Indications and contraindications
Ureteral reimplantation is utilized in cases of ureteral obstruction of the distal ureter. Ureteral obstruction may be due to inflammatory, infectious, iatrogenic, or traumatic causes, as well as stone disease and mass lesions—either benign or malignant. In certain cases, a medical or endoscopic approach may be initially considered. However, when conservative management is unsuccessful or deemed unsuitable for a certain pathology, ureteral reimplantation is indicated.
Traditionally, ureteral reimplantation has been performed through an open midline or Pfannenstiel incision. Fortunately, surgical and technological advancements have led to the increasing adoption of minimally invasive techniques, both laparoscopic and robotic-assisted. Minimally invasive surgery offers a shorter hospital stay, less postoperative pain, and improved cosmesis.
Ureteral reimplantation should only be considered when a tension-free anastomosis can be performed. Alternative surgical strategies should be considered for lesions that involve the middle or proximal ureter, multiple malignant masses throughout the urinary tract, or a poorly functioning ipsilateral kidney.
In children, ureteral reimplantation is commonly performed in the setting of vesicoureteral reflux. Further evaluation and surgical nonrefluxing techniques in the setting of vesicoureteral reflux are beyond the scope of this chapter.
Preoperative evaluation and preparation
Prior to considering ureteral reimplantation, the surgeon should take a detailed medical history of the patient, paying close attention to prior pelvic radiation, trauma, and abdominal or pelvic surgeries. Surgical treatment of ureteral pathology necessitates adequate antegrade and retrograde imaging to define the length and location of the segment of abnormal ureter. Furthermore, the preoperative bladder capacity allows the surgeon to know the feasibility of a bladder flap if necessary for a tension-free anastomosis. Computed tomographic urography is useful in the assessment of a patient’s anatomy for access considerations and intraoperative identification of structures. If there is concern regarding renal function, a nuclear medicine renal scan can also be performed. A preoperative ureteral stent can lead to inflammation and obscure the length and location of the abnormal ureter. Thus, a nephrostomy tube is often recommended to protect the kidney and allow for ureteral rest during surgical planning. Routine preoperative evaluation with laboratory tests is also recommended.
Armed with this information, the benefits and risks of open and laparoscopic or robotic-assisted repairs should be discussed with the patient. Furthermore, patients should be counseled about the possibility of alternative techniques for ureteral reconstruction such as a psoas hitch, Boari flap, buccal mucosa ureteroplasty, and ileal ureter, as well as the risk for conversion to an open procedure should it be necessary. Although extraperitoneal approaches do not traditionally warrant a bowel preparation, it should be strongly considered when utilizing a transperitoneal approach or the potential use of the bowel in reconstruction.
Operating room configuration and patient positioning
The operating room should be ergonomically configured, allowing enough space and adequate visualization of the procedure for all involved personnel. After general anesthesia and endotracheal intubation, an orogastric tube is placed for decompression of the stomach. Sequential compression devices are used for lower extremity thrombosis prophylaxis. The patient is positioned supine with arms tucked at the sides and the legs placed on spreader bars or stirrups. Padding is placed around the elbows to protect the ulnar nerve from injury and around the lateral knees to protect the common peroneal nerve (if the patient is placed in stirrups). Aligning the hips with the break in the table maximizes the ease of access to the pelvis. Security belts and tape are applied across the chest to provide support and safe positioning. The entire abdomen and genitalia are prepared in a sterile manner and draped. A urethral catheter (open tipped) is placed within the sterile field to allow for access during the surgical procedure. Angling the table approximately 15 degrees in Trendelenburg while simultaneously tilting the contralateral side of the table downward maximizes exposure for the procedure ( Fig. 25.1 ).
Access can be achieved via either Veress needle or the Hasson technique. A 12-mm supraumbilical incision is made for placement of an optical trocar, though an 8-mm port can be used if using the da Vinci XI robotic surgical system (Intuitive Surgical, Inc; Sunnyvale, California). An 8-mm robotic port is placed at the level of the iliac crest, just lateral to the rectus muscle on the contralateral side to the affected ureter. A second 8-mm robotic port is placed on the ipsilateral side of the affected ureter one to two fingerbreadths inferior to the supraumbilical optical port and lateral to the rectus muscle. A 12-mm assistant port is triangulated laterally to the optical port and superiorly to the contralateral robotic port. Laparoscopic trocar placement is similar, with each working trocar at the level of the iliac crest ( Fig. 25.2 ).
Procedure (see and )
After achieving insufflation, a 30-degree downward facing scope is used to identify patient anatomy and ensure no entrance injury. The colon is deflected medially, mobilizing it along the white line of Toldt (from the liver on the right and the spleen on the left). The ureter can be identified crossing anteriorly to the iliac vessels ( Fig. 25.3 ). Prior surgery or radiation can cause a significant amount of inflammation or adhesions surrounding the ureter in this area; care should be taken to identify known structures and use them as landmarks for dissection. For example, in men, the ureter can be found crossing posteriorly to the vas deferens; in women, it can be found deep in the peritoneal fold between the uterus and the bladder in the area of the trigone. Often, a plane around the adventitial tissue of the ureter can be identified and exploited to dissect out the ureter and maintain a healthy blood supply. A vessel loop can be helpful for manipulation of the ureter, preventing injury from direct handling. Mobilize the ureter caudally while carefully preserving the adventitial tissue to maintain vascularization ( Fig. 25.4 A).