Ureteric Stricture Disease: Difference between revisions

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**'''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.'''

====== ~~'''~~Technique~~'''~~ ======

====== Technique ======

*'''Approaches: intravesical, extravesical, or through a combination of the two'''

*Anastomosis can be tunneled or non-tunneled

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**'''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.

**'''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 lower aspect of the vertical 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 lower 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.

**'''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 upper 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 upperaspect 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'''

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*'''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.

*'''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.

*'''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.

**'''<span style="color:#ff0000">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.

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==Special Scenarios==

===Ureteroenteric anastomotic stricture===

==== Epidemiology ====

*'''Rates of ureteroenteric anastomotic stricture after continent diversion is 3-25%, majority occur within the first 2 years'''

*'''Most patients with a long-term urinary conduit will have an element of chronic hydronephrosis that is not secondary to obstruction; obstruction suggested by a decrease in renal function or loss of reflux on a routine loopogram should prompt diuretic renography to quantitatively assess for functional obstruction'''

*'''Factors predicting stricture after ureteroenteric anastomosis:'''

==== Risk factors ====

*#Technique used for ureteral dissection

#Technique used for ureteral dissection

*#Segment of bowel used for the diversion

#Segment of bowel used for the diversion

*#'''Type of anastomosis performed'''

#'''Type of anastomosis performed'''

*#*'''Risk of stricture is less in refluxing anastamoses compared to non-refluxing anastamoses and therefore the use of a reflexing anastamosis is preferred for continent reservoirs (note that there is no difference in risk of stricture for ureteroneocystotomy)'''

#*'''Risk of stricture is less in refluxing anastamoses compared to non-refluxing anastamoses and therefore the use of a reflexing anastamosis is preferred for continent reservoirs (note that there is no difference in risk of stricture for ureteroneocystotomy)'''

*#'''Side of anastomosis'''

#'''<span style="color:#ff0000">Side of anastomosis'''

*#*'''Higher incidence of stricture formation on the left'''

#*'''<span style="color:#ff0000">Higher incidence of stricture formation on the left'''

*#**When performing an ileal conduit, the left ureter is brought underneath the sigmoid mesentery just overlying the aorta. The additional length and dissection needed on the left and the possibility of angulation around the inferior mesenteric artery may lead to increased risk of stricture on the left side

#**When performing an ileal conduit, the left ureter is brought underneath the sigmoid mesentery just overlying the aorta. The additional length and dissection needed on the left and the possibility of angulation around the inferior mesenteric artery may lead to increased risk of stricture on the left side

====Diagnosis and Evaluation====

* '''Most patients with a long-term urinary conduit will have an element of chronic hydronephrosis that is not secondary to obstruction; obstruction suggested by a decrease in renal function or loss of reflux on a routine loopogram should prompt diuretic renography to quantitatively assess for functional obstruction'''

====Management====

*'''See Figure in Campbell's'''

*'''Antegrade endourologic management of ureteroenteric or ureterocolic strictures is preferred''', unlike the management of ureteral strictures

*'''Options'''

*'''Strictures > 2cm or on the left are less likely to succeed with endourologic management'''

**'''Endourologic management'''

**'''Surgical repair'''

*'''Endoscopic management'''

**'''Although long-term patency of minimally invasive procedures for ureteroenteric strictures is in the range of 50%, such approaches are still used as the initial intervention''', reserving operative management for those patients in whom endourologic intervention fails and for patients with strictures > 1 cm

**'''Technique'''

***'''Antegrade endourologic management of ureteroenteric or ureterocolic strictures is preferred''', unlike the management of ureteral strictures

***'''When considering endoscopic incision of a left ureteroenteric stricture, the risk of hemorrhage is a consideration because the sigmoid mesentery can be in close proximity. This, taken with the lower success rates of all endoscopic approaches on the left side, supports serious consideration for primary repair when treating left ureteroenteric anastomotic strictures'''

*'''<span style="color:#ff0000">Strictures > 2cm or on the left are less likely to succeed with endourologic management'''

**Endourologic success rate for

***Strictures > 1cm is 6% vs. 50% strictures < 1 cm

***Left sided-stricture 19% vs. 41% on the right

****No difference was noted in sidedness with open repair

*'''Although long-term patency of minimally invasive procedures for ureteroenteric strictures is in the range of 50%, such approaches are still used as the initial intervention''', reserving operative management for those patients in whom endourologic intervention fails and for patients with strictures > 1 cm

*'''When considering endoscopic incision of a left ureteroenteric stricture, the risk of hemorrhage is a consideration because the sigmoid mesentery can be in close proximity. This, taken with the lower success rates of all endoscopic approaches on the left side, supports serious consideration for primary repair when treating left ureteroenteric anastomotic strictures'''

===Retrocaval ureter===

*'''See Pediatrics Ureter Anomalies Chapter Notes'''

*'''See [https://test.urologyschool.com/index.php/Pediatrics:_Ectopic_ureter,_Ureterocele,_and_Ureteral_Anomalies#Retrocaval_Ureter_(Circumcaval_Ureter,_Preureteral_Vena_Cava) Retrocaval Ureter Section] in Pediatrics Ureter Anomalies Chapter Notes'''

==Questions==

#What are the causes of ureteral stricture disease?

@@ Line 151: / Line 151: @@
 **'''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.'''
-====== '''Technique''' ======
+====== Technique ======
 *'''Approaches: intravesical, extravesical, or through a combination of the two'''
 *Anastomosis can be tunneled or non-tunneled
@@ Line 159: / Line 159: @@
 **'''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.
+**'''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 lower aspect of the vertical 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 lower 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.
+**'''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 upper 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 upperaspect 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'''
@@ Line 181: / Line 181: @@
 *'''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.
 *'''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.
+*'''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.
+**'''<span style="color:#ff0000">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.
@@ Line 273: / Line 274: @@
 ==Special Scenarios==
 ===Ureteroenteric anastomotic stricture===
+==== Epidemiology ====
 *'''Rates of ureteroenteric anastomotic stricture after continent diversion is 3-25%, majority occur within the first 2 years'''
-*'''Most patients with a long-term urinary conduit will have an element of chronic hydronephrosis that is not secondary to obstruction; obstruction suggested by a decrease in renal function or loss of reflux on a routine loopogram should prompt diuretic renography to quantitatively assess for functional obstruction'''
-*'''Factors predicting stricture after ureteroenteric anastomosis:'''
+==== Risk factors ====
-*#Technique used for ureteral dissection
+#Technique used for ureteral dissection
-*#Segment of bowel used for the diversion
+#Segment of bowel used for the diversion
-*#'''Type of anastomosis performed'''
+#'''Type of anastomosis performed'''
-*#*'''Risk of stricture is less in refluxing anastamoses compared to non-refluxing anastamoses and therefore the use of a reflexing anastamosis is preferred for continent reservoirs (note that there is no difference in risk of stricture for ureteroneocystotomy)'''
+#*'''Risk of stricture is less in refluxing anastamoses compared to non-refluxing anastamoses and therefore the use of a reflexing anastamosis is preferred for continent reservoirs (note that there is no difference in risk of stricture for ureteroneocystotomy)'''
-*#'''Side of anastomosis'''
+#'''<span style="color:#ff0000">Side of anastomosis'''
-*#*'''Higher incidence of stricture formation on the left'''
+#*'''<span style="color:#ff0000">Higher incidence of stricture formation on the left'''
-*#**When performing an ileal conduit, the left ureter is brought underneath the sigmoid mesentery just overlying the aorta. The additional length and dissection needed on the left and the possibility of angulation around the inferior mesenteric artery may lead to increased risk of stricture on the left side
+#**When performing an ileal conduit, the left ureter is brought underneath the sigmoid mesentery just overlying the aorta. The additional length and dissection needed on the left and the possibility of angulation around the inferior mesenteric artery may lead to increased risk of stricture on the left side
+====Diagnosis and Evaluation====
+* '''Most patients with a long-term urinary conduit will have an element of chronic hydronephrosis that is not secondary to obstruction; obstruction suggested by a decrease in renal function or loss of reflux on a routine loopogram should prompt diuretic renography to quantitatively assess for functional obstruction'''
 ====Management====
 *'''See Figure in Campbell's'''
-*'''Antegrade endourologic management of ureteroenteric or ureterocolic strictures is preferred''', unlike the management of ureteral strictures
+*'''Options'''
-*'''Strictures > 2cm or on the left are less likely to succeed with endourologic management'''
+**'''Endourologic management'''
+**'''Surgical repair'''
+*'''Endoscopic management'''
+**'''Although long-term patency of minimally invasive procedures for ureteroenteric strictures is in the range of 50%, such approaches are still used as the initial intervention''', reserving operative management for those patients in whom endourologic intervention fails and for patients with strictures > 1 cm
+**'''Technique'''
+***'''Antegrade endourologic management of ureteroenteric or ureterocolic strictures is preferred''', unlike the management of ureteral strictures
+***'''When considering endoscopic incision of a left ureteroenteric stricture, the risk of hemorrhage is a consideration because the sigmoid mesentery can be in close proximity. This, taken with the lower success rates of all endoscopic approaches on the left side, supports serious consideration for primary repair when treating left ureteroenteric anastomotic strictures'''
+*'''<span style="color:#ff0000">Strictures > 2cm or on the left are less likely to succeed with endourologic management'''
 **Endourologic success rate for
 ***Strictures > 1cm is 6% vs. 50% strictures < 1 cm
 ***Left sided-stricture 19% vs. 41% on the right
 ****No difference was noted in sidedness with open repair
-*'''Although long-term patency of minimally invasive procedures for ureteroenteric strictures is in the range of 50%, such approaches are still used as the initial intervention''', reserving operative management for those patients in whom endourologic intervention fails and for patients with strictures > 1 cm
-*'''When considering endoscopic incision of a left ureteroenteric stricture, the risk of hemorrhage is a consideration because the sigmoid mesentery can be in close proximity. This, taken with the lower success rates of all endoscopic approaches on the left side, supports serious consideration for primary repair when treating left ureteroenteric anastomotic strictures'''
 ===Retrocaval ureter===
-*'''See Pediatrics Ureter Anomalies Chapter Notes'''
+*'''See [https://test.urologyschool.com/index.php/Pediatrics:_Ectopic_ureter,_Ureterocele,_and_Ureteral_Anomalies#Retrocaval_Ureter_(Circumcaval_Ureter,_Preureteral_Vena_Cava) Retrocaval Ureter Section] in Pediatrics Ureter Anomalies Chapter Notes'''
 ==Questions==
 #What are the causes of ureteral stricture disease?