INTRAPERITONEALIZATION OF THE URETER DURING LAPAROSCOPIC URETEROLYSIS: A MODIFICATION OF THE TECHNIQUE

0022-5347/01/1651-0180/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®

Vol. 165, 180 –181, January 2001 Printed in U.S.A.

INTRAPERITONEALIZATION OF THE URETER DURING LAPAROSCOPIC URETEROLYSIS: A MODIFICATION OF THE TECHNIQUE ¨ ˘ ˘ ˆ ¨ UER ¨ DENIZ DEMIRCI, IBRAHIM GULMEZ, OGUZ EKMEKC ¸ IOGLU, ERDOGAN M. SOZ ˘ ERTUGRUL KEKLIK

AND

Department of Urology, University Medical Faculty, Kayseri, Turkey KEY WORDS: laparoscopy, ureter, fibrosis

Ureteral obstruction due to idiopathic retroperitoneal fibrosis is a rare but severe clinical problem. When it is diagnosed, ureterolysis and intraperitonealization of the ureter are usually performed.1 We report our experience with laparoscopic ureterolysis and modified intraperitonealization of the ureter. CASE REPORT

A 41-year-old man presented with a 3-month history of nocturia. Serum creatinine was 5.5 mg./dl. (normal 0.5 to 1.6) and blood urea nitrogen was 51 mg./dl. (normal 5 to 23). Ultrasound showed that the right kidney had moderate hydronephrosis, whereas the left kidney was atrophic. The severe and long stricture in the right middle ureter was detected on retrograde pyelography (fig. 1). A periureteral mass was demonstrated on computerized tomography. Percutaneous nephrostomy was inserted into the right kidney to relieve obstruction. After normal renal function resumed, the patient was placed in the semi-flank position, pneumoperitoneum with carbon dioxide was achieved and 3 laparoscopic ports were used. The line of Toldt was incised and the right colon was reflected medially. The thickened and widened mid ureter was completely dissected between the ureteropelvic junction

and common iliac vessels. During the dissection, normal ureter was observed just below and above the involved ureteral segment. Histological analysis of the biopsies from periureteral tissue revealed chronic inflammation and fibrosis. The involved ureter was completely peeled away, and the fibrotic tissue, and right colon and cecum were passed under it, and the right colon was fixed to the abdominal wall with a 10 mm. hernia stapler. A drain was placed. There were no complications and operative time was 200 minutes. The drain was removed on postoperative day 4, and the patient was discharged from the hospital on postoperative day 5. Antegrade pyelography performed 1 month later showed decreased hydronephrosis and a normal ureteral passage. Therefore, percutaneous nephrostomy was removed. At 10-month followup excretory urography showed a moderately lateralized ureter from the spinal column with no evidence of obstruction (fig. 2). DISCUSSION

Laparoscopic operations have been performed as successfully as open operations for the treatment of retroperitoneal fibrosis. Kavoussi2 and Matsuda3 et al described laparoscopic

Accepted for publication August 18, 2000.

FIG. 1. Retrograde pyelography reveals long and severe mid ureFIG. 2. Excretory urography shows no obstruction and moderately ter stricture. lateralized right ureter. 180

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INTRAPERITONEALIZATION OF URETER

ureterolysis and intraperitonealization of the ureter. The intraperitonealization techniques used in both reports are similar, which consist of closing the peritoneal layer posterior from the ureter with titanium clips. In our case retracting the ureter into the peritoneum and closing the peritoneal layers were performed similarly. However, the difference between our approach and that of others is that we passed the right colon and cecum under the ureter first and fixed both on the abdominal wall through their mesentery. Our technique supports the ureter at the new position and removes it from the fibrotic area. There was no postoperative obstruction of the ureter and the right colon. To our knowledge we report the first use of this technique to treat retroperitoneal fibrosis. Due to the excellent results

in our patient we think that our technique could be applicable in addition to laparoscopic ureterolysis and intraperitonealization of the ureter. REFERENCES

1. Resnick, M. I. and Kursh, E. D.: Extrinsic obstruction of the ureter. In: Campbell’s Urology, 6th ed. Edited by P. C. Walsh, A. B. Retik, T. A. Stamey et al. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 12, pp. 533–569, 1992 2. Kavoussi, L. S., Clayman, R. V., Brunt, L. M. et al: Laparoscopic ureterolysis. J Urol, 147: 426, 1992 3. Matsuda, T., Arai, Y., Muguruma, K. et al: Laparoscopic ureterolysis for idiopathic retroperitoneal fibrosis. Eur Urol, 26: 286, 1994