Ureteroureterostomy and Transureteroureterostomy

Preoperative Preparation and Planning

Ureteroureterostomy (UU) and transureteroureterostomy (TUU) are most often used after trauma, either iatrogenic or penetrating. In such a setting, there is no time for preoperative workup, but some evaluation of the contralateral urinary tract should be performed. Options include intraoperative intravenous pyelography, direct visualization, or endoscopic evaluation. The use of UU and TUU in the elective setting should be only offered to carefully selected patients. Attention should be paid to factors that could result in failure of the operation—most notably radiation history and prior abdominal surgeries—so that the uretero–ureteral anastomosis can be completed in an area with healthy tissue and a robust blood supply.

The authors have an algorithmic approach to evaluating ureteral strictures. In patients with indwelling stents, we allow for 6 weeks of ureteral rest with stent removal and percutaneous nephrostomy tube placement before performing reconstruction. Nuclear medicine scans are obtained to determine differential renal function, and a bladder diary and American Urologic Association Symptom Index (AUA-SI) are solicited to evaluate baseline lower urinary tract symptoms. In patients with a history of radiation, urodynamics should be strongly considered.

Acutely ill patients or those not fit for surgery can be treated with chronic ureteral stents or percutaneous nephrostomy tube drainage. The latter may be performed in conjunction with ureteral ligation in the trauma setting. Endoscopic management with balloon dilation or incision with cold-knife or laser can also be considered in short (<1 cm), unifocal strictures. In appropriate surgical candidates, upper tract reconstructive options include UU; ureteroneocystostomy with psoas hitch, bladder flap, or both; TUU; and ileal ureter interposition. There are reports of laparoscopic and robotic ureteral reconstruction, as well as the use of buccal mucosal onlay grafts analogous to urethral stricture repair. This chapter focuses on open UU and TUU, but urologists should be prepared to use the full armamentarium of techniques before attempted ureteral reconstruction.

Patient Positioning and Surgical Incision

The incision depends on the level of the pathology. A midline vertical incision can be used to access the ureter at any level via a transperitoneal approach. A subcostal flank incision is preferable for a proximal site of pathology. Our preference for mid to lower ureteral injuries is an ipsilateral modified Gibson incision (see the chapter on Gibson incision). After gaining access to the retroperitoneum, the peritoneal contents are swept medially to expose relevant structurespsoas muscle and tendon, iliac vessels, ureter, and gonadal vessels. The ureter is generally identified in the soft tissue anterior to bifurcation of the common iliac artery, coursing posterior to the gonadal vessels in its distal aspect ( Figs. 36.1 and 36.2 ). To confirm the tubular structure in question is indeed the ureter, diluted methylene blue (2 cc in 50 cc of sterile saline) may be injected through the nephrostomy tube followed by aspiration of the ureter with a 25-gauge needle. Alternatively, gently squeezing the structure may elicit ureteral peristalsis, but this maneuver can lead to intimal disruption and thrombosis if performed aggressively on iliac vessels.

Ureteral pathology above the level of the pelvic brim will require medial mobilization of the colon and identification of the ureter in the tail of Gerota fascia posterior to the gonadal vessels; the proximal ureter is found posterior and lateral to the gonadal vessels, and the mid and distal ureter are identified posterior and medial to the gonadal vessels ( Fig. 36.3 ).

In the trauma setting, ureteral injury may be suspected after exploratory laparotomy and intraoperative urology consultation sought. In such cases, ureteral repair can usually be completed through the initial laparotomy incision. If needed, the posterior peritoneum overlying the great vessels can be opened to access either proximal ureter. This is especially useful in the trauma setting when renal hilar control is also desirable.

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