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Management of Upper Urinary Tract Obstruction: Difference between revisions

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== Ureteropelvic junction obstruction ==
== Ureteropelvic junction obstruction ==


* '''See Pediatrics Surgery of the Ureter Chapter Notes'''
* '''See [https://test.urologyschool.com/index.php/Pediatrics:_Surgery_of_the_Ureter#Ureteropelvic_Junction_Obstruction_(UJPO) Ureteropelvic Junction Obstruction Section] in [[Pediatrics: Surgery of the Ureter|Pediatrics Surgery of the Ureter Chapter Notes]]'''


=== Etiology ===
=== Etiology ===
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*# '''<span style="color:#0000ff">S</span><span style="color:#ff0000">tones</span>'''
*# '''<span style="color:#0000ff">S</span><span style="color:#ff0000">tones</span>'''


=== Diagnosis and evaluation ===
=== Diagnosis and Evaluation ===
* '''Imaging'''
 
** Performed to determine the anatomic site and functional significance of an apparent obstruction
==== History and Physical Exam ====
** '''Diuretic renography'''
 
***'''Commonly used''' for diagnosing both UPJ and ureteral obstruction  
*'''History'''
***'''Provides quantitative data regarding differential renal function and obstruction,''' even in hydronephrotic renal units '''(see Pathophysiology of UUT Obstruction Chapter Notes for nuclear imaging details)'''
**'''<span style="color:#ff0000">Signs and Symptoms</span>'''[https://www.ncbi.nlm.nih.gov/books/NBK560740/ §]
**** '''<span style="color:#ff0000">In general, kidneys with < 15% differential function are nonsalvageable in adults</span>''' (Chapter 48 suggests <10%)'''.'''
**# '''<span style="color:#ff0000">Periodic abdominal pain (loin pain), usually after diuresis'''
***** '''If the potential for salvageability of function is still unclear, an internal stent or percutaneous nephrostomy may be placed for temporary relief of obstruction and renal function studies subsequently repeated'''
**# '''<span style="color:#ff0000">Vomiting'''
**# '''<span style="color:#ff0000">Recurrent pyelonephritis'''
**# '''<span style="color:#ff0000">Fever'''
**# '''<span style="color:#ff0000">Uncommonly, abdominal mass, or hematuria secondary to infection'''
 
==== Imaging ====
* Performed to determine the anatomic site and functional significance of an apparent obstruction
* '''Diuretic renography'''
**'''Commonly used''' for diagnosing both UPJ and ureteral obstruction
**'''<span style="color:#ff0000">Most commonly used agent in renogram studies is technetium 99m mercaptoacetyltriglycine (99m Tc-MAG3), especially in the pediatric population[https://www.ncbi.nlm.nih.gov/books/NBK560740/ §]'''
***In the adult population, other agents can be used, such as diethylenetriamine pentaacetate (DTPA)
**'''<span style="color:#ff0000">Provides quantitative data regarding differential renal function and obstruction</span>''', even in hydronephrotic renal units '''(see Pathophysiology of UUT Obstruction Chapter Notes for nuclear imaging details)'''
*** '''<span style="color:#ff0000">In general, kidneys with < 15% differential function are nonsalvageable in adults</span>''' (Chapter 48 suggests <10%)'''.'''
**** '''If the potential for salvageability of function is still unclear, an internal stent or percutaneous nephrostomy may be placed for temporary relief of obstruction and renal function studies subsequently repeated'''


=== Management ===
=== Management ===
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*#'''<span style="color:#ff0000">Higher risk of failure than pyeloplasty</span>'''.  
*#'''<span style="color:#ff0000">Higher risk of failure than pyeloplasty</span>'''.  
*#*'''Patients should be counseled that the success rate of any endourologic approach may be less than that of formal reconstruction.'''
*#*'''Patients should be counseled that the success rate of any endourologic approach may be less than that of formal reconstruction.'''
*##* Success rates approach 85-90% for percutaneous endopyelotomy.
*#** Success rates approach 85-90% for percutaneous endopyelotomy.
*#'''Requires taking into account the degree of hydronephrosis, ipsilateral renal function, concomitant calculi, and possibly the presence of crossing vessels,''' whereas pyeloplasty (open, laparoscopic, or robotic) can be applied to almost any anatomic variation of UPJO
*#'''Requires taking into account the degree of hydronephrosis, ipsilateral renal function, concomitant calculi, and possibly the presence of crossing vessels,''' whereas pyeloplasty (open, laparoscopic, or robotic) can be applied to almost any anatomic variation of UPJO
*#* '''Moderate to severe hydronephrosis is most predictive of failure after percutaneous endopyelotomy'''
*#* '''Moderate to severe hydronephrosis is most predictive of failure after percutaneous endopyelotomy'''
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*** '''Long-term follow-up studies have shown a diminishing success rate over time'''
*** '''Long-term follow-up studies have shown a diminishing success rate over time'''
** '''<span style="color:#ff0000">Endopyelotomy</span>'''
** '''<span style="color:#ff0000">Endopyelotomy</span>'''
*** '''<span style="color:#ff0000">Full-thickness lateral incision</span> through the obstructing proximal ureter, from the ureteral lumen out to the peripelvic and periureteral fat'''
*** '''<span style="color:#ff0000">Contraindications (3):</span>'''
**** '''Rigorous anatomic studies have shown that the incision should usually be made laterally because this is the location devoid of crossing vessels'''
*** '''<span style="color:#ff0000">Contraindications to endopyelotomy (3):</span>'''
***# '''<span style="color:#ff0000">>2 cm of obstruction</span>'''
***# '''<span style="color:#ff0000">>2 cm of obstruction</span>'''
***# '''<span style="color:#ff0000">Active infection</span>'''
***# '''<span style="color:#ff0000">Untreated UTI</span>'''
***# '''<span style="color:#ff0000">Untreated coagulopathy</span>'''
***# '''<span style="color:#ff0000">Untreated coagulopathy</span>'''
*** Patients should also be counseled of the risk of bleeding requiring transfusion, urinary leak, drainage-related complications, and hydropneumothorax, particularly if upper pole access is used
*** '''Technique'''
*** Can be done with a percutaneous antegrade or retrograde ureteroscopic approach
****'''Approaches: percutaneous antegrade or retrograde ureteroscopic'''
**** The main advantage of retrograde ureteroscopic endopyelotomy is that it allows direct visualization of the UPJ and assurance of a properly situated, full-thickness endopyelotomy incision without the need for percutaneous access
***** The main advantage of retrograde ureteroscopic endopyelotomy is that it allows direct visualization of the UPJ and assurance of a properly situated, full-thickness endopyelotomy incision without the need for percutaneous access
*** Can be done with an endopyelotome, holmium laser or cutting balloon catheter
*****'''<span style="color:#ff0000">Percutaneous endopyelotomy remains appropriate for patients with UPJO and concomitant pyelocalyceal stones,</span> which can be managed simultaneously'''.
*** '''Little evidence for significant differences among endopyelotomy techniques.''' The differences lie in technical considerations and complications
****'''Methods: can be done with an endopyelotome, holmium laser or cutting balloon catheter'''
*** '''<span style="color:#ff0000">Percutaneous endopyelotomy remains appropriate for patients with UPJO and concomitant pyelocalyceal stones,</span> which can be managed simultaneously'''.
***** Cutting balloon catheters have the potential to better dilate ischemic and fibrotic lesions resistant to conventional balloon catheter dilation[https://pubmed.ncbi.nlm.nih.gov/19959311/]
**** '''When a percutaneous endopyelotomy fails, several options exist including:'''
*****'''Little evidence for significant differences in success among endopyelotomy techniques.'''  
***** '''Retrograde endopyelotomy'''
******Differences lie in technical considerations and complications.
***** '''Repeat percutaneous endopyelotomy'''
*****'''<span style="color:#ff0000">If using an endopyelotome or laser, a full-thickness lateral incision</span> is made through the obstructing proximal ureter, from the ureteral lumen out to the peripelvic and periureteral fat'''
***** '''Laparoscopic, robotic, or open operative intervention'''
****** '''Incision should usually be made laterally because this is the location devoid of crossing vessels'''
*** '''A stent is placed across the incision and is left to heal.''' There remains no consensus as to the optimal stent size or duration after endopyelotomy
**** '''A stent is placed across the incision and is left to heal.'''  
*** Postoperative care:
*****No consensus as to the optimal stent size or duration after endopyelotomy
**** Avoidance of strenuous activity for 8-10 days after the procedure is recommended
****'''Postoperative care'''
**** '''Once the stent is removed, that patient returns 1 month later for history and physical exam, urinalysis, and diuretic renography'''
*****Avoidance of strenuous activity for 8-10 days after the procedure
**** '''For most adults, 2-3 year follow-up is justified''' because studies indicate that even at 36 months some late failures are identified, but relatively few are identified at 60 months
*****'''Once the stent is removed, that patient returns 1 month later for history and physical exam, urinalysis, and diuretic renography'''
*****'''For most adults, 2-3 year follow-up is justified'''  
******Studies indicate that even at 36 months some late failures are identified, but relatively few are identified at 60 months
****'''Complications'''
*****'''Early'''
*****#'''Bleeding requiring transfusion'''
*****#'''Urinary leak'''
*****#'''Drainage-related complications'''
*****#'''Hydropneumothorax'''
*****#*'''Risk is increased if upper pole access is used'''
*****'''Late'''
*****#'''Recurrent obstruction'''
*****#*Options if percutaneous endopyelotomy fails:
*****#*#Retrograde endopyelotomy
*****#*#Repeat percutaneous endopyelotomy
*****#*#Laparoscopic, robotic, or open operative intervention


==== Pyeloplasty ====
==== Pyeloplasty ====
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*# '''<span style="color:#ff0000">Heal over a stent</span>'''
*# '''<span style="color:#ff0000">Heal over a stent</span>'''
*# '''Reconstructed UPJ should allow a <span style="color:#ff0000">funnel-shaped transition</span> between the pelvis and the ureter that is <span style="color:#ff0000">in a position of dependent drainage</span>'''
*# '''Reconstructed UPJ should allow a <span style="color:#ff0000">funnel-shaped transition</span> between the pelvis and the ureter that is <span style="color:#ff0000">in a position of dependent drainage</span>'''
* '''Absolute contraindications to pyeloplasty (3):'''
* '''Absolute contraindications (3):'''
*# '''Uncorrected coagulopathy'''
*# '''Untreated UTI'''
*# '''Untreated UTI'''
*#'''Uncorrected coagulopathy'''
*# '''Cardiopulmonary compromise unsuitable for surgery'''
*# '''Cardiopulmonary compromise unsuitable for surgery'''
* '''Before definitive surgical management, drainage of a kidney with UPJO is recommended only for infection associated with the obstruction or renal dysfunction resulting from obstruction in a solitary kidney or bilateral disease [suggesting no stent in renal dysfunction from single side obstruction if contralateral kidney fine]'''
* '''Before definitive surgical management, drainage of a kidney with UPJO is recommended only for infection associated with the obstruction or renal dysfunction resulting from obstruction in a solitary kidney or bilateral disease [suggesting no stent in renal dysfunction from single side obstruction if contralateral kidney fine]'''
* '''Transperitoneal laparoscopic approach is the most widely used method''' owing to its associated large working space and familiar anatomy.
* '''Technique'''
** Retroperitoneal laparoscopic approach and anterior extraperitoneal approach rely on creation of a working space using manual or balloon dilation.
**'''Approaches: transperitoneal, retroperitoneal, or anterior extraperitoneal'''
* '''<span style="color:#ff0000">A dismembered Anderson-Hynes pyeloplasty, which is preferred by most surgeons, or one of the non-dismembered methods such as Y-V plasty and flap pyeloplasty (Culp) can be used</span>'''
***'''Transperitoneal laparoscopic approach is the most widely used method''' due to its associated large working space and familiar anatomy.
** '''The Foley Y-V-plasty is designed for repair of a UPJ obstruction secondary to a high ureteral insertion.'''
*** Retroperitoneal laparoscopic approach and anterior extraperitoneal approach rely on creation of a working space using manual or balloon dilation.
** Flap procedures are not appropriate in the setting of crossing vessels and when reduction of redundant renal pelvis is desired
** '''<span style="color:#ff0000">Methods: dismembered vs. non-dismembered</span>'''  
* '''Dismembered pyeloplasty'''
***'''Dismembered pyeloplasty'''
** '''Preferred by most urologists because this procedure is almost universally applicable to different clinical scenarios'''
**** '''Example: Anderson-Hynes pyeloplasty'''
*** Can be used regardless of whether the ureteral insertion is high on the pelvis or already dependent.
****'''Preferred by most urologists because this procedure is almost universally applicable to different clinical scenarios'''
*** Permits reduction of a redundant pelvis or straightening of a tortuous proximal ureter
***** Can be used regardless of whether the ureteral insertion is high on the pelvis or already dependent.
*** '''Anterior or posterior transposition of the UPJ can be achieved when the obstruction is the result of accessory or aberrant lower pole vessels'''
***** Permits reduction of a redundant pelvis or straightening of a tortuous proximal ureter
**** In the presence of crossing aberrant or accessory lower pole renal vessels associated with UPJ obstruction, a dismembered pyeloplasty is the only method to allow transposition of the UPJ in relation to these vessels.
***** '''Anterior or posterior transposition of the UPJ can be achieved when the obstruction is the result of accessory or aberrant lower pole vessels'''
*** '''Unlike the flap techniques, only a dismembered pyeloplasty allows complete excision of the anatomically or functionally abnormal UPJ itself'''
****** In the presence of crossing aberrant or accessory lower pole renal vessels associated with UPJ obstruction, a dismembered pyeloplasty is the only method to allow transposition of the UPJ in relation to these vessels.
** '''A dismembered pyeloplasty is not well suited to UPJO associated with (2):'''
******'''If dismembered pyeloplasty is performed for the presence of crossing vessels, the renal pelvis is first transected circumferentially above the UPJ and the lateral aspect of the proximal ureter is spatulated.''' The renal pelvis and proximal ureter are then transposed to the opposite side of the crossing vessel and the ureteropelvic anastomosis is then completed with intracorporeal suturing techniques
**# '''Lengthy or multiple proximal ureteral strictures'''
***** '''Unlike the flap techniques, only a dismembered pyeloplasty allows complete excision of the anatomically or functionally abnormal UPJ itself'''
**# '''Small, relatively inaccessible intrarenal pelvis'''
**** '''Dismembered pyeloplasty is not well suited to UPJO associated with (2):'''
** '''If dismembered pyeloplasty is performed for the presence of crossing vessels, the renal pelvis is first transected circumferentially above the UPJ and the lateral aspect of the proximal ureter is spatulated.''' The renal pelvis and proximal ureter are then transposed to the opposite side of the crossing vessel and the ureteropelvic anastomosis is then completed with intracorporeal suturing techniques
****# '''Lengthy or multiple proximal ureteral strictures'''
* '''<span style="color:#ff0000">The provision of external drainage from the site of surgical repair is absolutely necessary</span>'''
****#*'''<span style="color:#ff0000">The spiral flap may be of significant value when both UPJO and a relatively long segment of proximal ureteral narrowing or stricture occur in the same setting</span>'''
** '''This helps minimize the risk of urinoma formation leading to possible disruption of the suture line, scarring, or sepsis'''
****# '''Small, relatively inaccessible intrarenal pelvis'''
* '''<span style="color:#ff0000">The Foley catheter is usually removed 24 to 36 hours postoperatively, and the surgical drain is removed before hospital discharge if the drain output remains negligible.</span>'''
***'''Non-dismembered pyeloplasty'''
** '''<span style="color:#ff0000">If the drain output increases after the Foley catheter removal, the Foley catheter should be replaced for 7 days to eliminate urinary reflux along the stent in the treated ureter and decrease urinary extravasation at the ureteropelvic anastomosis.</span>'''
****'''Examples: Y-V plasty and flap pyeloplasty (Culp)'''
* '''<span style="color:#ff0000">The ureteral stent is typically removed 4-6 weeks later in an outpatient setting, and follow-up including the use of imaging studies such as diuretic renal scan is performed</span>'''
***** '''The Foley Y-V-plasty is designed for repair of a UPJ obstruction secondary to a high ureteral insertion.'''
** '''Persistent urinary drainage after an unstented pyeloplasty is common, and will often require intervention.'''
***** Flap procedures are not appropriate in the setting of crossing vessels and when reduction of redundant renal pelvis is desired
*** '''When this is associated with a large blood clot, and likely edema at the anastomosis, the kidney will need early drainage until the bleeding resolves and edema improves.'''
** '''<span style="color:#ff0000">The provision of external drainage from the site of surgical repair is absolutely necessary</span>'''
**** '''In children, this is best managed with a nephrostomy tube, as stent placement in a young infant would likely result in stent occlusion from the renal pelvic blood clot.'''
*** '''Helps reduce risk of urinoma formation leading to possible disruption of the suture line, scarring, or sepsis'''
*** '''In the majority of cases not associated with an occlusive blood clot, the leak will resolve spontaneously, so observation is the best approach in the early postoperative period in these patients.'''
** '''<span style="color:#ff0000">Post-operative care</span>'''
*** '''If the leak is persistent and not associated with a consolidated clot, it would most likely resolve with retrograde stent placement.'''
***'''<span style="color:#ff0000">The Foley catheter is usually removed 24 to 36 hours postoperatively, and the surgical drain is removed before hospital discharge if the drain output remains negligible.</span>'''
* '''Most failures from laparoscopic pyeloplasty occur in the first 2 years.'''
**** '''<span style="color:#ff0000">If the drain output increases after the Foley catheter removal, the Foley catheter should be replaced for 7 days to eliminate urinary reflux along the stent in the treated ureter and decrease urinary extravasation at the ureteropelvic anastomosis.</span>'''
** '''<span style="color:#ff0000">For patients who fail laparoscopic pyeloplasty, open surgery has been used as a salvage procedure. However, most patients can be well managed with endoscopic intervention</span>'''
*** '''<span style="color:#ff0000">Ureteral stent is typically removed 4-6 weeks later in an outpatient setting</span>'''
* '''<span style="color:#ff0000">The spiral flap may be of significant value when both UPJO and a relatively long segment of proximal ureteral narrowing or stricture occur in the same setting</span>'''
***'''<span style="color:#ff0000">Follow-up including the use of imaging studies such as diuretic renal scan is performed</span>'''
** '''Complications'''
***'''Late'''
****'''Persistent urinary drainage'''
*****'''Common after an unstented pyeloplasty is common, and will often require intervention.'''
*****'''When associated with a large blood clot,''' and likely edema at the anastomosis, '''the kidney will need early drainage until the bleeding resolves and edema improves.'''
******'''In children, this is best managed with a nephrostomy tube, as stent placement in a young infant would likely result in stent occlusion from the renal pelvic blood clot.'''
*****'''In the majority of cases not associated with an occlusive blood clot, the leak will resolve spontaneously, so observation is the best approach in the early postoperative period in these patients.'''
******'''If the leak is persistent and not associated with a consolidated clot, it would most likely resolve with retrograde stent placement.'''
**** '''Recurrent obstruction'''
*****'''Most failures from laparoscopic pyeloplasty occur in the first 2 years.'''
***** '''<span style="color:#ff0000">Management</span>'''
******'''<span style="color:#ff0000">Options (2)</span>'''
*******'''<span style="color:#ff0000">Repeat pyeloplasty (open surgery has been used as a salvage procedure after failed laparoscopic pyelopasty)</span>'''
*******'''<span style="color:#ff0000">Endoscopic intervention (most patients can be managed</span>'''  


==== Ureterocalicostomy ====
==== Ureterocalicostomy ====
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#** Management
#** Management
#*** A trial of hormonal therapy using gonadotropin-releasing hormone agonists (Lupron) or medroxyprogesterone (Danazol) should be initiated for mild symptomatic obstruction when there is good preservation of renal function.
#*** A trial of hormonal therapy using gonadotropin-releasing hormone agonists (Lupron) or medroxyprogesterone (Danazol) should be initiated for mild symptomatic obstruction when there is good preservation of renal function.
#*** For more severe obstruction associated with significant periureteral fibrosis, surgical intervention to correct the obstruction, with or without hysterectomy and bilateral salpingo-oophorectomy, is advisable
#*** For more severe obstruction associated with significant periureteral fibrosis, surgical intervention to correct the obstruction, with or without hysterectomy and bilateral salpingo-oophorectomy, is recommended
* '''Hysterectomy accounts for over 50% of iatrogenic ureteral injuries'''
* '''Hysterectomy accounts for over 50% of iatrogenic ureteral injuries'''
** Most likely areas where the ureter can be occluded during hysterectomy (2):
** Most likely areas where the ureter can be occluded during hysterectomy (2):
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** '''The use of tandem ureteral stent placement (two parallel stents) has been shown to be effective in benign and malignant extrinsic ureteral obstruction'''
** '''The use of tandem ureteral stent placement (two parallel stents) has been shown to be effective in benign and malignant extrinsic ureteral obstruction'''
** '''Placement of a ureteral stent in an obstructed system will result in decreased ureteral contractility'''
** '''Placement of a ureteral stent in an obstructed system will result in decreased ureteral contractility'''
* No clear consensus regarding the benefits of metallic stents
** No clear consensus regarding the benefits of metallic stents


==== Endourologic procedures ====
==== Endourologic procedures ====


*'''<span style="color:#ff0000">Options: balloon dilation or endoureterotomy</span>'''
*'''<span style="color:#ff0000">Best management for ureteral strictures < 2 cm with no previous intervention is an endoscopic approach</span>'''
* '''<span style="color:#ff0000">The best management for ureteral strictures < 2 cm with no previous intervention is an endoscopic approach</span>'''
*'''<span style="color:#ff0000">Contraindications (1):</span>'''
* '''<span style="color:#ff0000">Contraindications (1):</span>'''
*# '''<span style="color:#ff0000">Strictures >2cm</span>''' because dilation alone is unlikely to be successful
*# '''<span style="color:#ff0000">Strictures >2cm</span>''' because dilation alone is unlikely to be successful
* '''<span style="color:#ff0000">Balloon dilation'''
*'''<span style="color:#ff0000">Options (2): balloon dilation or endoureterotomy</span>'''
** After 10 minutes of tamponade, the balloon is deflated and withdrawn. An internal stent is passed over a guidewire still in place, which is left indwelling for 2-4 weeks.
**'''<span style="color:#ff0000">Balloon dilation'''
** '''Follow-up diuretic renography''' is usually performed ≈1 month after stent extraction and at 6- to 12-month intervals thereafter
*** After 10 minutes of tamponade, the balloon is deflated and withdrawn. An internal stent is passed over a guidewire still in place, which is left indwelling for 2-4 weeks.
** Success rates range from 50-76%, long-term outcomes are unfavorable
*** '''Follow-up diuretic renography''' is usually performed ≈1 month after stent extraction and at 6- to 12-month intervals thereafter
** '''Best results obtained in patients with iatrogenic, non-anastomotic strictures such as those secondary to ureteroscopic instrumentation'''. In that setting, a success rate of 85% was achieved compared with a rate of 50% for anastomotic strictures
*** Success rates range from 50-76%, long-term outcomes are unfavorable
* '''<span style="color:#ff0000">Endoureterotomy'''
*** '''Best results obtained in patients with iatrogenic, non-anastomotic strictures such as those secondary to ureteroscopic instrumentation'''. In that setting, a success rate of 85% was achieved compared with a rate of 50% for anastomotic strictures
** '''<span style="color:#ff0000">The position for the incision is chosen as a function of the level of the ureter involved. In general</span>'''
** '''<span style="color:#ff0000">Endoureterotomy'''
*** '''Lower ureteral strictures are incised in an anteromedial direction to stay away from the iliac vessels'''
*** '''<span style="color:#ff0000">The position for the incision is chosen as a function of the level of the ureter involved. In general</span>'''
*** '''Upper ureteral strictures are incised laterally or posterolaterally'''
**** '''Lower ureteral strictures are incised in an anteromedial direction to stay away from the iliac vessels'''
** The incision itself can be performed using a cold knife, a cutting electrode, or a holmium laser
**** '''Upper ureteral strictures are incised laterally or posterolaterally'''
*** The incision can be performed using a cold knife, a cutting electrode, or a holmium laser


==== Surgical repair ====
==== Surgical repair ====
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* So-called end-to-end repair
* So-called end-to-end repair
* '''<span style="color:#ff0000">Bridges ureteral defect of 2-3cm</span>'''
* '''<span style="color:#ff0000">Bridges ureteral defect of 2-3cm</span>'''
* '''<span style="color:#ff0000">A short defect involving the upper ureter or mid-ureter, either in the form of stricture or as a consequence of recent injury, is most appropriate for ureteroureterostomy</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 (2-3cm) should be managed by end-to-end ureteroureterostomy</span>''' because tension on the anastomosis almost always leads to stricture formation
** '''<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">Conversely, a lower ureteral stricture is usually best managed by ureteroneocystostomy with or without a psoas hitch or Boari flap.</span>'''
** '''<span style="color:#ff0000">Lower ureteral strictures are usually best managed by ureteroneocystostomy with or without a psoas hitch or Boari flap.</span>'''
* In an open surgical approach, the choice of surgical incision depends on the level of the ureteral stricture
* Success rate for a tension-free, watertight ureteroureterostomy is > 90%
* '''Postoperative care'''
*'''Technique'''
** '''A surgical drain is placed, and a Foley catheter is usually left indwelling for 1 to 2 days. The surgical drain may be removed if there is minimal output for 24 to 48 hours.'''
**In an open surgical approach, the choice of surgical incision depends on the level of the ureteral stricture
*** 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.
**'''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.
** '''The double-J ureteral stent is usually removed 4-6 weeks postoperatively'''
**'''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.
* The success rate for a tension-free, watertight ureteroureterostomy is > 90%
**'''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'''
'''Ureterocalycostomy'''
* '''Ureteral stump is sewn end-to-side into an exposed renal calyx'''
* '''Ureteral stump is sewn end-to-side into an exposed renal calyx'''
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===== Ureteroneocystotomy =====
===== Ureteroneocystotomy =====
* Ureteroneocystostomy without a psoas hitch or Boari flap in an adult is appropriate for injury or obstruction affecting the distal 3 to 4 cm of the ureter
* '''<span style="color:#ff0000">Appropriate for injury or obstruction affecting 3-4 cm the distal of the ureter</span>'''
* '''<span style="color:#ff0000">Bridges ureteral defect of 4-5cm</span>'''
* '''<span style="color:#ff0000">Bridges ureteral defect of 4-5cm</span>'''
* '''After adequate proximal ureteral mobilization, direct ureteroneocystostomy is performed only if a tension-free anastomosis is possible. Otherwise, a psoas hitch or Boari flap should be used as an adjunct.'''
** '''After adequate proximal ureteral mobilization, direct ureteroneocystostomy is performed only if a tension-free anastomosis is possible. Otherwise, a psoas hitch or Boari flap should be used as an adjunct.'''
* A direct, non-tunneled anastomosis may be performed if postoperative reflux is acceptable
*'''Technique:'''
** In a retrospective review, '''no significant difference in the preservation of renal function or risk of stenosis was found between refluxing versus anti-refluxing procedures.''' '''However, it is unclear if a non-refluxing anastomosis increases the risk of pyelonephritis in an adult patient'''
**'''Approaches: intravesical, extravesical, or through a combination of the two'''
**Anastomosis can be tunneled or non-tunneled
***A direct, non-tunneled anastomosis may be performed if postoperative reflux is acceptable
**** In a retrospective review, '''no significant difference in the preservation of renal function or risk of stenosis was found between refluxing versus anti-refluxing procedures.''' '''However, it is unclear if a non-refluxing anastomosis increases the risk of pyelonephritis in an adult patient'''
**'''Extravesical ureteroneocystomy[https://pubmed.ncbi.nlm.nih.gov/20620446/]'''
***'''Cystotomy:''' Use cautery to make 1-1.5 cm vertical incision on anterior surface of bladder. Use 4-0 chromic to take inside out bites at 4 quadrants of the cystotomy. Apply snaps to these.
***'''Spatulate ureter'''. Use scissors to spatulate the ureter for 1-1.5 cm at 6 o'clock.
***'''Cephalad vesicoureteric anastomosis'''. Use 3-0 absorbable monofilament suture (e.g. monocryl or PDS) to take an outside-in bite on the bladder at the cephalad aspect of the cystotomy and then inside-out on one side of 6 o'clock apex of distal ureter. Use another 3-0 absorbable monofilament suture (e.g. monocryl or PDS) and repeat on contralateral side of cephalad aspect of cystotomy. Tie these down, cut end without needle, place needle end on shod.
***'''Insert double J stent'''. Advance guidewire through ureter into renal pelvis. Advance double J stent over this, remove guidewire , and allow distal curl to fall into bladder.
***'''Caudal vesicoureteric anastomosis'''. Use 3-0 absorbable monofilament suture (e.g. monocryl or PDS) and place a U stitch at 12 o'clock of ureter to caudal aspect of cystotomy: take an outside-in bite at 12 o'clock on the ureter followed by inside-out bite on caudal aspect of the cystotomy, then outside-in bite on caudal aspect of the cystotomy just opposite to previous bite, then inside-out on the opposite side at 12 o'clock on the ureter. Tie this down, cut needle off, and leave suture side long.
***'''Complete vesicoureteric anastomosis'''. Use previous 3-0 absorbable monofilament sutures at apex and run each stitch distally. First bite is outside-in on ureter, second bite is backhand inside-out on bladder. Then subsequent bites are forehand outside-in on ureter, inside out on bladder. Once at the caudal end of anastomosis, tie to previous long 3-0 vicryl U sutures. Cut sutures.
***'''Insert surgical drain'''


===== Psoas hitch =====
===== Psoas hitch =====
* An effective method to bridge a defect of the lower third of the ureter.
* '''An effective method to bridge a defect of the lower third of the ureter.'''
* May be preferred over ureteroureterostomy in lower ureteral injuries because the tenuous ureteral blood supply might not survive transection. However, '''<span style="color:#ff0000">a ureteral defect extending proximal to the pelvic brim usually requires more than a psoas hitch alone</span>'''
*'''<span style="color:#ff0000">Bridges ureteral defect of 6-10cm (other source says 5-8cm[https://pubmed.ncbi.nlm.nih.gov/23759011/])</span>'''
* '''<span style="color:#ff0000">Femoral nerve is most likely to be injured during a psoas hitch</span>'''
** Can provide up to 5 cm of additional length compared to simple ureteroneocystostomy
* '''<span style="color:#ff0000">Bridges ureteral defect of 6-10cm</span>'''
**May be preferred over ureteroureterostomy in lower ureteral injuries because the tenuous ureteral blood supply might not survive transection.  
** Can provide an additional 5 cm of length compared to simple ureteroneocystostomy
**'''<span style="color:#ff0000">A ureteral defect extending proximal to the pelvic brim usually requires more than a psoas hitch alone</span>'''
* '''<span style="color:#ff0000">Contraindications (1):</span>'''
* '''<span style="color:#ff0000">Contraindications (1):</span>'''
** '''<span style="color:#ff0000">A small, contracted bladder with limited mobility</span>'''
** '''<span style="color:#ff0000">A small, contracted bladder with limited mobility</span>'''
* '''<span style="color:#ff0000">With traction, the ipsilateral dome of the bladder should be able to reach the level proximal to the iliac vessels. Additional mobility can be achieved by dividing the contralateral superior vesical artery.</span>'''
* '''Technique[https://pubmed.ncbi.nlm.nih.gov/23759011/]'''
* '''<span style="color:#ff0000">The ipsilateral bladder dome is secured to the psoas minor tendon or the psoas major muscle using several absorbable sutures.</span> Care should be taken to avoid injury to the genitofemoral nerve and the femoral nerve'''
**'''Identify the ureter.''' The ureter can be identified medial to the medial umbilical ligament (contains obliterated umbilical ligament) or anterior to the bifuctation of the common iliac artery.
* '''Relative to the Boari flap, the advantages of psoas hitch include:'''
**'''Mobilize the ureter.''' Encircle the ureter with a vessel loop to facilitate traction. Mobilize the ureter distally and proximally. Care must be taken to preserve the periureteric adventitial tissue with its inherent blood supply of the ureter. Ligate and transect the ureter distally, and if being performed for ureteric mass or fistula, ligate and transect the ureter proximally above area of concern. For ureteric mass, send frozen section from the cut edge of the proximal ureter. Place a stay suture at 12 o'clock to facilitate orientation.
**'''Mobilize the bladder.''' Fill the bladder with 200-300 mL of saline via the foley catheter. Dissect the peritoneum off the bladder. Depending on the length of the remaining proximal ureter, further bladder mobilization can be obtained by dividing the median umbilical ligament (urachus) and ipsilateral medial umbilical ligament. Additional mobility can be achieved by dividing the contralateral superior vesical artery.
***'''Aim is to allow a tension-free fixation of the bladder to the psoas muscle at least 2-3cm above the common iliac vessel.'''  
** '''Cystotomy:''' Place two stay sutures, 4-5cm apart, in a oblique orientation such that the medial stay suture is more superior. Make a 4-5cm oblique incision between the stay sutures.
**'''Evaluate bladder tension:''' Use index finger inside the open bladder to elevate the ipsilateral most cranial aspect of the bladder. Check if the raised flap easily reaches the intended point of fixation at the psoas muscle. If the bladder cannot be brought to the psoas muscle without tension, the oblique bladder incision is extended to obtain a longer bladder flap.
**'''Fixation of bladder to psoas:''' Use two to three 3-0 absorbable monofilament sutures to take whole detrusor muscle thickness without mucosa and placed preferentially through the tendon of the psoas muscle above the common iliac artery and the femoral branch of the genitofemoral nerve.  
***'''Care should be taken to avoid injury to the genitofemoral nerve and the femoral nerve'''
**'''Ureteroneocystotomy.'''
**'''Insert stent.'''
**'''Bladder closure.'''
**'''Insert surgical drain'''
*'''Complications'''
**'''Occur uncommonly'''
**'''Early'''
***'''Nerve injury'''
****'''<span style="color:#ff0000">Femoral nerve is most likely to be injured during a psoas hitch</span>'''
***'''Bowel injury'''
***'''Iliac vein injury'''
***'''Urosepsis'''
**'''Late'''
***'''Urinary fistula'''
***'''Ureteral obstruction'''
*'''Relative to the Boari flap, the advantages of psoas hitch include:'''
*# '''Increased technical simplicity'''
*# '''Increased technical simplicity'''
*# '''Decreased risk of vascular compromise'''
*# '''Decreased risk of vascular compromise'''
*# '''Decreased risk of voiding difficulties'''
*# '''Decreased risk of voiding difficulties'''
* '''Complications occur uncommonly but include urinary fistula, ureteral obstruction, nerve injury, bowel injury, iliac vein injury, and urosepsis'''


===== Boari flap =====
===== Boari flap =====
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