Ureteral Reconstruction

The ureter has been opened, repaired, or reconstructed predominately utilizing sutured techniques (39). Nezhat probably was the first to report a clinical application of intracor-poreal-sutured reconstruction of a ureter obstructed by endometriosis. Excision of the involved segment and ureteroureterostomy was performed over 7 French catheter with four interrupted 4-0 absorbable sutures. A CO2 laser was utilized for the bloodless dissection prior to reconstruction with an estimated surgical time of 117 minutes (40). Wichham explored and performed a laparoscopic ureterolithotomy without repair of the ureter in 1978 (41). Closure of the ureteral wall following ureterolithotomy was described utilizing a running 4-0 absorbable sutures® anchored on each end with absorbable clips (42). The procedure lasted approximately 180 minutes. We have recently resected a stenotic segment of ureter with an eroded proximal calculus and performed a Heinike-Mikulitz type of ureteroureterostomy with interrupted 4-0 chromic gut sutures intracor-poreally tied over a stent (Fig. 4). A case of a right circumcaval ureter requiring transposition has also been reported (43). Retrograde dissection of the right ureter from the iliac vessels identified the post caval segment. Next, the middle third of the ureter was dissected until it passed behind the cava to the renal hilum. The renal pelvis was identified and dissected to the area of obstruction, divided, the distal ureter was spatulated and anastomosed with five 4-0 polyglactin interrupted sutures over a wire guide. This procedure was accomplished in 560 minutes and stented following the repair. Others have repeated the procedure of ureteral repair for retrocaval ureter, most now support a complete intracorporeal sutured repair (44). The laparoscopic approach and treatment of benign retroperitoneal fibrosis has been described (45). After mobilizing the ureter in a 15-year-old female, the ureter was secured within the abdomen with a biting clip applier. The correction of vesicoureteral reflux using laparoscopic biting clips to reapproximate the muscularis over the distal ureter and create a nonrefluxing tunnel has been described in the porcine model (46). There are now several series in which retroperitoneal fibrosis has

FIGURE4 ■ Laparoscopic ureteral exploration for an eroded proximal left ureteral calculus. Use of an arthroscopic hooked-blade knife is shown (above left), and stone extraction (above right). Sutured reconstruction over a stent with interrupted 4-0 chromic intracorporeal stitches is shown below.

FIGURE4 ■ Laparoscopic ureteral exploration for an eroded proximal left ureteral calculus. Use of an arthroscopic hooked-blade knife is shown (above left), and stone extraction (above right). Sutured reconstruction over a stent with interrupted 4-0 chromic intracorporeal stitches is shown below.

Ricostruzione Uretere

been explored, biopsied and peritonealization of the ureter has been accomplished. In fact, Puppo et al. have even reported upon the classic method of bilateral ureterolysis because of the risk of bilateral involvement (47). Finally, the ureter has been taken apart and reconstructed laparoscopically with intracorporeal suturing techniques for severe endometriosis in nine patients. Long-term follow-up for these laparoscopic ureteroureterostomies is available between two months and seven years. Only one patient developed a mild ureteric stricture that required balloon dilation (48).

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