Segemental ureterectomy

Proximal or mid-ureter

• Achieving a clear margin and still being able to mobilize enough well-vascularized ureter to perform a tension-free anastomosis is paramount to the success of this procedure and the major limiting challenge
• Technique
  • Position: full or modified flank position
  • Incision: flank incision from the tip of the 12th rib provides access to the proximal ureter or mid-ureter.
  • Summary of Steps:
    • With use of an extraperitoneal approach, the ureter is identified, mobilized, and secured with vessel loops.
    • The tumor is palpated, and the ureter is ligated 1 to 2 cm above and below the suspected tumor margin (Fig. 58-22). This location can be also verified by preoperative cross-sectional imaging.
    • The diseased ureter is excised and clear margins ascertained by frozen pathology.
    • After regional lymphadenectomy is performed, both ends of the ureter are spatulated and anastomosed with an interrupted 4-0 Vicryl suture. If a large segment of ureter is excised, mobilization and descensus of kidney may be performed to provide additional length to the proximal ureter. A ureteral stent is placed before completion of the anastomosis.

Distal ureter

• See Management of Upper Urinary Tract Obstruction Chapter Notes
• Ureterectomy and Direct Neocystostomy or Ureteroneocystostomy with a Bladder Psoas Muscle Hitch or a Boari Flap
  • Technique
    • Summary of Steps:
      • The distal ureterectomy is performed as described in the prior section.
      • The ureter is mobilized to achieve a tension-free anastomosis and spatulated.
      • Ureterovesical anastomosis may be performed using an extravesical or intravesical approach.
        • Whether to perform a refluxing or nonrefluxing anastomosis remains a matter of debate.
          • The benefits of a non-refluxing anastomosis include limit of infection to the lower tract and the theoretic possibility of avoiding seeding of the upper tract.
          • A refluxing anastomosis may make surveillance of the upper tracts easier.
        • If an extravesical approach is desired, bladder detrusor muscle is incised, exposing the mucosa. A mucosal slit is performed at the distal aspect of this incision. An anastomosis is performed using continuous or interrupted 3-0 Vicryl sutures through the full thickness of the ureter and bladder mucosa. At the distal portion of the anastomosis, two of these sutures are passed through the full thickness wall of the bladder to anchor the ureter and prevent sliding out of the tunnel. The bladder detrusor is then closed on the top of the ureter with interrupted absorbable sutures, such as 2-0 Vicryl, to achieve a non-refluxing mechanism. A ureteral stent may be placed before completion of the anastomosis.
        • For the intravesical technique, an anterior cystotomy is made. An incision is made at the posterolateral wall of the bladder and a 2- to 3-cm submucosal tunnel is fashioned. The ureter is brought through this tunnel. After the ureter is spatulated, the anastomosis is performed with interrupted absorbable sutures.
      • If a long segment of distal ureter is excised and a tension-free anastomosis cannot be achieved by simple ureteroneocystostomy, an additional 5 cm in length can be gained by using a psoas hitch of the bladder. The bladder is mobilized anteriorly and laterally, and in women the round ligament is divided. The contralateral superior vesical artery can also be divided to gain further mobility. After ureterovesical anastomosis is completed, the ipsilateral dome of the bladder is sutured to the psoas tendon using several interrupted sutures. Care should be taken to avoid injury or entrapment of the genitofemoral nerve.
        • Femoral nerve more commonly injured than genitofemoral at time of psoas hitch.
      • If additional length is desired, a Boari flap can help gain another 10-15 cm in length and in some cases may be able to reach all the way to renal pelvis (Fig. 58-23).
        • If a Boari flap is planned, it is advisable to obtain a preoperative cystogram to assess bladder capacity, because a small-capacity irradiated bladder is a contraindication to this technique.
        • A U-shaped bladder wall flap or, if a longer segment is desired, an L-shaped segment, is developed.
        • To achieve good blood supply to the flap, the base of the flap should be at least 2 cm greater than the apex.
        • To achieve adequate width of tubularized segment, the width of the flap should be at least 3x the diameter of the ureter.
        • The tip of the flap is secured to the psoas muscle using interrupted absorbable suture, and the spatulated ureter is anastomosed to the flap in the end-to-end fashion. The flap is then tubularized and closed with two layers of absorbable sutures. A ureteral catheter is placed before closure of the flap.
      • After all of these techniques, it is advisable to use a suction drain in the retroperitoneum and 7- to 10-day Foley drainage of the bladder. After extensive reconstruction, a cystogram should precede Foley removal.
      • Ileal ureter replacement
        • When a long segment of ureter is diseased, a segment of ileum can be used to reconstruct the urinary system. The appendix has also been used for segmental ureteral substitution
        • Through a midline intraperitoneal incision, 20 to 25 cm of ileum is harvested at least 15 cm away from the ileocecal valve. Bowel continuity is re-established using a stapled anastomosis. With a running absorbable suture, the ileal segment is anastomosed to the renal pelvis proximally in an end-to-end fashion and an isoperistaltic direction. If the proximal portion of the ureter is healthy, the ileal segment can be anastomosed to it in an end-to-side fashion. A ureteral catheter is placed before completion of the anastomosis. Distally, the segment is anastomosed to the posterior wall of the bladder in an end-to-side manner through an intravesical approach. This anastomosis is done in two layers. A suction drain is positioned in retroperitoneum close to anastomotic sites. Optimal drainage is important for proper healing, so a large Foley catheter is inserted in the bladder and left for at least 1 week postoperatively. It may need to be irrigated frequently. A nephrostomy tube may be used to drain the kidney. Before removal of the tubes, a cystogram and nephrostogram are obtained.
      • Renal auto-transplantation is a feasible alternative to ileal replacement in skilled hands
      • Laparoscopic or Robotic Distal Ureterectomy and Reimplantation. [Further details in Campbell’s]

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 58