Robotic Ureterolithotomy with Flexible Pyeloscopy for Stone Clearance

Introduction: We report a case of a 58 year-old female who presented with urosepsis secondary to a left 2 cm impacted proximal ureteral stone. She also had a 1 cm lower pole renal stone. In the operating room, stent placement was extremely difficult due to the impacted stone.

Objective: We elected to perform a robotic assisted laparoscopic ureterolithotomy with intraoperative endoscopic retrieval of renal calculi in order to achieve maximum stone clearance.

Methods: Robotic ports were placed similar to a pyeloplasty template. The proximal ureter was carefully isolated and subsequent transverse ureterotomy was performed using robotic Potts scissors. The stone was easily extracted from the ureter and placed in a laparoscopic retrieval bag and the stent replaced into the renal pelvis. A 15.5 Fr flexible cystoscope with a preloaded nitinol basket was placed through the infraumbilical 8mm robotic port and was gently passed into the renal pelvis. The additional 1 cm stone was identified, basketed and removed from the patient. The ureterotomy was closed interrupted 4.0 monocryl sutures ensuring a watertight closure with excellent mucosal opposition. We employed a Heineke-Mikulicz closure to ensure a large proximal ureteral lumen.

Results: Total operative time was 93 minutes. The Jackson-pratt drain was removed on post-operative day #1 and the patient was also discharged home that day. The ureteral stent was removed six weeks after surgery.

Conclusion: Minimally invasive approaches may be used to treat large, impacted ureteral calculi as well as renal calculi in patients where retrograde access may be difficult.

Video by:

Jayram Krishnan, DO, MBA; Gordon Brown, DO; Rajen Butani, MD
University of Medicine and Dentistry of New Jersey -- Stratford, NJ