Ureterolysis is performed to relieve ureteral obstruction caused by extrinsic compression. Retroperitoneal fibrosis (RPF) is a rare (1 in 200,000-500,000) chronic process characterized by inflammation and mononuclear infiltration that is idiopathic in about two thirds of patients. Secondary causes include certain malignancies, infections, prior radiation, previous surgeries, autoimmune disorders, and certain drugs. Patients typically have flank or abdominal pain, azotemia, and hydronephrosis from ureteral involvement, which is present in 60% to 100% of cases. The aorta and vena cava are also frequently involved; this may result in lower extremity edema, claudication, or testicular pain. Medical treatment with glucocorticoids can be effective, but the dose and duration of treatment have not been well established.
Open ureterolysis has been associated with a success rate exceeding 90% in long-term resolution of ureteral obstruction. In 1992, Kauvoussi and colleagues first described laparoscopic ureterolysis. Since that time, multiple authors have reproduced these techniques with success rates similar to the open approach. In 2006, Mufarrij and Stifelman reported the first successful robotic-assisted laparoscopic ureterolysis. They described improved visibility and dexterity and decreased surgeon fatigue. This chapter focuses on both purely laparoscopic and robotic-assisted laparoscopic ureterolysis, although hand-assisted techniques have also been described.
Indications and Contraindications
No current consensus exists on whether patients should undergo primary ureterolysis or steroid treatment for RPF after renal obstruction is relieved either through ureteral stenting or placement of a nephrostomy tube. There are several reports of a vigorous response to a course of high-dose prednisone, often in combination with azathioprine, tamoxifen, or mycophenolate mofetil. Unfortunately, the optimum dose and duration are not well established and some cases are refractory to these treatments.
Indications for surgical intervention include failure of or intolerance to medical treatments (e.g., diabetes) or recurrent RPF. Arguments for “up-front” surgery have been made, especially when tissue diagnosis is needed, which often requires deep tissue samples that are not readily obtained through percutaneous sampling. Surgical treatment is contraindicated when extrinsic compression is known to be from malignancy (e.g., lymphoma or metastatic disease) or other treatable conditions such as endometriosis.
Patient Preoperative Evaluation and Preparation
Initial workup for RPF includes a detailed history and physical examination. Serum laboratory values are obtained, including complete blood count with differential, metabolic panel with creatinine, erythrocyte sedimentation rate, and C-reactive protein. If there is any reason to suspect an underlying malignancy or autoimmune disease, appropriate consultations with oncologists and rheumatologists, respectively, are undertaken. Computed tomography (CT) or magnetic resonance imaging (MRI) is performed to assess for burden of disease and evidence of hydronephrosis or renal atrophy. If there is evidence of long-standing obstruction, a diuretic renal scan is performed. Contrast-enhanced images of the ureters are obtained through CT or MRI urography if there is no planned ureteral decompression but are otherwise obtained with pyelography at the time of stent or nephrostomy tube placement. Images of the affected ureter typically reveal a classic triad of medial deviation, extrinsic compression, and hydronephrosis ( Fig. 26-1 ).
After confirmed diagnosis and ureteral decompression, it is our current practice to offer patients a choice between a trial of medical therapy or up-front robotic-assisted ureterolysis. Medical therapy is guided by rheumatologic or oncologic consultation. If patients are intolerant of medical therapy or improvement does not occur after 4 to 8 weeks of medical therapy, we recommend robotic-assisted ureterolysis. Before informed consent is given, all patients are counseled regarding the possibility of neoureterocystostomy with or without Boari flap or psoas hitch, ileal ureter, nephrectomy, or conversion to open surgery.
Operating Room Configuration and Patient Positioning
We use an operative table that is fluoroscopy compatible, can be slid toward the head and foot, and has a removable foot to accommodate lithotomy positioning for the endoscopic portion of the procedure. The operating room scrub and equipment tables are placed opposite the operative side (e.g., on the patient’s right if the left ureter is being lysed), as shown in Figure 26-2 . This will also be the location of the assistant during a robotic-assisted procedure or both surgeon and assistant during a pure laparoscopic procedure. A monitor is placed opposite the assistant. The table is padded with either gel or foam before the patient is transferred.
After induction of general anesthesia, an orogastric tube is placed and the patient is completely paralyzed. The patient is initially placed in lithotomy position. Bilateral retrograde pyelograms are obtained to localize the affected area of the ureter(s) and ensure there is no contralateral involvement when unilateral disease is suspected. A new ureteral stent is placed and a Foley catheter is inserted. The patient’s midline is then marked and marks are made for the anticipated location of the ports, as described later. The patient is left in stirrups and placed in a modified lateral decubitus position with the affected side up ( Fig. 26-3 ). Keeping the patient in stirrups allows for access to the urethra should the stent need to be manipulated or for performance of simultaneous ureteroscopy. A large gel roll is placed under the scapula of the operative side. A small gel roll is used for an axillary roll to prevent a brachial plexus injury. The dependent arm is secured on an arm board and protected with thick egg crate foam. The other arm is placed caudally, with the wrist resting over the iliac crest. Foam is used above and below the arm, and the elbow is subtly flexed to protect the ulnar nerve. The patient’s chest is secured with 3-inch cloth tape that is wrapped across the upper shoulder, coming just under the patient’s nipples and then around the table two times. The nipples and chest skin are protected with foam. The hip is secured similarly, crossing the pubic bone and securing the Foley catheter. The patient is test rolled in each direction to ensure that the patient is secure and all pressure points are amply padded. Often the anesthesia provider must secure the head with additional towels or foam and a piece of thin tape to prevent movement. An alcohol-based preparation is used over the entire abdomen in case open conversion is necessary, and the patient is draped. An open tray should be in the room for the duration of the procedure.
