The primary goal of a TUU is to reestablish nonobstructive, nonrefluxing drainage of the ureter. Historically, TUU in children has been performed either to salvage a failed ureteral reimplantation or in conjunction with cutaneous ureterostomy for urinary diversion (4,5,6). Because TUU requires only one ureter for reimplantation, this procedure was commonly employed in the 1980s for urinary undiversion of conduits or in the construction of continent urinary reservoirs (3,7). In the majority of these cases, TUU was used simultaneously with reimplantation of the recipient ureter, many of which required tapering or tailoring frequently with a psoas hitch and/or bladder augmentation. TUU has also been used as an adjunct to reimplant procedures complicated by an abnormal bladder, which precludes reimplantation of more than one ureter, or as a salvage procedure for failed ureteral reimplantation surgery (3). More recently, indications for TUU have been broadened to allow for harvesting the distal donor ureter to construct a continent ureteral conduit for clean intermittent catheterization or for unilateral ureterocystoplasty in cases where there is sufficient ureteral dilatation (2).

Ureteral reconstruction with TUU may not be possible if there is insufficient donor ureter (approximately one-half the original length) for a tension-free anastomosis. Any disease process that has the potential to affect contralateral renal function or drainage is also a contraindication, such as retroperitoneal fibrosis, high-dose radiation therapy, calculus disease, recurrent pyelonephritis, and urothelial malignancy. Although size disparity between ureters has been regarded as a relative contraindication in the past, successful TUU has been accomplished by use of a longer vertical ureterotomy in the recipient ureter to accommodate a larger-caliber donor ureter (3,5,7).

Other procedures to be considered in lieu of TUU include ureteroneocystostomy with a psoas hitch or Boari flap, nephropexy to allow ureteroneocystostomy or ureteroureterostomy, ileal substitution, and autotransplantation. Other alternatives to TUU include mitigating or temporizing procedures such as cutaneous ureterostomy, pyelostomy, nephrostomy drainage, and ureteral stenting. Nephrectomy should also be considered in cases of marginal donor renal function.

The patient is placed supine with such options as kidney rest elevation, retroflexion of the surgical bed, and Trendelenburg positioning to enhance retroperitoneal exposure. A midline vertical incision is usually made in the abdomen, extending from just above the umbilicus to the pubic symphysis. However, in cases of distal TUU following a failed reimplantation, a Pfannenstiel incision may be sufficient. A choice of exposure approaches is then available.