Introduction
Ureterolysis is performed to relieve ureteral obstruction caused by extrinsic compression. Obstructive encasement of the ureter is most often secondary to prior retroperitoneal insults resulting in a desmoplastic reaction. Most common etiologies include radiation treatment for malignancy, vascular surgery, infections, autoimmune disorders, and certain drugs. A less common indication for ureterolysis is primary retroperitoneal fibrosis (RPF). RPF is a rare, chronic process characterized by inflammation and mononuclear infiltration and is idiopathic in approximately two-thirds of patients. Patients typically have flank or abdominal pain, azotemia, and hydronephrosis from ureteral involvement. The aorta and vena cava are also frequently involved, which 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, Kavoussi et al. 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 (RALU). This chapter focuses on both purely laparoscopic and RALU procedures.
Indications and contraindications
No current consensus exists on whether patients should undergo primary ureterolysis or steroid treatment with mycophenolate mofetil or RPF after renal obstruction is relieved either through ureteral stenting or nephrostomy tube placement. There are several reports of a response to a course of high-dose prednisone. The optimum dose and duration are not standardized; however, many authors recommend treatment with 0.6–1 mg/kg/day of prednisolone for 2–4 weeks, then tapering to 2.5–5 mg/day for >6 months. Unfortunately, some cases are refractory to these treatments.
Indications for surgical intervention include failure of (or intolerance to) medical treatments or recurrent RPF. Arguments for “upfront” surgery have been made, especially when tissue diagnosis is needed, which often requires deep tissue samples not readily obtained through percutaneous sampling. Surgical treatment is contraindicated when extrinsic compression is known to be from malignancy or another other treatable condition.
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 to determine the functionality of the renal unit. 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. In the case of primary RPF, images of the affected ureter typically reveal a classic triad of medial deviation, extrinsic compression, and hydronephrosis. In patients with an iatrogenic cause of obstruction (i.e., prior radiation or surgery), the affected portion of the ureter may be more focal and isolated to the distal ureter ( Fig. 24.1 ).
After confirmed diagnosis and ureteral decompression, we offer patients a choice between a trial of medical therapy or upfront robotic-assisted ureterolysis. Medical therapy is guided by rheumatologic consultation. If patients are intolerant of medical therapy or improvement does not occur within 6 months of medical therapy, we recommend laparoscopic or robotic-assisted ureterolysis. Before informed consent is given, all patients are counseled regarding the possibility of neoureterocystostomy with or without a Boari flap or psoas hitch, ileal ureter, nephrectomy, or conversion to open surgery.
Operating room configuration and patient positioning
We use an operating table that is fluoroscopy compatible and has a removable foot to accommodate lithotomy positioning for the endoscopic portion of the procedure, if need be. The operating room scrub and equipment tables are placed opposite the operative side ( Fig. 24.2 ). This will also be the location of the assistant during a robotic-assisted procedure or both the surgeon and assistant during a pure laparoscopic procedure. A monitor is placed opposite the assistant. The table is padded before the patient is transferred.
After induction of general anesthesia, the patient is initially placed in the 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. 24.2 ). 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. An axillary roll is placed to prevent a brachial plexus injury. The dependent arm is secured on an arm board and protected with 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 cloth tape that is wrapped across the upper shoulder and around the table two times. The nipples and skin are protected with foam. The hip is secured similarly, crossing the pubic bone. The patient is test rolled in each direction to ensure that the patient is secure. An alcohol-based preparation is used over the entire abdomen in case open conversion is necessary, and the patient is draped.
For secondary RPF that is thought to be isolated to the pelvis, the patient is secured in the lithotomy position to permit ready access to the distal ureters bilaterally. This approach also allows for bladder mobilization or creation of a Boari flap or a psoas hitch if ureteral reimplantation is required.
Trocar placement
Use a Veress needle to establish intraperitoneal access and insufflation. Enter at the umbilicus in a virgin abdomen or at a site that is superior and lateral on the abdomen when there has been prior surgery. After insertion, aspirate to ensure that no blood or bowel contents are present, and perform a drop test with saline. Insufflation is started on low flow (1 L/min) to confirm low opening pressures before increasing the flow rate to a maximum pressure of 15–18 mm Hg.
A 12-mm camera port is placed through the umbilicus or strategically in the midline with a 12-mm Visiport (Covidien, Norwalk, CT) or a 12-mm bladeless trocar dilator such as the Endopath Xcel (Ethicon Endo-Surgery, Cincinnati, OH). If RALU is performed and an assistant port is not desired, the 8-mm direct visual access robotic port is used. After entrance into the abdomen, the obturator is removed and the zero-degree lens is reinserted to ensure that there has been no injury at the insertion site. A 30-degree laparoscopic camera is then used to confirm placement of the Veress needle and place the other trocars.
In the instance of RALU, all 8-mm trocars can be placed in the midline. This configuration allows access to the entire ureter. If bilateral ureterolysis is indicated, patient repositioning is required; however, changes in robotic port placement are not. A 5- or 12-mm assistant port(s) may be placed lateral to the contralateral rectus, splitting the distance between any of the midline 8-mm robotic ports.
Other trocar configuration for RALU can be readily employed. On a line 8 cm lateral to the midline in the direction of the affected ureter, measuring one handbreadth both above and below the umbilicus, 8-mm robotic ports are inserted. A 5-mm assistant port is placed on the midline below the caudal robotic port ( Fig. 24.3 A). If a pure laparoscopic approach is planned, we do not place an assistant port, and we use 5-mm trocars in lieu of the robotic ports. The cephalad trocar is kept on the midline between the umbilicus and the xiphoid process, and the caudal port is placed on a line between the ipsilateral anterior superior iliac crest and the umbilicus ( Fig. 24.3 B).
