Ureteroneocystostomy

Distal ureteral reimplantation or ureteroneocystostomy in adults is indicated in the setting of distal ureteral stricture disease or ureteral injury sustained during gynecologic or pelvic laparoscopic surgery. While both refluxing and nonrefluxing reimplantations have been performed laparoscopically in adults, the former is much more common. The first laparoscopic ureteroneocystostomy was reported by Reddy and Evans for the treatment of a 1-cm distal obliterate ureteral stricture that developed in a 74-year-old man as a delayed complication of transurethral resection of the prostate (20). Operative time in this transperitoneal refluxing reimplant was 4.5 hours, and estimated blood loss was less than 50 cc. The patient required only four tablets of acetaminophen/codeine for pain control during the first 36 hours after surgery and was discharged home on postoperative day 2. His recovery was unremarkable and at one-year follow-up, he had excellent urinary drainage documented by excretory urogram.

Attesting to the feasibility of laparoscopic ureteroneocystostomy, other investigators have reported excellent results in the treatment of secondary ureteral stricture due to perforations from ureteroscopy as well as in gynecologic cases where infiltrative ureteral endometriosis or inadvertent ureteral injuries necessitate distal ureteral resection and reimplantation (21-25).

In performing laparoscopic ureteroneocystostomy, placing the patient in a low dorsal-lithotomy position is ideal, and the table is tilted at 15 to 45 degree of Trendelenburg to allow overlying bowel fall out of the pelvis (20-25). A transperitoneal approach provides excellent exposure and is important in longer strictures where a bladder psoas hitch may be needed for a tension free repair. Typically, four ports are needed. After creation of pneumoperitoneum and medial mobilization of the colon, the ureter is identified and circumferentially mobilized where it crosses the iliac vessels. An umbilical tape or vessel loop can be placed around the ureter and used for traction during dissection distally toward the bladder. Care is taken to preserve periureteral blood supply and avoid thermal injury from overly aggressive use of coagulation. The ureter is transected, and the pathologic ureteral segment is resected or ligated and left in situ. The proximal end of the ureter is inspected and then spatulated in preparation of reimplantation. The bladder is filled with saline, and under both cystoscopic and laparoscopic visualization, a location closest to the spatulated ureter is selected for the cystostomy. A 1-2 cm full-thickness cystostomy is made.

The typical refluxing anastomosis is created with four to five interrupted fine absorbable sutures that traverse all layers of the bladder and the ureter.

Intracorporeal and extracorporeal knot-tying as well as the Endostitch device can be used to bring the ureter and bladder together. Nonrefluxing anastomosis has also

Laparoscopic cutaneous ureterostomy is a valuable palliative procedure in the management of distal ureteral obstruction from advanced pelvic cancers such as prostate, bladder, and uterine cancer.

Attesting to the feasibility of laparoscopic ureteroneocystostomy, other investigators have reported excellent results in the treatment of secondary ureteral stricture due to perforations from ureteroscopy as well as in gynecologic cases where infiltrative ureteral endometriosis or inadvertent ureteral injuries necessitate distal ureteral resection and reimplantation.

The typical refluxing anastomosis is created with four to five interrupted fine absorbable sutures that traverse all layers of the bladder and the ureter.

been reported in the clinical setting with success (25-27). In either nonrefluxing or refluxing reimplants, it is also important to avoid tension, ureteral torsion and angulation. When additional length is needed, the ureter can be mobilized further proximally or a vesicopsoas hitch can be used (22,23). At the end, the repair is then tested by bladder filling and direct laparoscopic visualization. At the conclusion of the repair, a pelvic drain is left for one to two days, and the ureteral stent is left for four to six weeks. Follow-up intravenous pyelograms or retrograde pyelograms should be obtained to ensure continuity and patency. Given the fact that indications for ureteral reimplant vary and that reimplantations are sometimes performed at the same setting of other gynecologic procedures such as hysterectomies, data on operative times, blood loss, and postoperative hospitalization are difficult to compare. In general, laparoscopic ureteroneocystostomy takes three to four hours (3.5-4.5 hours) with estimated blood loss of less than 50 cc (20,21,25). Patients can expect minimal postoperative pain, a short convalescence and excellent urologic outcomes.

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