How is transureteroureterostomy performed for iatrogenic ureteral injury repair?

Updated: Nov 12, 2020
  • Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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A transureteroureterostomy is approached best via a midline incision and can be performed using both intraperitoneal and extraperitoneal approaches. A left-to-right intraperitoneal transureteroureterostomy is described.

After a Foley catheter is placed and the patient is prepared and draped in a sterile manner, a midline incision is made, and the peritoneal cavity is opened. The small bowel is packed medially, and the posterior peritoneum lateral to the sigmoid and descending colon is incised to expose the ureter. The ureter is dissected, preserving its adventitia. The diseased portion of the ureter is identified, and a clamp is placed on the ureter proximal to the diseased portion. The diseased portion of ureter is excised, a stay stitch is placed on the proximal segment of the ureter, and the distal stump is ligated. The proximal ureter is dissected for a length of approximately 9-12 cm, while the adventitial vessels are preserved.

Attention is then turned to exposing the right ureter. The ascending colon is retracted medially while an incision is made through the posterior peritoneum lateral to the colon. Blunt dissection aids in the identification of the ureter. Approximately 4-6 cm above the level of transection of the left ureter, the right ureter is exposed to make room for an anastomosis.

A retroperitoneal tunnel is created via blunt dissection, and the left ureter is pulled through the tunnel by the stay suture. When the left ureter is pulled through, taking care not to wedge the ureter between the inferior mesenteric artery (IMA) and the aorta is important, because obstruction may result. Instead, the ureter should be passed either over or under the IMA and should not be angulated or be under any tension. If the ureter is too short and a tension-free anastomosis can only be performed with the ureter firmly wedged between the IMA and the aorta, it is appropriate to consider ligation of the IMA. If this maneuver is not performed and the ureter is left firmly between the IMA and the aorta, a fibrous reaction of the ureter typically occurs, which causes obstruction that must be treated later with a surgical procedure.

The tip of the left ureter is spatulated, and the medial wall of the right ureter is incised using a hook blade for a distance just longer than the diameter of the lumen of the left ureter. Using 4-0 or 5-0 absorbable suture material, a suture is placed at each end of the ureteral incision from the outside in. Each stitch is run over the course of one half of the anastomosis. Before finishing the second side of the anastomosis, a stent is placed along the entire right ureter using the technique described in ureteral stent placement. The 2 stitches are tied to each other.

After the anastomosis is completed, a Penrose drain or a JP drain is placed in the retroperitoneum and is brought out through the skin. Omentum or any adjacent retroperitoneal fat may be used to wrap the repair. The anterior abdominal fascia and skin are closed.

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