We gratefully acknowledge the contribution of Dr. John Pope, who authored this chapter in previous editions.
When a patient is in need of bladder augmentation and a significantly dilated ureter is present, ureterocystoplasty should be considered. Ureterocystoplasty has advantages over enterocystoplasty because it is does not produce mucus, decreases the risk of metabolic disturbances, and may decrease long-term risk of urinary tract infections, stones, and neoplasia. In addition, bladder compliance and capacity can be restored with urothelial-lined tissue that may function synergistically with the native bladder, allowing for more physiologic filling and emptying and the potential for coordinated spontaneous voiding.
Unfortunately, even when dilated ureteral tissue is present, legitimate therapeutic indications for ureterocystoplasty are limited, and the surgeon should be realistic in terms of anticipated outcomes. Spontaneous voiding to completion can only be reasonably expected if the patient already enjoys that dynamic; this may be unlikely in the setting of a clinical need for bladder augmentation. The typical patient who might be considered for ureterocystoplasty is an individual with massive vesicoureteral reflux or hydroureteronephrosis with nonfunction of the ipsilateral kidney. However, in the current era of aggressive management of neurogenic bladder dysfunction, there are relatively few practical applications of ureterocystoplasty; markedly dilated ureters and severe renal dysfunction are rarely present. In this setting, although the indications have been expanded with the use of transureteroureterostomy, the distal ureteral diameter may be inadequate for effective augmentation. In a multi-institutional review of 64 patients, Husmann and colleagues identified a nonrefluxing ureter of larger than 1.5 cm diameter as predictive of postoperative increased bladder capacity. Refluxing ureters and less dilated nonrefluxing ureters were found unlikely to yield success in terms of improved capacity and compliance.
A plethora of surgical variations have been described. Incorporation of the entire ureter and pelvis in the setting of nephrectomy and utilization of unilateral or bilateral distal ureters have been described. In the latter situation, preservation of the renal units involves tapered reimplantation of the proximal ureter or transureteroureterostomy.
Preoperative urodynamic evaluation should be performed to determine the unique needs of the bladder in terms of capacity and compliance. When considered in combination with the available ureteral resources, the surgeon is better prepared to realistically counsel the patient and family regarding potential intraoperative decision for enterocystoplasty in addition to or in lieu of ureterocystoplasty. Preoperative bowel preparation, as per the surgeon’s preference or practice, also allows this intraoperative flexibility.
A midline transperitoneal incision provides excellent exposure and access for additional reconstructive procedures that may be indicated: bladder neck reconstruction, creation of a continent catheterizable channel, and management of the proximal and distal ureteral segments. Other authors advocate a fully extraperitoneal approach via one or two incisions. For cases including a nephrectomy, a laparoscopic approach with or without a low transverse incision (Pfannenstiel) or lower midline incision is used.
If the ipsilateral kidney is to be preserved as shown in Fig. 62.1 , the distal ureteral segment is used for augmentation while the proximal ureteral drainage is restored through transureteroureterostomy or tapered reimplantation into the native bladder. If the ipsilateral kidney is nonfunctional, it should be removed by dividing the renal vessels near the parenchyma and meticulously preserving the renal pelvis with its adventitial tissue. The ultimate success of the procedure hinges on the health of the ureteral flap, which in turn relies on preservation of the blood supply along the length of the ureter.
Dissect the ureter from the retroperitoneal tissues, keeping the segmental blood supply intact. Adventitia and periureteral tissue should be swept from the peritoneum toward the ureter during mobilization to protect the ureteral blood supply. Proximally, this blood supply typically arises medially. As the ureter enters the true pelvis, the blood supply arises posterolaterally. It is important to remember that ureteral blood supply arises from numerous sources, including the aorta, the iliac, vesical, and gonadal vessels. If previous surgery has been performed on the distal ureter, preserving the proximal blood supply is even more critical. The ureter should be divided to allow approximately 5 to 8 cm of length for augmentation but with adequate length remaining proximally for anastomosis to the contralateral ureter if a transureteroureterostomy is needed.
The distal ureteral segment is opened along its anteromedial border down through the ureterovesical junction. It is important to avoid spiraling the incision. The ureter is not detached from the bladder but rather is opened longitudinally along its entire length. The bladder is then opened in the sagittal plane in a clamshell fashion in continuity with the ureteral incision. The extent of the cystotomy depends on the quantity of ureteral tissue.
The spatulated ureter is folded on itself to form a U -shaped patch ( Fig. 62.2, A ). As with an enterocystoplasty, a spherical configuration of the augmented bladder maximizes the volume that is achieved. Before completion of the augmentation, a suprapubic catheter is inserted through the native bladder wall. The ureteral U patch is anastomosed to the bivalved bladder with running 3-0 absorbable suture ( Fig. 62.2, B ). A drain should be placed in the perivesical space, and the suprapubic tube should be connected to gravity drainage for 14 to 21 days. Before the suprapubic catheter is removed, cystography may be performed to confirm the absence of a urine leak.