Transperitoneal Ureteroureterostomy (End-to-Side Anastomosis)

Home / Site Map / Vulva and Introitus / Vagina and Urethra / Bladder and Ureter / Cervix / Uterus
Fallopian Tubes and Ovaries / Colon / Small Bowel / Abdominal Wall / Malignant Disease: Special Procedures

Transperitoneal Ureteroureterostomy
(End-to-Side Anastomosis)

In some patients, resection of the terminal ureter is required for complete removal of a pelvic malignancy. In these cases, diversion of the urine must be achieved by either ureteroneocystostomy or transperitoneal ureteroureterostomy.

If the opposite ureter is normal and healthy and if there is any sizeable distance between the damaged ureter and the bladder, transperitoneal ureteroureterostomy is preferred. Postoperative stricture formation following ureteroneocystostomy is frequently produced by tension on the anastomotic suture line. Therefore, in these cases, end-to-side transperitoneal ureteroureterostomy may allow a tension-free anastomosis.

In those cases associated with pelvic irradiation, transperitoneal ureteroureterostomy allows diversion of the urine at a site outside the fields of irradiation without tension, thus avoiding the problem of stenosis in a surgical anastomosis within heavily irradiated tissue.

The basic concept of transperitoneal ureteroureterostomy is to bring the ureter from one side across the peritoneal cavity under the mesentery of the intestine to the healthy ureter on the opposite side and to anastomose it. We prefer to perform all of these anastomoses over a Silastic catheter stent that is left in place for approximately 2 weeks.

The purpose of the operation is to save the kidney, when its ureter has been injured or obstructed, by implanting that ureter in a healthy ureter on the opposite side to allow the free flow of urine from both kidneys through one ureter to the bladder.

Physiologic Changes. If stricture is avoided at the anastomotic site and if there is no obstruction to the terminal portion of the recipient ureter, few if any physiologic changes occur. A single ureter is capable of carrying the entire flow of urine from both kidneys. If the disease process has obstructed the ureter on one side, however, it may eventually obstruct the ureter on the opposite side, thus requiring a second diversion by ileal loop.

Points of Caution. Care should be taken to excise the damaged portion of the injured ureter. The affected ureter should be handled in a delicate manner to avoid damaging the network of vessels under the ureteral sheath that provides the blood supply to the ureter from the renal pelvis to the bladder. A 1 x 1/2 cm segment of the wall in the recipient ureter is removed for the anastomosis rather than making an incision into the ureter for the anastomosis. This, we feel, reduces the incidence of postoperative stricture formation. We prefer (1) to spatulate all ureteral anastomoses to prevent iris contracture and (2) to perform the anastomosis over a Silastic tube stent. The site of the anastomosis should be drained retroperitoneally through the lower quadrant by a closed suction drain.

Technique

The patient is placed on the operating table in the dorsal supine lithotomy position. A Foley catheter has been placed in the bladder. The abdomen is opened through a lower midline incision.

The peritoneum over the common iliac vessels of the affected side is elevated and opened with Metzenbaum scissors, exposing the entire path of the diseased or damaged ureter. The diseased portion of the ureter is identified. The distal segment of ureter going to the bladder is cross-clamped and tied with a 0 synthetic absorbable suture. The proximal segment of the ureter for implantation is carefully mobilized, preserving the blood supply by preventing damage to the ureteral sheath and the underlying network of vessels. All damaged portions of the ureter should be removed, and in cases of pelvic irradiation, the entire irradiated portion of the ureter should be removed. The peritoneum covering the mesentery of the large bowel is opened, and a tunnel is created under the mesentery. Care is taken to prevent damage to the vessels in the mesentery of the large bowel.

The damaged ureter is brought through the tunnel in the mesentery of the large bowel. The peritoneum overlying the common iliac artery on the opposite side is elevated and opened. The healthy ureter is identified and dissected for an appropriate distance.

The recipient ureter is elevated with a vein retractor. The ureter to be implanted is brought adjacent to the recipient ureter at a convenient site. Extreme care should be taken at this point to ensure that there is proper mobility and that there will be no tension on the suture line. The damaged ureter should be brought to the normal ureter. The normal ureter should be mobilized only enough to perform the anastomosis.

We prefer to perform all ureteral anastomoses over a Silastic tube stent. It is difficult to insert a flexible Silastic tube stent down the recipient ureter into the bladder. Therefore, we have evolved the following technique to bring a flexible Silastic tube into the bladder. A cystotomy is performed, and a No. 5 French whistle-tip ureteral catheter is inserted through the ureteral orifice up the recipient ureter to the area of ureterotomy. The No. 5 French whistle-tip ureteral catheter is passed through the defect in the recipient ureter and sutured to the Silastic T-tube with a 4-0 Prolene suture.

The Silastic tube stent is then pulled through the distal ureter with the ureteral catheter into the bladder. The arms of the T-tube are passed into the recipient and the implanted ureters.

The Silastic T-tube is coiled in the bladder. The cystotomy in the bladder is closed in two layers with 3-0 synthetic absorbable suture. The second arm of the T-tube is fed into the ureter to be implanted.

The ureteroureterostomy end-to-side anastomosis is performed with interrupted 4-0 synthetic absorbable sutures in a through-and-through technique, creating a mucosa-to-mucosa anastomosis. A spatulated ureteral anastomosis is less likely to develop an iris contracture.

The peritoneum is closed over the ureteral anastomosis. A closed suction drain is placed through the lower quadrant of the abdomen and brought retroperitoneally up to the site of the ureteroureterostomy. It is left in place until drainage ceases. A water cystoscopy is performed 2-3 weeks postoperatively, and the Silastic T-tube stent is removed. An intravenous pyelogram (IVP) is performed at that time and repeated every 2 months until the surgeon is satisfied with the results of the anastomosis.