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Ureteroureterostomy: End-to-End Anastomosis of the Ureter

Indication for Ureteroureterostomy

• Ureter injury (Elliot and McAninch, 2006)
• 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 injuries, which do not allow a tension-free end-to-end anastomosis.
• Kidneys without sufficent function (<15% of total glomerular filtration rate)
• Underlying diseases with excessive surgical risk, if a ureteral stent is an alternative.

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, insert a DJ ureter stent (if possible).
• Insertion of a transurethral catheter

Surgical Approach:

Surgical Approach

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

Anastomosis of the Ureter:

• After identification of the stricture or injury, the diseased part of the ureter ist removed. Both ends of the ureter must be free of scarred tissue, with good vascular supply and should 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 a interrupted fashion [fig. ureteroureterostomy].
• Insert a wound drainage
• Wound closure

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

Care after Ureterureterostomy

General measures:

Early mobilization. Respiratory therapy. Thrombosis prophylaxis. Laboratory controls (Hb). Wound inspections.

Analgesia:

In adults, a flank approach is painful and an epidural catheter is an option. In addition, analgesics according to the ladder of WHO pain management are given, e.g. metamizol and tramadol.

Drains and catheters:

The retroperitoneal drainage is removed if daily volume of drainage is well below 50 ml, Bladder catheter additional 1–2 days, ureteral stent 2–4 weeks.

Complications of Ureteroureterostomy

Bleeding. Infection. Urinoma. Recurrence of the ureteral stricture. Injury to adjacent organs (e.g. bowel).

References

Elliott, S. P. & McAninch, J. W.

Ureteral injuries: external and iatrogenic
Urol Clin North Am, 2006, 33, 55-66, vi

  Deutsche Version: Ureteroureterostomie