Laparoscopic ureterolithotomy: a simple device to retrieve stones.

We report on the use of Perc NCircle atraumatic stone forceps to retrieve stones during laparoscopic ureterolithotomy. We think that it is a safe, simple device and that it has significant advantages over other methods.

INTRODUCTION

The treatment options for ureteric calculi consist of a conservative approach, extracorporeal shockwave lithotripsy, endoscopic manipulation, and open surgery.[1] Since the initial report by Clayman et al in 1991, laparoscopic surgery has become an integral part of the urologist's armamentarium.[2] In the last few years, laparoscopy has been used to treat problematic ureteric stones as an alternative to open surgery.[3-5] A variety of methods have been described to retrieve stones after ureterotomy, including a Babcock forceps to grasp the stone and removal of ports along with forceps,[6] putting stones in a bag,[7] using large grasping forceps,[3] or Maryland forceps.[4] Herein, we report a device originally designed for stone extraction during percutaneous nephrolithotomy, used during laparoscopic ureterolithotomy, which permits the easy, safe, simple removal of stones.

METHODS

From September 2004 to July 2005, we performed 3 laparoscopic ureterolithotomies. All patients received perioperative antibiotics and were operated on while under general anesthesia. Patients were placed in a lateral position, and a retroperitoneal space was created by using a balloon (Extra view balloon, Autosuture, Tyco Healthcare, Mansfield, MA). By using sharp, blunt dissection, the ureter was exposed and the stone site was localized by gentle palpation of the ureter. Following localization, a longitudinal ureterotomy was made to retrieve the stone. In our first case, a grasper was used to hold the stone and to pull it out through the port. Unfortunately, because of the pressure from the grasper, it broke into 2 pieces, these being removed successfully. In our next 2 patients, we used an atraumatic stone extractor basket (Perc NCircle Rapid Atraumatic PCNL Stone Extractor, 12Fr, 38 cm, Cook Urological, Inc., Indianapolis, IN) ( commonly used during percutaneous nephrolithotomy, to retrieve the stone from the retroperitoneal space.

Perc NCircle® Rapid Atraumatic PCNL Stone Extractor tipless basket.

DISCUSSION

Hemal et al[6] reported using a Babcock forceps or cup forceps to hold stones and pull them out with the port.[6] Similarly, a large grasper or Maryland forceps has been used. However, the drawback to these instruments is the possibility of loosing the stone or breaking it during retrieval. Nouria[7] suggested placing the stone on the psoas and later removing it in a bag. The problem with this technique is that the stone can be lost in the retroperitoneal tissue and requires a bag for safe retrieval.

Hoffman et al[8] assessed the efficacy of various devises available for stone removal after percutaneous nephrolithotomy and concluded that the Perc NCircle basket facilitates a swift approach to percutaneous stone extraction.[8] The Perc NCircle is a nitinol tipless 4-wire stone basket (. The outer diameter of the sheath is 12Fr and the length is 38 cm. The device is operated in a similar fashion to the traditional graspers by placement through the nephroscope. Opening and closing of the basket is manipulated with a spring-loaded handle (. The basket has 4 tipless wires, and this allows secure stone removal. In addition, the flexibility of the basket facilitates easy release of the stone, which can be useful in a patient with multiple ureteric or renal calculi. This instrument can be safely introduced through a 10 mm port, and the rigid sheath allows safe, secure removal of the stone through the port. The limitation is that a very large stone would be difficult to grasp and withdraw intact. The other drawback is that the Perc NCircle is a disposable instrument.

A nitinol tipless 4-wire stone basket. Spring-loaded handle allows controlled manipulations.