Ureteroileoneocystostomy

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Ureteroileoneocystostomy

When a large segment of the ureter must be excised as a result of radiation stenosis and/or chronic ureteritis, it is unwise to try to anastomose the remaining stenosed, radiated, and inflamed ureter to the bladder. Therefore, if the patient's kidney is reasonably healthy, the surgeon may choose among three procedures: (1) a cutaneous nephrostomy, (2) a transureteroureterostomy, and (3) a ureteroileoneocystostomy. This last procedure has the advantage of using nonirradiated materials in the entire system.

Physiologic Changes. The most important physiologic changes are that (1) obstruction is taken away from the ureter and (2) the kidney is allowed to survive. The loss of a 10-15 cm segment of terminal ileum has few long-term sequelae. If a longer portion of the ileum is removed, however, vitamin B12 should be administered systemically.

Points of Caution. All diseased ureter should be removed. The anastomosis of ileum into the renal tract can be made from the renal pelvis, along the ureter, down to the bladder. Frequently, this is unnecessary, as the proximal portion of the ureter coming off the renal pelvis may be nonirradiated and noninflamed. As in all cases of ureteral surgery, the ureter should be stented with medical grade Silastic double-J catheters.

Technique

A segment of terminal ileum is selected. The vascular branches in the mesentery of the ileum are observed by transillumination prior to transection of the terminal ileum. An incision is made into the avascular plane of Treitz medial to the ileocolic artery. The terminal ileum does not have to be selected; proximal ileum or even terminal jejunum can be used.

An ileoileostomy is performed either with sutures or with staples.

All diseased ureter has been removed. In this particular figure, a stump of ureter is shown coming off the renal pelvis and out of the bladder. The surgeon should not hesitate, however, to make a cystostomy in the bladder and to excise any diseased ureter noted.

The proximal stump of ureter is opened longitudinally to prevent iris contracture at the anastomotic site. A Silastic-grade double-J catheter has been inserted up into the renal pelvis.

The segment of ileum is moved into place. The medical grade Silastic double-J catheter has been brought through the lumen of the ileum. Anastomosis of the ileum to the ureter is made with interrupted synthetic absorbable suture.

The Silastic double-J catheter is inserted down the distal portion of the ileum into the bladder.

The ileum is shown anastomosed to the distal ureter. The Silastic double-J stent is in place. A Jackson-Pratt suction drain is placed adjacent to the anastomosis. Both the Jackson-Pratt suction drain and the stent can be removed in 2-3 weeks.