperitoneal
fat and peritoneum, which can be bluntly
dissected and pushed anteriorly.
Incise the external and internal oblique
muscles starting at their posterior free
border, and incise the serratus posterior
inferior muscle

8. Identify the firm white lumbodorsal fascia,
and incise it in the middle of the incision.
This allows insertion of two fingers to push
the peritoneum forward before completing
the incision through the muscle and thus
avoids cutting into it.
The fingers also aid hemostasis. Sharply cut
the fascia to its junction with the anterior
musculature.

9. Insert a self-retaining retractor, and
proceed with entry into Gerota’s
Fascia

10. • The stone can be located by:
o Visualizing a bulge within the ureter
o Gentle palpation
• Carefully dissection of the ureter to :
o Preserve as much periureteral tissue as possible
o Minimize stone migration
o Ureteral devascularization.

11. • The ureter is opened
longitudinally over the stone with
a scalpel and extended with Potts
scissors if needed
• a vessel loop should be placed
around the ureter both proximally
and distally to the stone
• After the stone is identified

12. • A stent can be placed at the
discretion of the surgeon but is
recommended to control any
potential urinary leaks that could
result in stricture.
• After removal of the stone, a 5-Fr
feeding tube is placed proximally
and distally to interrogate the ureter
for remaining stone fragments.
• The stone is then loosened from the
ureteral wall and removed intact.

13. The Foley catheter can be removed on postoperative day 1,
and the drain can be removed 24 hours later if output is low.
A Foley catheter is left in place.
The drain should be placed near the ureterotomy
but not in direct contact.
The ureter can be wrapped with periureteral fat,
and a drain is placed.
The ureterotomy is closed longitudinally with
interrupted absorbable sutures

14. Thank You

17. Uraian Pembedahan :
• Pasien posisi lumbotomi kanan dalam anastesi umum.
• Dilakukan insisi subcostal XII (dextra/sinistra) menembus kutis, subkutis, fascia dan otot
MOE, MOI, MTA.
• Peritoneum disisihkan kearah anteromedial. Dilakukan identifikasi ureter proximal kanan.
Batu ureter teraba
• Ureter dibebaskan dari jaringan sekitar & periureter sheath. Ureter proximal dari batu
difiksasi nelaton.
• Insisi ureter secara longitudinal dari proksimal batu sampai diatas batu, batu dibebaskan
dan diekstraksi dengan stone forceps. Spooling ke ureter distal - lancar
• Jahit ureter dengan Vicryl 4.0 simpel interupted. Perdarahan dikontrol
• Luka operasi ditutup lapis demi lapis dengan meninggalkan drain retroperitoneal NGT 18fr
• Posisi pasien litotomi, a&antisepsis
• Dilakukan cystoscopy evaluasi lensa 30o, mukosa buli normal, trabekulasi (-), massa (-),
batu (-), muara ureter kiri dan kanan normal, verumontanum normal, prostat normal, bladder
neck tidak tinggi.
• Pasang Foley Catheter 18fr
• Operasi selesai
•

18. Post Op :
• Vital Sign, localized state, UOP & drain
• Diet
• Antibiotik
• Analgetik
• Inj Ranitidin
• Cek DPL post op