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Ureteroureterostomy: Surgical Technique and Complications

Ureteroureterostomy is the end-to-end anastomosis of the ureter, which is possible with open surgery, laparoscopy or robotic-assisted laparoscopy (Elliot and McAninch, 2006).

Ureteroureterostomy: both ends of the ureter are spatulated. After placement of corner sutures, the anastomosis is done in a running or interrupted fashion.

Indication for Ureteroureterostomy

• Ureter injury
• Treatment of short segment (<3 cm) ureteral stricture of the middle and proximal ureter. Distal ureteral strictures are best treated with reimplantation of the ureter.
• Treatment of retrocaval ureter

Contraindications

• Coagulation disorders.
• Long ureteral stricture or ureteral defects, which do not allow a tension-free end-to-end anastomosis.
• Kidneys without sufficient function (<15% of total glomerular filtration rate)
• The further contraindications depend on the surgical risk due to the comorbidity of the patient, the renal function of the contralateral kidney and the impact of the surgical procedure on the quality of life of the patient.

Surgical Technique of Ureteroureterostomy

Preoperative Patient Preparation

• Exclusion or treatment of a urinary tract infection
• Perioperative antibiotic prophylaxis
• Retrograde pyelography to confirm diagnosis and length of the ureteral defect. Insert a DJ ureteral stent (if possible).
• Transurethral catheter

Surgical Approach

The surgical approach to the proximal ureter is via a flank incision. The mid-ureter and distal ureter are reached with a retroperitoneal or transperitoneal lower abdomen incision: e.g., paramedian laparotomy or Gibson incision. A laparoscopic (robotic-assisted) approach is also possible, depending on previous operations. After identification, the ureter is marked with a vessel loop, followed by mobilization cranial and caudal to the stricture. It is essential to treat the ureter atraumatically and to spare its vascular supply.

Anastomosis of the Ureter:

• After the stricture or injury is identified, the diseased part of the ureter is removed. Both ends of the ureter must be free of scarred tissue, have a good vascular supply, and be brought together without tension.
• The proximal and distal end are spatulated about 7–10 mm at 180 degrees apart.
• Sometimes, complete mobilization of the kidney is necessary to obtain sufficient ureteral length for a tension-free anastomosis.
• Insert a ureteral stent, if you have not done preoperatively.
• Place corner sutures (e.g., PDS 5-0). The ureteral anastomosis is completed by using the corner sutures (running suture) or in an interrupted fashion [fig. ureteroureterostomy].
• Insert a wound drainage near the ureteral anastomosis.
• Wound closure

Postoperative Care after Ureterureterostomy

General measures:

Early mobilization, respiratory therapy, thrombosis prophylaxis, laboratory tests (hemoglobin, creatinine), regular physical examination of the abdomen and incision wound.

Analgesia:

With a combination of NSAIDs and opioids, a peridural anesthesia facilitates postoperative pain management.

Drains and catheters:

The retroperitoneal drainage is removed if the daily drainage volume is well below 50 ml, Bladder catheter additional 1–2 days or 3–5 day in total, ureteral stent 2–4 weeks.

Complications of Ureteroureterostomy

Bleeding, infection, urinoma, recurrent ureteral stricture, loss of kidney function, injury to adjacent organs (liver, spleen, pancreas).

References

Elliott, S. P. & McAninch, J. W. Ureteral injuries: external and iatrogenic
Urol Clin North Am, 2006, 33, 55-66, vi

  Deutsche Version: Ureteroureterostomie