Editing Management of Upper Urinary Tract Obstruction (section)

===== Ureteroureterostomy =====
* So-called end-to-end repair
* '''<span style="color:#ff0000">Bridges ureteral defect of 2-3cm</span>'''
* '''<span style="color:#ff0000">Most appropriate for a short defects</span>''' '''<span style="color:#ff0000">(2-3cm)</span>''' '''<span style="color:#ff0000">involving the upper ureter or mid-ureter,</span>''' either in the form of stricture or as a consequence of recent injury
** '''<span style="color:#ff0000">Only short defects should be managed by end-to-end ureteroureterostomy</span>''' because tension on the anastomosis almost always leads to stricture formation
** '''<span style="color:#ff0000">Lower ureteral strictures are usually best managed by ureteroneocystostomy with or without a psoas hitch or Boari flap.</span>'''
* Success rate for a tension-free, watertight ureteroureterostomy is > 90%
*'''Technique'''
**In an open surgical approach, the choice of surgical incision depends on the level of the ureteral stricture
**'''Place stay stitches:''' Use 3-0 silk to place stay stitches at 12 o'clock on proximal and distal ureter, a few cm away from the cut ends. This will facilitate orientation. These will be removed later.
**'''Spatulate ureters:''' Use scissors to spatulate both ureters for 1-1.5 cm. Spatulate proximal ureter at 6 o'clock and distal ureter at 12 o'clock, using the silk stay sutures to guide orientation.
**'''Posterior anastomosis:''' Use 4-0 absorbable monofilament suture (e.g. monocryl or PDS) to take an outside-in bite on proximal ureter at one corner of cut apex at 6 o’clock and then take corresponding inside-out bite on distal ureter just lateral to 6 o’clock. Tie stitch, cut tail, and place needle on rubber-shod clamp. Repeat bite on opposite side of cut apex at 6 o'clock and place needle on rubber-shod clamp.
**'''Insert double J stent'''. Advance guidewire through proximal ureter into renal pelvis. Advance double J stent over guidewire and remove wire when stent in renal pelvis (meets resistance). To pass the distal end of the stent into the bladder, cut a side hole in the stent, and then pass the floppy end of the wire into the bladder and the firm end of the wire through the distal end of the stent and through the previously cut hole in the midportion of the stent. Advance the stent over the wire into the bladder and remove the wire.
**'''Anterior anastamosis:''' Use 4-0 absorbable monofilament suture (e.g. monocryl or PDS) and place a U stitch at 12 o’clock: take an outside-in bite at 12 o’clock on the proximal ureter followed by inside-out bite on distal ureter just lateral to 12 o’clock apex, then outside-in bite on distal ureter on contralateral side of 12 o’clock apex, then corresponding inside-out on the proximal ureter. Tie this down, cut needle, and leave each suture side long.
**'''Complete anastamosis:''' Use previous 4-0 absorbable monofilament sutures on shods and run each stitch anteriorly. Consider backhand for first bite at on corners. Once completed to 12 o'clock, tie to long tails from U suture. Cut tails.
***'''If tissue quality is tenuous, interrupted anastomosis is recommended'''
****Interrupted anastomosis allows more precise closure and ensures that the entire repair is not in jeopardy if a single area becomes compromised because of poor tissue quality, delayed ischemia, or an inadequate bite during the suturing.
****With interrupted anastomosis, keep tail long as handles for subsequent stitch and cut them after stitch next to it is placed.
**'''Remove silk stay sutures.'''
**'''Insert surgical drain'''
** '''Postoperative care'''
*** '''Foley catheter is usually left indwelling for 1 to 2 days.''' 
***'''Surgical drain may be removed if there is minimal output for 24 to 48 hours.'''
**** If the surgical procedure is not performed entirely in a retroperitoneal manner, it is important to determine the nature of the fluid from the surgical drain by checking the creatinine level of the fluid. If there is no urinary extravasation, the drain can then be removed.
*** '''The double-J ureteral stent is usually removed 4-6 weeks postoperatively'''
'''Ureterocalycostomy'''
* '''Ureteral stump is sewn end-to-side into an exposed renal calyx'''
* '''Rarely used; <span style="color:#ff0000">used where there is profound damage to the renal pelvis and UPJ</span>'''