1423Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Departments of Urology, Sisli Etfal Training and Research Hos- pital, Istanbul, Turkey. Goksel Bayar, Orhan Tanriverdi, Mehmet Taskiran, Umut Sariogullari, Huseyin Acinikli, Elshad Abdullayev, Kaya Horasanli, Cengiz Miroglu Comparison of Laparoscopic and Open Ureterolithotomy in Impacted and Very Large Ureteral Stones Corresponding Author: Goksel Bayar, MD Sisli Etfal Egitim ve Arastirma Hastanesi, Uroloji Klinigi, 19 may St., Istanbul, Turkey. Tel: + 90 212 3735171 Fax: + 90 212 2339876 E-mail: goxelle@gmail.com Received February 2013 Accepted February 2014 Purpose:‎To‎compare‎the‎efficacy‎of‎laparoscopic‎and‎open‎ureterolithotomy‎in‎patients‎with‎ ureteral stones. Materials and Methods:‎Patients‎who‎had‎undergone‎open‎or‎laparoscopic‎ureterolithotomy‎ between‎2001‎and‎2013‎in‎our‎clinic‎were‎enrolled‎in‎the‎study.Ureterolithotomy‎was‎performed‎ due‎to‎the‎following‎reasons:‎failure‎to‎position‎the‎patient‎for‎ureteroscopy,unreachable‎stone‎ with‎ureteroscopy‎also‎use‎of‎balloon‎dilatation,‎high‎stone‎volume,‎and‎the‎need‎for‎removal‎ of‎kidney‎stones‎at‎the‎same‎session..‎The‎patients’‎demographic‎data,‎the‎volume‎of‎the‎stones,‎ the‎duration‎of‎the‎operation‎and‎the‎hospital‎stay,‎the‎amount‎of‎analgesics‎administered‎after‎ the‎operation,‎and‎the‎need‎for‎another‎procedure‎were‎compared. Results:‎Of‎study‎subjects‎32‎patients‎had‎undergone‎open‎and‎20‎patients‎had‎undergone‎laparo- scopic‎ureterolithotomy.‎When‎the‎two‎groups‎were‎compared,‎there‎was‎no‎statistically‎signifi- cant‎difference‎with‎regard‎to‎the‎mean‎age‎(44.5-44‎years),‎the‎body‎mass‎index‎(26-24.7‎kg/m²),‎ the‎stone‎volume‎(420-580‎mm³),‎the‎duration‎of‎operation‎(122-123‎min),‎the‎need‎for‎another‎ procedure‎and‎complications.‎The‎mean‎amount‎of‎analgesics‎administered‎after‎the‎operation‎ (3.6‎and‎1.81‎doses,‎P‎=‎.02)‎and‎the‎mean‎hospital‎stay‎(6.1‎and‎2.9‎days,‎P =‎.01)‎were‎signifi- cantly‎lower‎in‎the‎laparoscopic‎ureterolithotomy‎group. Conclusion:‎Laparoscopic‎ureterolithotomy‎is‎a‎good‎alternative‎with‎less‎need‎for‎analgesia‎ and‎a‎shorter‎hospital‎stay‎when‎compared‎with‎open‎ureterolithotomy. Keywords:‎laparoscopy;‎methods;‎ureteral‎calculi;‎surgery;‎treatment‎outcome. LAPAROSCOPIC UROLOGY 1424 | INTRODUCTION In‎ recent‎ years,‎ with‎ development‎ of‎ extracorporeal‎shock‎wave‎lithotripsy‎(SWL),‎percutaneous‎nephroli-thotomy‎(PNL)‎and‎with‎the‎advances‎in‎the‎technolo- gy‎of‎ureteroscopy‎(URS),‎the‎rates‎of‎‎invasive‎surgery‎for‎ stones‎in‎the‎urinary‎tract‎has‎dropped‎to‎levels‎of‎1-5.4%.‎ The‎rate‎of‎open‎surgery‎procedures‎is‎about‎1.5%‎in‎all‎ procedures,‎with‎the‎remaining‎surgical‎procedures‎com- prising laparoscopic procedures.(1-5) For‎patients‎who‎are‎unsuitable‎for‎SWL‎and‎URS‎and‎ir- responsive‎to‎these‎treatment‎modalities,‎invasive‎treatment‎ modalities‎are‎put‎forth.‎For‎the‎upper‎part‎of‎the‎ureter,‎an- tegrade‎percutaneous‎ureteroscopy‎is‎a‎good‎alternative.‎If‎ the‎patient‎is‎not‎suitable‎for‎antegrade‎percutaneous‎ureter- oscopy‎and‎for‎stones‎of‎the‎other‎parts‎of‎the‎ureter,‎the‎only‎ alternative‎treatment‎is‎ureterolithotomy.‎Radiofrequency‎in- cision‎of‎intramural‎ureter‎and‎the‎extraction‎of‎the‎stone‎is‎a‎ new‎alternative‎technique‎for‎distal‎impacted‎ureteral‎stone. (6)‎But‎this‎is‎not‎gold‎standard‎technique‎and‎described‎issue‎ on urology guidelines. In‎the‎European‎Urology‎Guideline‎on‎urolithiasis,‎it‎is‎ac- cepted‎ that‎ if‎ laparoscopic‎ ureterolithotomy‎ is‎ performed‎ with‎the‎right‎indications,‎it‎is‎superior‎to‎SWL‎and‎ureter- oscopy‎with‎an‎evidence‎level‎of‎“1a”.‎And‎for‎patients‎with‎ impacted‎large‎ureteral‎stones‎who‎cannot‎be‎treated‎with‎ SWL‎and‎endoscopic‎procedures,‎the‎evidence‎level‎for‎lapa- roscopic‎ureterolithotomy‎has‎been‎reported‎to‎be‎“2”‎with‎a‎ recommendation‎level‎of‎“B”.(7)‎‎ Impacted‎stones‎are‎defined‎as‎stones‎remaining‎at‎the‎same‎ localization‎for‎at‎least‎for‎2‎months.‎The‎minimal‎time‎pe- riod‎for‎the‎diagnosis‎of‎an‎impacted‎stone‎may‎be‎unclear‎ for‎each‎patient.‎Definitions‎for‎impacted‎stones‎include‎the‎ following:‎if‎the‎contrast‎media‎is‎radiological‎observed‎not‎ to‎have‎passed‎to‎the‎distal‎of‎the‎stone;‎and‎preoperatively,‎if‎ the‎guide‎wire‎does‎not‎pass‎to‎the‎proximal‎of‎the‎stone,‎and‎ when‎the‎stone‎remains‎at‎the‎same‎anatomical‎position‎for‎2‎ months.(8-10)‎Being‎of‎state‎of‎impacted‎is‎very‎important‎for‎ postoperative‎long-term‎complications.‎Because‎after‎uret- eroscopy,‎for‎impacted‎stones,‎strictures‎may‎develop‎with‎ rates‎as‎high‎as‎24%.(11)‎We‎can‎referee‎to‎the‎European‎Urol- ogy‎Guideline‎on‎urolithiasis‎for‎the‎definition‎of‎“very‎large‎ stone”,‎a‎large‎ureter‎stone‎is‎>10‎mm,‎whereas‎very‎large‎ stones‎are‎described‎to‎be‎larger‎than‎15‎mm‎in‎diameter.(7) So,‎for‎these‎reasons,‎we‎have‎aimed‎to‎comparison‎of‎open‎ and‎laparoscopic‎approach‎for‎ureterolithotomy‎in‎terms‎of‎ postoperative‎ureteral‎stricture,‎amount‎of‎the‎analgesic‎drug‎ needing‎and‎hospitalization‎interval‎in‎patients‎who‎had‎we‎ can‎take‎out‎this‎part‎of‎sentence‎impacted‎very‎large‎ureteral‎ stones. MATERIALS AND METHODS Thirty-two‎patients‎who‎had‎undergone‎open‎ureterolithoto- my‎and‎20‎patients‎who‎had‎undergone‎laparoscopic‎uretero- lithotomy‎between‎2001‎and‎2013‎were‎retrospectively‎ana- lyzed.‎Ureterolithotomy‎was‎performed‎due‎to‎the‎following‎ reasons:‎failure‎to‎position‎the‎patient‎for‎ureteroscopy‎(1‎ patient);‎unreachable‎stone‎with‎ureteroscopy‎also‎use‎of‎bal- loon‎dilatation‎(17‎patients);‎high‎stone‎load‎(31‎patients),‎ and‎the‎need‎for‎removal‎of‎kidney‎stones‎at‎the‎same‎ses- sion‎(3‎patients).‎All‎of‎patient’s‎stones‎are‎very‎large‎and‎ impacted.‎Open‎ureterolithotomy‎was‎preferred‎between‎the‎ years‎of‎2001-2008,‎and‎with‎the‎advances‎in‎laparoscopic‎ surgery‎in‎our‎clinic,‎laparoscopic‎ureterolithotomy‎was‎pre- ferred‎between‎2008-2013.‎One‎patient‎underwent‎open‎ure- terolithotomy‎in‎2011‎and‎another‎patient‎underwent‎open‎ ureterolithotomy‎in‎2012,‎both‎due‎to‎the‎fact‎that‎they‎were‎ unsuitable‎for‎laparoscopic‎surgery.‎Two‎patients‎underwent‎ open‎ureterolithotomy‎at‎2013‎due‎to‎patients’‎request. In‎open‎procedures,‎ lombotomy‎for‎superior‎and‎mid-part‎ ureteral‎stones‎and‎the‎Gibson‎incision‎for‎distal‎part‎ureteral‎ stones‎were‎used.‎After‎palpation‎of‎the‎ureter‎for‎stones,‎the‎ ureter‎was‎opened‎through‎a‎vertical‎incision‎and‎the‎stone‎ was‎extracted.‎Then‎a‎double‎J‎ureteral‎stent‎was‎placed‎in‎ ureter and ureter was closed with absorbable sutures. An ab- dominal‎drain‎was‎then‎placed‎at‎the‎operation‎site.‎Fifteen‎ patients‎had‎been‎operated‎for‎upper,‎3‎mid‎and‎14‎distal‎ure- teral‎segment‎stones. Laparoscopic‎ procedures‎ were‎ performed‎ trans‎ and‎ retro- peritoneally.‎Having‎palpated‎the‎stone‎with‎the‎laparoscopic‎ instrument,‎with‎the‎technique‎that‎we‎have‎developed‎in‎our‎ clinic‎to‎increase‎safety,‎the‎ureter‎was‎vertically‎incised‎us- ing‎a‎No.11‎or‎a‎No.15‎scalpel‎and‎the‎stone‎was‎extracted.‎ Laparoscopic Urology 1425Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Ureterolithotomy for Impacted Stones | Bayar et al A double J ureteral stent was then placed and the ureter was closed‎ using‎ absorbable‎ sutures.‎An‎ abdominal‎ drain‎ was‎ then‎placed‎at‎the‎operation‎site.‎Fifteen‎patients‎had‎been‎op- erated‎for‎upper,‎4‎mid‎and‎1‎distal‎ureteral‎segment‎stones.‎ All‎of‎operations,‎open‎and‎laparoscopic,‎were‎performed‎by‎ same‎surgeon. The‎demographic‎data‎of‎the‎patients,‎the‎age,‎sex‎and‎the‎ body‎mass‎index‎were‎recorded.‎The‎analgesic‎medications‎ that‎had‎been‎administered‎postoperatively‎were‎analyzed.‎ Amount‎of‎analgesic‎drug‎needed‎was‎taken‎into‎account‎for‎ first‎24‎hours.‎One‎analgesic‎dose‎is‎accepted‎to‎be‎50‎mg‎ pethidine,‎50‎mg‎diclofenac,‎and‎500‎mg‎paracetamol.‎The‎ stone‎volume‎was‎calculated‎with‎the‎formula:‎(stone‎width‎ ×‎stone‎length‎×‎π‎×‎0.25)^1.27‎×‎0.6. The‎patients‎were‎divided‎into‎two‎groups‎according‎to‎the‎ surgery‎being‎open‎or‎laparoscopic,‎and‎their‎demographic‎ data,‎stone‎volumes,‎durations‎of‎operation‎and‎hospitaliza- tion,‎amount‎of‎analgesics‎administered‎after‎the‎operation‎ and‎the‎need‎for‎another‎procedure‎were‎compared.‎Finishing‎ of‎operation‎laparoscopically‎and‎reaching‎stone-‎free‎were‎ considered‎success‎criteria.‎Complications‎were‎classified‎by‎ Clavien-‎Dindo‎system. Mann Whitney U‎and‎Fisher’s‎exact‎test‎were‎used‎for‎the‎ statistical analyses and P‎value‎of‎<‎.05‎was‎considered‎as‎ significant.‎ RESULTS All‎of‎the‎open‎procedures‎were‎retroperitoneal,‎while‎5‎of‎ the‎laparoscopic‎procedures‎were‎transperitoneal‎and‎15‎of‎ the laparoscopic procedures were retroperitoneal. In the open procedure‎group,‎7‎patients‎were‎women‎and‎25‎were‎men,‎ with‎a‎mean‎age‎of‎44.5‎years.‎In‎the‎laparoscopy‎group,‎4‎ patients‎were‎women‎and‎16‎were‎men,‎with‎a‎mean‎age‎of‎ 44‎years.‎When‎the‎body‎mass‎indexes‎of‎the‎two‎groups‎ were‎compared,‎there‎was‎no‎statistically‎significant‎differ- ence‎(Table‎1). For‎the‎stone‎volumes,‎although‎the‎volumes‎in‎the‎laparos- copy‎group‎were‎higher,‎the‎difference‎between‎two‎groups‎ was‎not‎statistically‎significant.‎We‎think‎that‎it‎was‎because‎ of‎the‎small‎number‎of‎patients.‎When‎we‎compared‎the‎op- eration‎times,‎interestingly,‎the‎mean‎operation‎times‎were‎ very‎close‎to‎each‎other‎for‎the‎two‎groups.‎Operation‎times‎ are‎ similar‎ between‎ trans‎ and‎ retroperitoneal‎ laparoscopy‎ groups‎(114‎vs.‎126‎min,‎P‎=‎.45).‎The‎need‎for‎analgesia‎ was‎significantly‎lower‎in‎the‎laparoscopy‎group‎in‎the‎post- operative‎period.‎Furthermore,‎the‎postoperative‎hospitaliza- tion‎time‎was‎significantly‎shorter‎in‎the‎laparoscopy‎group‎ (Table‎1). In‎the‎open‎ureterolithotomy‎group,‎3‎patients‎had‎pain‎and‎ hydronephrosis‎after‎the‎double‎J‎stent‎was‎removed‎at‎the‎ fourth‎postoperative‎week.‎They‎underwent‎diagnostic‎uret- Table 1. Demographic and clinical characteristics of study subjects. Variables Open Laparoscopic p Female/Male ratio 7/25 4/16 .72 Mean age (years) 44.5 ± 17 44 ± 12 .9 Mean BMI (kg/m²) 26 ± 3 24.7 ± 3 .41 Mean stones volume (mm³) 420 ± 280 580 ± 325 .085 Operation time (minutes) 122 ± 38 123 ± 40 .9 Hospitalization time (days) 6 ± 2.6 2.9 ± 1.4 .01* Analgesic drug needing (doses) 3.6 ± 2.7 1.81 ± 1.2 .02* Additional treatment 3 1 .12 Complication 1 2 .4 Key: BMI, body mass index. * Statistically significant. 1426 | eroscopy,‎and‎the‎remaining‎stones‎in‎the‎ureter‎were‎treated‎ endoscopically.‎That‎patients‎stones‎may‎be‎broken‎during‎ open‎ureterolithotomy.‎In‎the‎open‎ureterolithotomy‎group,‎1‎ patient‎had‎developed‎ureterovesical‎obstruction.‎Then,‎with‎ open‎surgery,‎the‎obstructed‎segment‎was‎excised‎and‎uret- eroneocystostomy‎was‎performed.‎On‎the‎follow-up,‎it‎was‎ seen‎that‎the‎obstruction‎had‎been‎alleviated.‎Furthermore,‎ in‎the‎open‎ureterolithotomy‎group,‎1‎patient‎had‎permanent‎ obstruction‎in‎a‎long‎segment‎of‎the‎mid-part‎of‎the‎ureter.‎As‎ the‎other‎kidney‎was‎hypoplastic‎and‎the‎obstruction‎was‎in‎ the‎long‎segment,‎he‎was‎on‎follow-up‎for‎91‎months‎with- out‎any‎further‎complications‎by‎changing‎the‎double‎J‎stent‎ every‎6‎months.‎All‎of‎patients‎were‎followed‎mean‎15,‎mini- mum‎3‎months‎in‎open‎group.‎‎ In the laparoscopy group, in the one and only patient in whom‎a‎double‎J‎stent‎had‎not‎been‎placed,‎the‎drain‎re- vealed‎over‎1000‎mL‎day‎drainage‎with‎urine‎content‎post- operatively.‎Hence,‎we‎performed‎endoscopy‎after‎2‎days,‎ and‎the‎remaining‎stone‎was‎treated‎endoscopically.‎We‎have‎ recovered‎to‎open‎procedure‎at‎one‎patient‎due‎to‎bleeding.‎ Postoperative‎ileus‎occurred‎in‎none‎of‎the‎patients.‎All‎of‎ patients‎were‎followed‎mean‎30,‎minimum‎6‎months‎in‎lapa- roscopy‎group.‎There‎were‎no‎differences‎between‎the‎two‎ groups‎with‎regard‎to‎the‎requirement‎for‎an‎extra‎procedure.‎ DISCUSSION The‎success‎of‎the‎operation‎is‎defined‎as‎finishing‎the‎sur- gery‎laparoscopically‎and‎reaching‎a‎stone‎free‎state‎for‎lapa- roscopic‎ureterolithotomy.‎The‎success‎rate‎for‎this‎procedure‎ is‎ usually‎ reported‎ as‎ 90%;‎ however,‎ there‎ are‎ reports‎ of‎ 100%‎success,‎too.(15,18,21) In our study, the success rate was 90%,‎all‎the‎procedures‎were‎completed‎laparoscopically‎and‎ with‎a‎complete‎stone‎free‎state‎except‎one‎patient‎(Table‎1). Simforoosh‎and‎colleagues‎reported‎96.7%‎success‎rate‎and‎ their‎series‎was‎123‎patients.(22) Nasseh and colleagues report- ed‎94%‎success‎rate.‎Also‎this‎study‎was‎published‎at‎2013‎ years and operations were done between 2008-2011 years.(23) That‎is‎to‎say,‎we‎think‎real‎success‎rate‎of‎laparoscopic‎uret- erolithotomy‎is‎about‎95%. In‎the‎literature,‎the‎complication‎rates‎are‎low‎and‎the‎high- Laparoscopic Urology Table 2. Our and other studies’ databases about laparoscopic ureterolithotomy in current literature. Studies Patients No. Success Rate (%) Complication Rate (%) Additional Treat- ment Rate (%) Operation Time (min) Hospitalization Time (day) Our Study, 2014 20 90 10 5 123 2.9 El Moula et al. 2008(12) 74 94.6 0 1.4 58.7 6.4 Ko HY et al. 2011(13) 71 93.8 12.5 4.2 118 5.9 Flasko et al. 2005(14) 75 98.7 0 0 45 3 Skrepetis et al. 2001(15) 18 100 0 0 130 3 Kijvikai et al. 2006 (16) 30 96 13.3 3.3 121.38 3.86 Gaur et al. 2002(17) 101 92 11 0 79 3.5 Fang et al. 2012(18) 25 100 0 0 41.8 2.9 Huri et al. 2010(19) 41 97.5 12.5 12.5 124 4.8 Wang et al. 2010(20) 36 94.5 17.6 0 131.5 5.8 Keeley et al. 1999(21) 14 100 0 14 105 5.6 Simforoosh et al. 2007(22) 123 96.7 11.4 10.5 143 5.86 1427Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L est‎reported‎rate‎is‎17.6%.(24)‎There‎are‎several‎studies‎report- ing‎the‎complication‎rate‎of‎0%.(12,14,15,18,21) In our study, the complication‎rate‎was‎10%‎(Table‎2).‎Ureteral‎stricture‎is‎the‎ main‎complication‎concern‎after‎the‎operation.‎In‎a‎review‎of‎ the‎literature,‎Nouira‎and‎colleagues‎reported‎this‎complica- tion‎rate‎as‎2.5%.(25)‎To‎prevent‎the‎strictures,‎it‎is‎important‎ not‎to‎disturb‎the‎vasculature‎of‎the‎incised‎part‎of‎the‎ureter‎ during‎the‎operation.‎Gaur‎and‎colleagues‎reported‎that‎it‎is‎ safe‎to‎use‎the‎hook‎device‎in‎the‎cutting‎mode‎of‎the‎elec- trocautery‎device‎for‎the‎ureter‎incision.‎They‎reported‎that‎ in‎the‎10-year‎follow-up‎of‎75‎patients,‎only‎3‎had‎strictures‎ in‎the‎part‎that‎the‎stone‎had‎been‎impacted,‎but‎they‎did‎not‎ mention‎anything‎about‎the‎incision‎technique‎in‎the‎patients‎ who‎had‎developed‎strictures.‎Two‎of‎those‎3‎patients‎were‎ treated with balloon dilatation and 1 underwent double J stent placement‎for‎3‎months‎and‎no‎recurrence‎was‎observed.(17) We‎used‎the‎scalpel‎for‎incision‎with‎a‎safe‎technique‎that‎ we‎had‎developed‎in‎our‎clinic,‎and‎in‎the‎mean‎follow-up‎ time‎of‎30‎months‎(range,‎7-42‎months),‎none‎of‎the‎patients‎ experienced‎ureteral‎stricture.‎ The‎extra‎procedures‎were‎ureteroscopy,‎percutaneous‎neph- rolithotomy‎and‎double‎J‎stent‎placement‎for‎patients‎with‎ prolonged‎urinary‎leakage‎or‎patients‎who‎could‎not‎be‎ren- dered‎stone‎free.‎This‎rate‎has‎been‎reported‎to‎be‎as‎high‎as‎ 14%‎in‎the‎literature,(20) but there are studies reporting the rate‎as‎0%‎(Table‎2).(14,15,17,18,21) In our study, the one and only‎patient‎in‎whom‎we‎did‎not‎place‎a‎double‎J‎ureteral‎ stent,‎developed‎urine‎leakage‎of‎1000‎mL/day,‎and‎hence,‎ we‎performed‎ureteroscopy‎on‎the‎second‎postoperative‎day‎ and‎placed‎a‎double‎J‎ureteral‎stent‎(Table‎1).‎Urinary‎leak- age‎for‎a‎prolonged‎duration‎should‎be‎avoided,‎since‎it‎must‎ be‎kept‎in‎mind‎that‎prolonged‎retroperitoneal‎urinary‎leak- age‎can‎cause‎retroperitoneal‎fibrosis.(26) The‎operation‎time‎in‎the‎available‎literature‎shows‎a‎wide‎ range‎from‎41.8‎to‎132‎minutes‎(Table‎2).‎Fan‎and‎colleagues‎ demonstrated‎that‎after‎completion‎of‎a‎20‎case‎series‎com- prising‎the‎teaching‎curve,‎the‎operation‎time‎decreased‎from‎ 120‎minutes‎to‎65‎minutes‎in‎the‎second‎20‎cases.(26)‎Gaur‎ and‎colleagues‎reported‎that‎closing‎the‎ureter‎with‎primary‎ sutures‎prolongs‎the‎operation‎by‎about‎26‎minutes.(17) In our study,‎we‎closed‎the‎ureter‎with‎primary‎sutures,‎and‎due‎to‎ the‎fact‎that‎the‎teaching‎curve‎for‎laparoscopic‎ureterolithot- omy‎was‎not‎completed,‎the‎operation‎time‎was‎longer‎(Ta- ble‎1).‎It‎is‎expected‎that‎when‎we‎have‎a‎sufficient‎number‎ of‎cases,‎the‎operation‎time‎will‎decrease.‎ The‎duration‎of‎hospital‎stay‎has‎been‎reported‎to‎be‎between‎ 2.9-6.4‎days‎(Table‎2),(16,25)‎and‎in‎our‎study‎it‎is‎estimated‎to‎ be‎2.9‎days‎(Table‎1).‎Since‎the‎previous‎studies‎had‎been‎car- ried‎out‎with‎regard‎to‎laparoscopic‎ureterolithotomy‎experi- ences‎and‎its‎comparison‎with‎ureteroscopy,‎there‎is‎hardly‎ any‎mention‎about‎the‎duration‎of‎hospital‎stay.‎Skrepetis‎and‎ colleagues‎reported‎the‎duration‎of‎hospital‎stay‎for‎the‎lapa- roscopy‎group‎as‎3‎days‎and‎that‎for‎the‎open‎surgery‎group‎ as 8 days.(15)‎Gaur‎and‎colleagues‎demonstrated‎that‎with‎ ureter‎suturing‎and‎placement‎of‎a‎double‎J‎ureteral‎stent,‎the‎ urinary‎leakage‎time‎in‎patients‎decreased‎from‎5.5‎days‎to‎ 3.2‎days.(17)‎In‎our‎study,‎when‎we‎compared‎the‎groups,‎the‎ time‎duration‎was‎determined‎to‎be‎significantly‎lower‎in‎the‎ laparoscopy‎group.‎We‎think‎that,‎except‎for‎one,‎we‎sutured‎ the ureter and placed double J ureteral stent in all the other operations‎and‎this‎decreased‎the‎duration‎of‎hospital‎stay.‎In‎ that‎one‎particular‎patient,‎the‎duration‎of‎hospital‎stay‎was‎ 7‎days.‎Many‎of‎open‎ureterolithotomy‎patients‎have‎stayed‎ prolonged‎time‎due‎to‎pain.‎A‎patient,‎one‎of‎open‎ureteroli- thotomy‎has‎stayed‎16‎days‎in‎hospital‎only‎due‎to‎pain. Unfortunately,‎the‎need‎for‎analgesia‎has‎not‎been‎defined‎ with‎a‎common‎drug‎or‎a‎unit.‎Every‎clinic‎has‎reported‎the‎ drugs‎for‎its‎own‎practical‎use‎and‎analgesia‎unit‎of‎their‎ own.‎The‎number‎of‎studies‎about‎the‎need‎of‎analgesia‎for‎ open‎and‎laparoscopic‎ureterolithotomy‎groups‎is‎very‎lim- ited.‎Skrepetis‎and‎colleagues‎reported‎the‎daily‎requirement‎ of‎analgesics‎in‎the‎laparoscopic‎group‎as‎1,‎and‎that‎in‎the‎ open‎surgery‎group‎as‎4‎we‎can‎takeout‎tihs‎part.(15) In our study,‎the‎need‎for‎analgesia‎was‎expressed‎as‎unit‎analgesia,‎ and‎this‎was‎1.8‎units‎in‎the‎laparoscopy‎group‎and‎3.5‎units‎ in‎the‎open‎group,‎which‎is‎significantly‎lower‎in‎the‎laparos- copy‎group‎(Table‎1).‎ Small‎sample‎size‎and‎retrospective‎design‎are‎limitations‎of‎ our study. CONCLUSION Laparoscopic‎ureterolithotomy‎has‎similar‎success‎and‎com- plication‎rates‎to‎open‎ureterolithotomy.‎In‎the‎treatment‎of‎ large‎impacted‎ureteral‎stones,‎laparoscopic‎ureterolithotomy‎ Ureterolithotomy for Impacted Stones | Bayar et al 1428 | may‎be‎preferred‎to‎open‎ureterolithotomy‎due‎to‎low‎amount‎ of‎analgesic‎drug‎needed‎and‎hospitalization‎time. ACKNOWLEDGEMENTS We‎thank‎our‎clinical‎secretary,‎Ayfer‎Guzel,‎for‎her‎efforts‎in‎ reaching‎the‎patients’‎data. CONFLICT OF INTEREST None declared. REFERENCES 1. Assimos DG, Boyce WH, Harrison LH, McCullough DL, Kroovand RL, Sweat KR. The role of open stone surgery since extracorporeal shock wave lithotripsy. J Urol. 1989;142:263-7. 2. Segura JW. Current surgical approaches to nephrolithiasis. Endo- crinol Metab Clin North Am. 1990;19:919-35. 3. Honeck P, Wendt-Nordahl G, Krombach P, et al. Does open stone surgery still play a role in the treatment of urolithiasis? Data of a primary urolithiasis center. 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