A thorough bimanual and speculum examination of the pelvis should be performed prior to ureteroneocystostomy.

Two mL of indigo carmine solution are injected intravenously prior to the procedure to provide a urinary marker for fast identification of the ureter in the distorted pelvic anatomy. If there is confusion as to whether a tubular structure is a ureter or a blood vessel, aspiration with a 21-gauge needle and  a 5-mL syringe will yield the blue dye from the indigo carmine if the structure is the ureter.

The patient is operated on in the supine position. A lower midline incision is made.

The peritoneum is entered, and the omentum and intestinal contents are dissected out of the pelvic cavity.

The peritoneum over the ureteral area is incised at the bifurcation of the common iliac artery, and the dissection is continued into the pelvis until the damaged portion of the ureter is exposed.

The ureter is transected above the damage, and the distal end is tied with 0 synthetic absorbable suture. The proximal portion is dissected out of its bed with careful surgical technique to ensure the continuity of the ureteral sheath that is so important for adequate blood supply to the ureter.

The bladder is mobilized by entering the space of Retzius behind the pubic symphysis and dissecting the bladder cephalad so that a portion of posterior bladder wall meets the proximal portion of ureter to be implanted. The dome of the bladder is picked up with Allis clamps, and a cystostomy is made by cautery.

The defect is expanded by blunt dissection with the finger to reduce bleeding.

The bladder is brought into position adjacent to the proximal portion of the ureter to ensure that there is adequate mobilization of the bladder and that the anastomosis will be free from tension.

A Kelly clamp is inserted in the bladder through the cystostomy and pressed against the bladder wall at a point adjacent to the ureter to be implanted. The Kelly clamp is advanced through the bladder wall and opened sufficiently to allow at least a 2-cm defect. The tip of the ureter is sutured with a 3-0 suture and grasped with the Kelly clamp.

The ureter is drawn into the bladder through the cystostomy.

A No. 8 French Silastic double-J urethral stent catheter is inserted into the ureter and advanced to the renal pelvis. A small fish-mouth incision is made at the 3 o'clock and 9 o'clock positions in the ureter with scissors or a scalpel to prevent iris contracture at the anastomosis.

Under direct vision the ureter is anastomosed mucosa to mucosa to the bladder with interrupted 4-0 synthetic absorbable suture.

A Finney "J" catheter stent is inserted up into the ureter. The J catheter stent is designed to prevent peristalsis from pushing the catheter out of the ureter and into the bladder. We prefer to leave the catheter in the bladder for a minimum of 12 days and, in irradiated patients, for approximately 3 weeks.

To ensure that the anastomosis will be free of tension, a site on the psoas fascia is located, and the dome of the bladder is sutured to it with multiple interrupted 0 synthetic absorbable sutures. The bladder is mobilized by entering the space of Retzius.

A soft closed suction drain is placed through the lower quadrant of the abdomen adjacent to the ureteroneocystostomy. The cystostomy in the dome of the bladder is closed with interrupted 3-0 synthetic absorbable sutures in two layers. Three of the first layer sutures are shown.

A running 3-0 synthetic absorbable suture is used to close the bladder musculature and serosa.

An additional closed suction drain is placed through the opposite lower quadrant and brought adjacent to the anastomosed area. These drains should remain in place until no urinary drainage is noted.

BLADDER FLAP

Occasionally, the excised portion of ureter is so great that anastomosis with the bladder cannot be made without tension. This is frequently the case in ureteral stricture resulting form irradiation. Rather than chance placing the ureteroneocystostomy under tension that will result in retraction of the ureter, stenosis, and eventually hydronephrosis, it is preferable to create a bladder flap from the dome of the bladder that can extend to the transected ureter. This is begun by measuring the distance between the bladder wall and the proximal portion of the ureter. This distance, usually 8-9 cm, is marked off on the posterior bladder wall with brilliant green in the area of insertion of the superior vesical artery. The flap is incised out of the bladder wall by use of scissors or scalpel. The base of the flap should be wider than the length. A No. 8 French Silastic ureteral catheter is inserted into the ureter to the renal pelvis.

The flap is raised and brought into a position adjacent to the proximal portion of the ureter. Care must be taken at this point to ensure that there is no tension on the anastomosis. If an inadequate flap has been developed, the flap incisions may be extended at the base of the flap. The flap is rolled in a tubular fashion and closed with interrupted 4-0 synthetic absorbable suture over the catheter.

An end-to-end anastomosis between the proximal ureter and the tube flap is made with interrupted 4-0 synthetic absorbable suture. A single layer of through-and- through 4-0 synthetic absorbable suture is used for closure of the tube flap, rather than the two-layer technique normally used on the bladder wall. This alteration in technique guards against stenosis in the bladder flap that could result from a two-layer closure.

The bladder wall is closed by using the two-layer technique, the first on the bladder mucosa and the second layer on the muscle and serosa (as in Figs. 16 and 17). A closed suction drain is brought into the anastomosis site through the lower quadrant of the abdomen. The ureteral catheter is left in place for a minimum of 2 or 3 weeks. It is removed by water cystoscopy.