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UROLOGY BOARD REVIEW MANUAL

Urology Volume 12, Part 3 1

STATEMENT OF EDITORIAL PURPOSE

The Hospital Physician Urology Board ReviewManual is a study guide for residents andpracticing physicians preparing for boardexaminations in urology. Each quarterly man-ual reviews a topic essential to the currentpractice of urology.

PUBLISHING STAFFPRESIDENT, GROUP PUBLISHER

Bruce M. White

EDITORIAL DIRECTORDebra Dreger

EDITORRobert Litchkofski

ASSISTANT EDITORTricia Faggioli

EXECUTIVE VICE PRESIDENTBarbara T. White

EXECUTIVE DIRECTOR OF OPERATIONS

Jean M. Gaul

PRODUCTION DIRECTORSuzanne S. Banish

PRODUCTION ASSISTANTKathryn K. Johnson

ADVERTISING/PROJECT MANAGERPatricia Payne Castle

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Copyright 2004, Turner White Communications, Inc., 125 Strafford Avenue, Suite 220, Wayne, PA 19087-3391, www.turner-white.com. Allrights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,mechanical, electronic, photocopying, recording, or otherwise, without the prior written permission of Turner White Communications, Inc.The editors are solely responsible for selecting content. Although the editors take great care to ensure accuracy, Turner WhiteCommunications, Inc., will not be liable for any errors of omission or inaccuracies in this publication. Opinions expressed are those of theauthors and do not necessarily reflect those of Turner White Communications, Inc.

NOTE FROM THE PUBLISHER:This publication has been developed with-out involvement of or review by theAmerican Board of Urology.

Adult Ureteral ReconstructionEditor:Bernard Fallon, MDProfessor of UrologyDepartment of UrologyUniversity of IowaIowa City, IA

Contributor:Darlene M. Gaynor-Krupnick, DOFellow, Female and Reconstructive SurgeryDepartment of UrologyUniversity of IowaIowa City, IA

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Surgical Considerations . . . . . . . . . . . . . . . . . . . 2

Options for Ureteral Repair . . . . . . . . . . . . . . . 3

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Table of Contents

Cover Illustration by mb cunney

2 Hospital Physician Board Review Manual

INTRODUCTION

Many approaches are available for the managementof ureteral strictures. Open surgical techniques for ure-teral repair include ureteroneocystostomy, psoas hitch,Boari flap, ureteroureterostomy, transureteroureterosto-my, ileal ureter substitution, and renal autotransplanta-tion. Before deciding on definitive management of astricture, the urologist must carefully consider the indi-cations, contraindications, risks, and benefits of the vari-ous types of repair. A thorough workup will aid in prop-erly diagnosing the cause of the defect and provideimportant information to guide therapy decisions. Thelength and location of the ureteral injury or stricture arekey factors in decision making, as are prior medical his-tory (eg, radiation exposure), pathology involving thecontralateral collecting system, and the performancestatus of the patient. Knowledge of the anatomy sur-rounding the ureter at the upper, middle, and lowerportions is critical. Although selecting the most appro-priate approach is essential to achieving optimal out-comes, urologists should have a variety of treatmentoptions within their surgical armamentarium, as the in-traoperative course may require the urologist to per-form alternative forms of surgical treatment.

This manual reviews forms of open surgical repair ofureteral injuries with a focus on indications, contraindi-cations, surgical technique, success rates, and possiblecomplications.

SURGICAL CONSIDERATIONS

ANATOMY

From a surgical perspective, the ureter is divided intothe abdominal and pelvic portions. The renal pelvis isthe upper border of the abdominal ureter, and the iliacvessels are the inferior border. The pelvic ureter ex-tends from the iliac vessels to the bladder. Radiologi-cally, the ureter is divided into 3 portions: the upper,middle, and lower ureter. The upper ureter is the

length between the renal pelvis and the upper borderof the sacrum; this segment overlies the psoas muscle.The upper ureter receives its blood supply mediallyfrom branches of the renal artery, gonadal artery, ab-dominal aorta, and common iliac artery. The midureterextends from the upper border to the inferior borderof the sacrum at the level of the iliac vessels and is locat-ed posterior to the gonadal artery and vein. It receivesits blood supply from the gonadal artery, internal iliacartery, and the superior vesical artery. The lower sectionof the midureter crosses anterior to the common iliacvessels, a key landmark in identifying the ureter intra-operatively. This portion of the left ureter runs posteri-or to the sigmoid and descending colon, and the rightureter runs under the cecum. The lower ureter extendsfrom the inferior border of the sacrum to the ureteralorifice and receives its blood supply laterally from thesuperior and inferior vesical arteries and the uterine,middle rectal, and vaginal arteries. An adventitial net-work of anastomosing vessels allows the ureter to beextensively mobilized without ischemia if the adventitiais preserved.1

ETIOLOGY

Ureteral calculi, instrumentation, external malig-nancy, infection, fibrosis, radiation, and trauma are themajor causes of ureteral strictures. Rare causes includeschistosomiasis, tuberculosis, and endometriosis. Ure-teral stricture is a complication in 4.5% of ureteroscop-ic procedures and in 1.1% of hysterectomies.2 Externalviolence is responsible for 6% of traumatic ureteral in-juries.2 Intrinsic ureteral malignancy is another poten-tial cause of ureteral narrowing. Ureteroscopy, selectivecytology, barbotage, and brush biopsies are importantmethods of evaluation for intrinsic ureteral malignancythat may lead to ureteral strictures.

Approximately 80% of ureteral injuries are iatro-genic,3 and 30% to 45% of these injuries are recognizedintraoperatively. A study by Ghali et al emphasized thatearly diagnosis is the most critical aspect affecting out-come.4 Postoperative flank pain, fever, and evidence ofpossible adynamic ileus, such as nausea and vomiting,are highly suggestive of iatrogenic ureteric injury

UROLOGY BOARD REVIEW MANUAL

Adult Ureteral ReconstructionDarlene M. Gaynor-Krupnick, DO

following a hysterectomy. Intraoperative recognitionand repair is best, but when the injury is diagnosed post-operatively early repair within 3 months is recommend-ed.3

Ureteral injuries occur in 0.4% to 2.5% of all gyne-cologic procedures.5 Abdominal hysterectomy is by farthe most common setting for surgical ureteral injuries,with 2% to 3% of patients who undergo hysterectomyexperiencing ureteral injury.6 Gynecologic-relatedmalignancy increases the rate of ureteric injury toapproximately 10%.7 Ureteral injuries are the leadingcause of medicolegal issues following hysterectomy.

Two thirds of all gynecologic-related injuries occurbelow the pelvic brim at the point where the uretercourses under the uterine vessels.8 The left ureter is athigher risk of injury because it is located 2 cm from thecervical cuff.9,10 Most injuries occur during attempts toobtain hemostasis while ligating the infundibulopelvicligament. The success rate following definitive treat-ment for a pelvic ureteric complication due to gyneco-logic surgery is more than 90%.

PREOPERATIVE IMAGING STUDIES

An intravenous pyelogram (IVP) and retrogradepyelogram are useful in visualizing ureteral defects.3 TheIVP will define the proximal border of the stricture area.A “goblet sign” on the IVP is characteristic of an intrin-sic malignancy. A retrograde pyelogram will demon-strate the distal border of the stricture and may outlineits length and severity. If a percutaneous nephrostomytube is present, an antegrade nephrostogram may beobtained to demonstrate the upper border of the ureter-al defect. A furosemide-stimulated renal scan with aFoley catheter in place can provide additional informa-tion regarding the presence, location, and degree ofupper tract obstruction and overall renal function.

ENDOSCOPIC TREATMENT

Minimally invasive methods of treatment such as bal-loon dilation and endopyelotomy can be used to dilateshort strictures. Endoscopic methods are best reservedfor strictures less than 2 cm in length. For treating stric-tures 1 to 2 cm in length, better long-term success hasbeen reported with endoureterotomy with stent place-ment as opposed to balloon dilatation.11 Active infec-tion is considered a contraindication for balloon dila-tion or endopyelotomy. Typically, a lower ureteralstricture should be approached with an anteromedialincision with endopyelotomy; a midureter or upperureter stricture should be approached with a lateral andsometimes a posterolateral incision away from the ure-

teral blood supply and the great vessels.12 A computedtomography (CT) angiogram may demonstrate cross-ing vessels and aid in planning the best approach withendoureterotomy.

SURGICAL KEY POINTS

When mobilizing the ureter, care must be taken topreserve the adventitia and blood supply. Nonviable tis-sue must be débrided. Spatulation of the ureteral end isnecessary to create a sufficiently wide anastomosis. An-astomoses should be performed in a mucosa-to-mucosa, watertight fashion. Previously radiated por-tions of the ureter should not be used for anastomosisbecause further stricturing is likely to occur.

OPTIONS FOR URETERAL REPAIR

CASE PRESENTATION 1

A 56-year-old man with a 5-month history of diffuseabdominal pain and anorexia presents to the urologydepartment. Past medical and social history are signifi-cant for coronary artery disease, a 32-pack-year smokinghabit, and pulmonary embolism and Greenfield filterplacement. Urinalysis reveals microscopic hematuria,and a full genitourinary workup is ordered, including cys-toscopy with urine cytology. The results of the workup arenormal. An abdominopelvic CT scan demonstrates alower pelvic mass as well as moderate to severe hydro-nephrosis on the left and mild hydronephrosis on theright. No other pathology is noted on the CT scan.

An IVP is obtained, which reveals medial deviation ofthe left ureter. A furosemide-stimulated renal scandemonstrates 35% function on the left and 65% func-tion on the right. Retrograde pyelogram demonstratesobstruction at the left midureter (Figure 1). There is no obstruction or medial deviation evident at the rightureter. It is not possible to place a left ureteral stent in a retrograde fashion; percutaneous placement of anephrostomy tube is performed to decompress theaffected left renal pelvis. (Another indication for percu-taneous nephrostomy drainage, in general, is activeinfection. The nephrostomy tube also allows an ap-proach for further treatment and radiography in stablepatients.) An antegrade nephrostogram is obtained,which reveals complete ureteral obstruction at theupper portion of the proximal left ureter (Figure 2).Urine cytology specimens are collected and are nega-tive for malignant cells.

Laparoscopic biopsy of the pelvic mass is performed.


A d u l t U r e t e r a l R e c o n s t r u c t i o n

A pathologic diagnosis of idiopathic retroperitonealfibrosis (IRF) is made. The final diagnosis is left ureter-al stricture extending 15 cm from the upper ureter tothe lower midureter.

• What are the surgical options for treating the left ure-teral stricture?

Typically, ureterolysis with an omental flap is the pro-cedure of choice to treat ureteral obstruction caused byIRF. However, because an extensive length of the ureteris obliterated, another form of therapy should be con-sidered in this patient. Left ileal ureter substitution maybe safely performed in the setting of benign IRF. Therisks associated with this procedure include bacteriuriaand increased mucus production, which can lead toobstruction. It is unlikely that a Boari flap would reachthe upper ureter tension-free. A renal autotransplantmay be a viable option, but the risk of ischemia to thekidney may outweigh the risks associated with ilealureter substitution. Surgical intervention is not re-quired on the right side, as there was no evidence of sig-nificant obstruction or deviation to the right ureter.

The best tissue for ureteral reconstruction is urotheli-um, which may be obtained from the bladder or from tis-sue harvested from a hydroureter. The benefits ofurothelium are difficult to match. It is resistant to in-flammatory and carcinogenic effects of urine,13 and,most important, it does not reabsorb toxins or solutes,which in excess may be harmful. Nonetheless, ureter sub-

stitution with an ileal segment has been reported as aneffective form of ureteral reconstruction. The benefit ofusing an ileal segment to replace a large ureteral defectis that it is readily available and not as scarce in supply asurothelium. Other forms of replacement have beendescribed, including tubularized collagen-based porcinesmall intestine submucosa14 and polytetrafluoroethyleneconduits.15–17 However, anastomotic leakage and stenosishave been reported with various techniques for ureteralsubstitution, including in-situ prosthetic ureters.18–20

ILEAL URETER SUBSTITUTIONContraindications

There are 4 major contraindications for ureteral ilealsubstitution. 1) A serum creatinine level greater than 2 mg/dL is associated with an increased risk for hyper-chloremic metabolic acidosis when ileum is used. Thisoccurs when chloride and hydrogen ions are absorbedwithin the bowel segment in greater amounts than sodi-um and ammonium ions, resulting in a net loss of bicar-bonate through the ileal segment.21 Renal insufficiencyprecipitates this action and further increases the acidload. Normal preoperative renal function indicated by aserum creatinine level below 2 mg/dL helps to avoidhyperchloremic metabolic acidosis in the majority ofcases.22 2) Bladder outlet obstruction or a neurogenicbladder may increase intravesical pressures and pres-sures to the ileal segment, resulting in an increased fre-quency of complications. 3) Inflammatory bowel disease



Figure 2. Supine view of left antegrade nephrostogram.

Figure 1. Left retrograde pyelogram with midureteral obstruc-tion.

may affect the ileal tissue and peristalsis. 4) Radiationenteritis increases the risk for strictures and poorly vas-cularized bowel.

Technique

Preoperatively, the patient receives a mechanical andantibiotic bowel preparation. A transperitoneal incisiontypically is used to provide sufficient exposure. The ure-ter is mobilized and the defect area is excised, if possi-ble; a frozen section may be sent for evaluation. Themethod for creating an ileal ureter is similar to themethod for creating an ileal conduit, with mobilizationof the ileal segment under the sigmoid colon. Thebowel segment is isolated in standard fashion. The seg-ment chosen should be at least 15 cm from the ileoce-cal valve in order to avoid vitamin B12 malabsorption. Itis important to properly identify and mark the distaland the proximal ends of the segment, so the segmentcan be placed in an isoperistaltic fashion. For a bilater-al ureteral ileal substitution, one longer segment maybe anastomosed to each collecting system and then tothe bladder. Alternatively, 2 separate ileal segments canbe used. The segment is then anastomosed to the prox-imal end of the ureter with 4-0 polydioxanone suturesand at the distal end to a cystotomy incision with 3-0Vicryl sutures (Figures 3–5). It is imperative to positionand anastomose the isolated ileal segment in an isoperi-staltic fashion in order to avoid functional obstruction.Tapering the ileal segment has not been found to pro-vide benefit and may increase the risk for stricture at thelevel of the anastomosis.23,24 Although ileal ureters doreflux, segments greater than 15 cm have not beenfound to reflux into the renal pelvis.25 A laparoscopicapproach may be performed, although it is associatedwith a longer intraoperative time.26

Postoperative care includes an antegrade nephros-togram and removal of the indwelling stent within 3 to4 weeks. An IVP should be obtained 3 months postop-eratively. The patient should be followed with annualevaluations alternating between measurement of creati-nine level and renal ultrasonography unless there arechanges in clinical status.

Complications

Early extravasation leading to a possible urinoma orfistula may occur postoperatively. Obstruction fromedema, a mucus plug, or a kink in the ileal segment mustbe considered when flank pain, signs associated withileus, or a rise in the creatinine level are present. Longileal segments increase the risk of mucus obstruction,and these obstructions may need to be treated endo-scopically if they do not resolve spontaneously. Long-

term complications include ureterointestinal stricture,reflux, hyperchloremic metabolic acidosis, mucosal ob-struction, chronic bacteriuria, and renal insufficiency.Ureterointestinal stricture may be treated initially withlaser endopyelotomy or open revision, which is consid-ered the gold standard.27

Pyelonephritis remains a concern following ileal sub-stitution, although the risk of damage to renal functiondue to pyelonephritis is extremely low. The risk forpyelonephritis may be diminished with an antirefluxanastomosis; however, this issue is controversial becausereflux may occur in an antirefluxing vesicoileal anasto-mosis as well. In studies of ileal replacement of theureter, Vatandaslar23,24 and Verduyckt28 concluded thatthere was no difference in renal function with eitherrefluxing or antirefluxing ileal ureters. However, in areport on ileal ureteric replacement in 43 patients,Bonfig and colleagues concluded that although ascend-ing bacteriuria is inevitable, pyelonephritis and poten-tial renal damage may be prevented by an antirefluxinganastomosis.29 A procedure such as Leadbetter-Politanoureteral reimplantation may be considered. If pyelo-nephritis does occur, prophylactic antibiotics may aid inpreventing further episodes. If a patient has preexistingrenal insufficiency, an antireflux anastomosis may helpto decrease the risk for hyperchloremic metabolic aci-dosis.

When utilizing bowel within the genitourinary sys-tem, the risk for malignancy must be considered as well.In a study by Ali-El-Dein et al, tumor was discovered in2 of 258 (0.8%) patients with ileal ureters.30 Althoughthe risk for malignancy is low, close surveillance is high-ly recommended with monitoring of creatinine levelsand upper tract studies as well as with urine cytologystudies. Despite the risks and complications associatedwith an ileal ureter, the overall success rate has rangedfrom 81% to 100%.3,19

CASE PRESENTATION 2

A 39-year-old gravida 4 para 3 woman undergoes alaparoscopic abdominal hysterectomy for severe endo-metriosis. The patient describes symptoms of right flankpain and mild nausea 4 days postoperatively. She deniesany urinary storage or emptying complaints.

The patient has a low-grade fever of 100.1°F (36.2°C).Her abdomen is soft, with good bowel sounds. There isno rebound, rigidity, or guarding and no masses are ap-preciated. Physical examination reveals right-sided cos-tovertebral angle tenderness. Her bimanual examinationis unremarkable. Past medical history is significant forfibromyalgia, endometriosis, and chronic back pain.There is no history of smoking, drug use, or allergies.





Figure 3. Positioning for ileovesical anastomo-sis during single J stent placement.

Figure 5. Posterior side of proximal ileoure-teral anastomosis.

Figure 4. Ileovesical anastomosis with inter-rupted suture placement.

Distal endof ilealsegment

Proximal ilealsegment end

Right ureteral injury during the recent surgery is sus-pected. Both the serum creatinine level and urinalysisresults are normal. IVP is obtained, which reveals de-creased function of the right side and hydronephrosisof the right collecting system to the level of the pelvicbrim. Retrograde stent placement is not possible. Apercutaneous nephrostomy tube is placed and an ante-grade nephrostogram shows obstruction of the rightureter at the pelvic brim (Figure 6).

• Which other studies should be considered to furtherevaluate the right-sided obstruction?

A CT scan of the abdomen and pelvis with and with-out contrast likely would give no new informationbeyond that obtained by IVP. It would, however, illus-trate the extent of urinoma formation. A renal scanwould assess function of the obstructed kidney. Retro-grade ureteroscopy should be done to evaluate theureter below the site of injury, while combined ante-grade and retrograde pyelogram would illustrate thelength of the defect.

CASE 2 CONTINUED

An antegrade nephrostogram combined with a ret-rograde study demonstrates a 3-cm ureteral defect at themiddle to lower ureter. An attempt to place a double-Jstent is unsuccessful, and surgical correction of the ur-eteral defect is planned.

• What are the surgical options?

The surgical options for this patient from worst to bestchoices are ureteroureterostomy, transureteroureteros-tomy, right renal autotransplantation, ureteral ileal sub-stitution, right psoas hitch with a neoureterocystostomy,and right Boari flap and psoas hitch with ureteral reim-plantation. A ureteroureterostomy would not be the bestchoice because a segment of the lower ureter is devascu-larized and the blood supply at this level may be tenuous.Because it is difficult to salvage a sufficient amount ofhealthy, well-vascularized ureteral tissue at the lowerlevel, a direct anastomosis to the bladder would be moresuccessful. Transureteroureterostomy may be an option,but it should be low on the list because it places the nor-mal contralateral collecting system at risk for intraopera-tive damage or postoperative complications. Renal auto-transplantation places the kidney at risk for ischemiaduring the harvesting process and vascular reanasto-moses, and with a normal functioning contralateral kid-ney with no pathology, it is not mandatory. Also, becausethe defect is low and not excessive in length, autotrans-plantation is not necessary in this case. Ureteral ileal sub-stitution may be a viable option, although its possible

complications (eg, mucosal obstruction, urinary tractinfection, and reflux) must be considered.

A ureteroneocystostomy is indicated for injury orobstruction of the lower 3 to 4 cm of ureter. If greaterlength must be traversed, then a Boari flap and/orpsoas hitch may be necessary to avoid tension on theanastomosis. A direct, nontunneled anastomosis maybe created if there is no prior history of reflux. If thereis a concern of reflux, then a tunneled ureteral re-implant may be necessary. A retrospective study byStefanovic et al determined that there was no differencein renal function or risk of stenosis in adult patients whounderwent tunneled or nontunneled ureteral reim-plant procedures.31 A contraindication for ureteroneo-cystostomy, Boari flap, or psoas hitch is a small, con-tracted bladder. Such a bladder is not only difficult tomobilize, but it also increases pressure in the upper col-lecting system. Consequently, a urodynamics study maybe needed preoperatively.

Ureteral reimplantation is considered the procedureof choice for treating gynecologic-related ureteral in-juries located between 4 and 6 cm from the ureterovesi-cal junction. However, Boari flap along with a psoashitch is most commonly utilized when the defect islonger, when midureteral defects or lower ureteraldefects have questionable blood supply, or when it is notpossible to obtain a tension-free anastomosis with apsoas hitch. Laparoscopic procedures have been de-scribed for most types of ureteral stricture repair, butexperience with these procedures is not yet extensive.32



Figure 6. Prone view of right antegrade nephrostogram.

BOARI FLAP WITH URETERONEOCYSTOSTOMY ANDPSOAS HITCHPsoas Hitch

A psoas hitch may provide an additional 5 cm oflength and facilitates the creation of a tension-free anas-tomosis of the distal ureter to the bladder. The psoashitch procedure is best suited to strictures that do notextend above the pelvic brim. The key to performing asuccessful tension-free hitch is sufficient mobilization ofthe bladder. Occasionally, the contralateral superior vesi-cal artery may be ligated and divided to gain additionallength. The psoas minor tendon typically is used for thehitch, but the psoas major muscle or even the peri-toneum may be used as well. It is important to keep inmind that the genitofemoral nerve courses along thepsoas muscle and should be avoided. After a cystotomy,typically placed at the cephalad ipsilateral side of thebladder dome, a ureterovesical anastomosis is created.As discussed above, tunneling is not necessary if there isno prior history of vesicoureteral reflux. The ipsilateraldome of the bladder posterior to the anastomosis issutured to the psoas minor tendon, if present, or to thepsoas major muscle. Stents are recommended, but somesuggest that they may not be necessary.1

The most common complications of a psoas hitchare urinary fistulae and ureteral obstruction. The adultand pediatric success rate is greater than 95%.33 Successrates for psoas hitch with neoureterocystostomy are typ-ically 90% to 95%.19

Boari Flap

A psoas hitch alone may be insufficient to allow for atension-free anastomosis if the distal ureteral defect islonger than 8 to 10 cm. A Boari flap can be used torepair defects as long as 15 cm. Spiral flaps that reachthe renal pelvis have been described.34 Once again, it isimperative to create a watertight, tension-free anasto-mosis. Preoperatively, a urodynamics study may be indi-cated in order to rule out a small, contracted bladderthat can cause high pressures in the renal unit or maybe insufficient in size to allow for the creation of thedesired flap.

A wide bladder flap is necessary to ensure a suffi-ciently patent anastomosis. The flap should be at least 4 cm wide at the base and 3 cm wide at the apexbecause once incised it may narrow and not provide atubular segment wide enough for the ureterovesicalanastomosis. The flap length should equal the length ofthe ureteral defect. It is important to maintain theblood supply from the superior vesical and the inferiorvesical arteries. The apical end of the flap is turnedupwards and secured to the psoas minor tendon, if

available. Otherwise, it is sutured to the psoas majormuscle or nearby peritoneum. A mucosa-to-mucosaanastomosis is created after wide ureteral spatulation. Aureteral stent is placed into the bladder and the ureterwith the flap posterior to the stent. The flap is thenrolled anteriorly and closed over the indwelling stentwith long-acting, absorbable sutures.

The most common complication following Boari flapand psoas hitch with ureteral reimplantation is recur-rent stricture formation due to ischemia or a non–tension-free anastomosis. Anastomotic stricture rates forBoari flaps range from 0% to 17%, and success rates forlong ureteral defects range from 81% to 100%.19

CASE PRESENTATION 3

A 27-year-old man is status post-exploratory laparo-tomy for 2 gunshot wounds to the left abdomen. Intra-operatively, a splenic laceration was repaired, and therewere no other findings of injury following exploration.On postoperative day 3, the patient has notable abdom-inal distention with a rising blood urea nitrogen level(36 mg/dL) and a slightly elevated creatinine level (1.2 mg/dL).

A CT scan with intravenous contrast shows evidenceof extravasated contrast at the level of the left midureter.The contralateral side is normal. An IVP demonstrates adiffuse “ground glass” appearance overlying the abdo-men as a result of extravasation of contrast within theabdominal cavity. The patient is reexplored because it islikely that transection of the ureter occurred from oneof the bullets. Intraoperatively, the ureter is found to betransected at the junction of the upper and middle por-tions, and débridement of the ends is performed untilhealthy tissue is encountered.

• What are the surgical options?

IPSILATERAL URETEROURETEROSTOMY

A ureteroureterostomy is most commonly per-formed by a urologist during an intraoperative consultrelating to transection of a ureter. The ideal setting forthis procedure is a benign transection or stricturecaused by iatrogenic injury or penetrating trauma. Ure-teroureterostomy may be performed safely for shortdefects and is best performed on the midureter andupper (abdominal) ureter, which can be mobilizedmore easily than the lower ureter. However, due to thewide débridement necessary following a gunshotwound, ureteroureterostomy would not be recom-mended.35 As discussed earlier, defects in the lowerthird of the ureter can be repaired with a ureteroneo-cystostomy, with or without a Boari flap.



Technique

Mobilization of the ureter at each end must be care-fully performed with attention to maintaining the peri-ureteral adventitia. Mobilization must be sufficient toallow for spatulation of both ends and a water-tight,tension-free anastomosis. The first 5 to 6 mm of eachfresh end are spatulated 180° apart. If possible, the an-astomosis is wrapped with omentum or retroperitonealfat for added protection. A Foley catheter and closed-suction drain are placed and may be removed within afew days following the procedure depending on thepostoperative course. A ureteral stent should be main-tained for approximately 4 weeks. Complications in-clude ureteral strictures and urinary leak.

TRANSURETEROURETEROSTOMY

A transureteroureterostomy is commonly performedwhen the injury is located above the level of the pelvicbrim, the distal ureter is not viable, and a Boari flap withureteroneocystostomy may not be possible.1,35 As themaximum tension-free length for a Boari flap is 12 to 15 cm in theory, longer defects may require treatment bytransureteroureterostomy. Preoperatively, it is importantto rule out reflux with a voiding cystourethrogram if thesituation is nonemergent. A baseline IVP or CT urogramand retrograde pyelogram also should be obtained.

Success rates with transureteroureterostomy for ur-eteral stricture repair have ranged from 90% to 97%.1,36

Absolute contraindications are a diseased contralateralureter and inadequate length of the upper portion ofthe donor ureter. A length of at least 10 cm of upperureter should be intact to allow it to reach the contralat-eral ureter. Relative contraindications include tumor,nephrolithiasis, pelvic or abdominal radiation, chronicpyelonephritis, retroperitoneal fibrosis, and reflux of therecipient ureter.

Technique

A transperitoneal midline incision allows exposureto both ureters. Typically, for either side, the sigmoidcolon is mobilized and a peritoneal window is devel-oped inferior to the inferior mesenteric artery to avoidkinking of the donor ureter. Mobilization of the ureterabove the inferior mesenteric artery would preventkinking for short upper ureters.37 The ureteral adventi-tia must be handled with care to maintain sufficientblood supply after mobilization. A recipient ureteroto-my incision is made at the level of the midureter. A wideend-to-side spatulation is necessary for the donor andrecipient ureters, respectively. A stent is maintainedthrough the donor ureter and down to the distal recip-ient ureter. Closed-suction drainage is advisable.

Complications of transureteroureterostomy occur atrates ranging from 11% to 53% and include hema-tomas, infections, ureteral strictures, ureteral fistulae,recurrent urinary tract infections, and hydronephrosis.3

Stenosis of the ureteroureteral anastomosis and urinaryleak also occur.38 Both complications may be a conse-quence of the failure to obtain a tension-free anasto-mosis.

CASE 3 RESOLUTION AND DISCUSSION

Due to the level of the injury and débridement thatis necessary, a transureteroureterostomy is performed.Following ureteral injury due to gunshot wounds, widedébridement, possibly up to 2 cm from the point ofinjury, is necessary as microvascular injury may not beclearly evident.35,39 This procedure removes the risk ofbacteriuria associated with an ileal substitution andallows the creation of a tension-free, water-tight anasto-mosis, which may not have been safely performed with aureteroureterostomy.

CASE PRESENTATION 4

A 44-year-old man presents with sudden onset ofright-sided flank pain. The pain radiates to the rightgroin region and is associated with nausea and vomit-ing. He denies fevers, chills, or gross hematuria. Pastmedical history is significant for eosinophilic interstitialpneumonitis. Urinalysis reveals microscopic hematuria.Serum creatinine and electrolytes are normal. An IVPdemonstrates high-grade obstruction of the right kid-ney with nonvisualization of the ureter. The left kidneyfunctions normally and promptly. Bilateral nephrolithi-asis is evident on CT scan. Two calcifications are visual-ized in the right proximal ureter, and a crescent shaped,dysmorphic calcification is seen at the junction of themiddle to upper segment. The left collecting systemholds a 1-cm calculus in the upper pole.

Retrograde ureteroscopy with possible laser lithotrip-sy and biopsy of any suspicious lesions is planned. Resis-tance at the midureter is encountered intraoperativelywhen passing a guidewire. Flexible ureteroscopy revealsconcentric calcifications. A retrograde pyelogram re-veals irregular narrowing of the ureter from the junc-tion of the middle and upper segments to the uretero-pelvic junction. The upper ureter has a “moth-eaten”appearance associated with severe hydronephrosis(Figure 7). Urine cytology results are returned as nega-tive for malignancy. Cultures from the right kidneyurine are negative, and a tuberculosis skin test is nega-tive as well. As the patient has a history of eosinophilicpneumonitis, it is theorized that the same process hasaffected his kidney.



Later, a right-sided nephrostomy tube is placed; re-peat cytology studies of specimens extracted from thetube are persistently negative. Flexible nephroscopy re-veals the same concentric calcifications at the upperureter. Due to the severity of the ureteral strictures, it isnot possible to incise the strictures percutaneously.Extracorporeal shock wave lithotripsy of the left-sidedstone is performed at this time. Nuclear renal scanreveals 30% total renal function on the right side.

• Knowing that the upper half of the ureter is stric-tured, what are the most appropriate surgical optionsfor this patient?

Nephrectomy is not indicated with 30% of totalrenal function present, especially considering the pa-tient’s young age. Boari flap is not helpful for upperureteral defects. Ileal substitution is an option, but thereis an increased risk for infections with direct anastomo-sis to the renal pelvis. In addition, possible functionalobstruction may occur at the anastomosis of ileal seg-ment to the lower ureter with the smaller diameter.Transureteroureterostomy is not indicated in a patientwith bilateral nephrolithiasis. Also, the right donorureter would not reach the left side due to insufficientlength. Autotransplant with pyelovesicostomy wouldcreate an anastomosis of the renal pelvis to the bladderwith direct transmission of intravesical pressures. An

advantage of this approach would be easy passage ofstones into the bladder. Autotransplant with anastomo-sis to the lower ureter would avoid anastomosis directlyto the bladder and, therefore, aid in preventing trans-mission of intravesical pressures and vesicoureteral re-flux. A consult with a transplant surgeon is necessary ifthe urologist is not an expert with renal transplant.

RENAL AUTOTRANSPLANT

Indications for an autotransplant include long ure-teral stricture or injury, resectable upper ureteral malig-nancies, and branch renal artery disease.26 Autotrans-plant also could be considered in cases of severe,frequent nephrolithiasis, where pelviovesicostomy mightallow for easier passage of stones. Autotransplant alsohas been performed in loin pain hematuria syndrome,with success rates of 70% in relieving the symptoms asso-ciated with this syndrome.

The kidney is “harvested”; maximum vessel length isobtained with anastomosis to the iliac vessels and blad-der or lower ureter depending on the individual case.Two incisions may be necessary—a flank incision forharvesting the kidney and a Gibson incision for thetransplant. Occasionally, one long Gibson or midlineincision is used. Harvesting of the kidney may be donethrough a transperitoneal or retroperitoneal laparo-scopic approach. A Gibson incision is then used for thetransplant. Meng et al had success using ipsilateraltransperitoneal laparoscopic nephrectomy with auto-transplantation for severe proximal ureteral loss in 7 pa-tients.40 All of these cases were associated with severeperinephric and perihilar fibrosis due to nephrolithiasisor trauma. In these 7 patients, all grafts functionedimmediately. There were no intraoperative complica-tions at 17 months follow-up and there was a meandecrease in creatinine level of 5%.

Advantages of autotransplant are that it avoids use ofbowel and therefore reduces rates of intestinal compli-cations such as mucus or electrolyte problems, avoidschronic bacteriuria associated with bowel substitutes,and allows easier access for endoscopic procedures.Disadvantages of autotransplant are that it requires 2 incisions, can lead to vascular injury, and increases therisk of reflux into the pelvis.

CASE 4 RESOLUTION

In this case, a renal autotransplant is performed withanastomosis of the renal pelvis to the lower ureter. Theupper ureter is excised. Pathology reveals nondysplasticurothelium, chronic inflammation, extensive calcifica-tion, and focal ossification in addition to extensive stric-ture along the course of the ureter. The indwelling stent



Figure 7. “Moth-eaten” appearance of right ureter.

is removed 4 weeks following the surgery. An IVP 3 months later reveals excellent function and drainageof the kidney.

CONCLUSION

Multiple options are available for treating ureteraldefects. The best possible form of ureteral repair isdetermined based on the length and location of theureteral injury or stricture, the patient’s prior medicalhistory, pathology involving the contralateral collectingsystem, and the patient’s performance status. Repairsfor strictures above the pelvic brim include transure-teroureterostomy, ureteroureterostomy, ureteral ilealsubstitution, and renal autotransplant. Midureteral de-fects, if short, may be treated with ureteroureterostomyas well. For repairing injuries below the pelvic brim, aureteral reimplant typically would be recommendedwith a psoas hitch or Boari flap to traverse a greater dis-tance. In addition, an antireflux ureteroneocystostomywith a Leadbetter-Politano ureteral reimplant, for in-stance, may be preferred if necessary and feasible. Thetiming of repair should be judged on an individual casebasis. It is important to keep in mind the mainstays ofsuccessful repair such as a watertight, tension-free anas-tomosis and preservation of the ureteral adventia andblood supply.

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