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A modification of extravesical ureteroneocystostomy in kidney transplantation
SUHGlWN’S
WORKSHOP
A MODIFICATION OF EXTRAVESICAL URETERONEOCYSTOSTOMY IN KIDNEY TRANSPLANTATION J. FREDY ABED, M.D. JOHN L. HUSSEY, M.D. From the Department of Surgery, Division of Transplantation, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, Louisiana Several ureteral reimplantation procedures have been used to create a ureteroneocystostomy. These are usually performed in renal transplantation, for which a quick, safe, and reliable technique is highly desirable. Lich, Howerton, and Davis’ and Gregoir and Van Regemorter2s3 originated the extravesical ureteroneocystostomy commonly used today. In this technique, the muscularis of the bladder is incised for about 4 cm and the mucosa is opened for 1 cm at the distal angle of the incision. The ureter is anastomosed to the mucosa, and the muscle layer is closed over the terminal ureter, keeping this portion in a submucosal tunnel (Fig. 1). In terms of antireflux therapy, Gregoir’s technique has a failure rate of 4.5 percent, either because of obstruction or persistent reflux.4 Failure to create an adequate length of submucosal tunnel can result in reflux. Obstruction
may occur because of angulation of the ureter at its entry into the bladder wall or because of compression as it enters into the tunnel (Fig. 2). It is difficult to know how much of the extravesical ureter is compressed by closing the
FIGURE 2. Angulation
of ureter at its entry into bladder wall. Proximity of last stitch to ureteral entrance.
FICURE~. FIGURE1.
172
Standard Lich-Gregoir technique.
Margin of submucosal dissection around
incision.
UROLOGY
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FIGURE 4.
Tunnel
between
incision and ureteral
entrance.
Ureteral entry is 1.0-l .5 cm distant FIGURE 6. from bladder incision. Muscle layer is closed and ureter remains unobstructed in tunnel free of stitches.
FIGURE 7. Our modification, indicating position of ureter as it enters bladder wall.
FIGURE5.
Anastomosis of ureter to mucosa.
bladder muscle, as the angulation of the ureter depends on how it enters the bladder wall and on how close to the entry the proximal stitch is placed. We propose the following modifications: 1. After the muscularis is incised, a submucosal dissection is performed (Fig. 3). 2. A 2.0-cm submucosal tunnel is created by inserting a hemostat and gently spreading at the proximal corner of the incision and exiting 1.52.0 cm proximal to the incision through a separate “stab incision” (Fig. 4). 3. The distal ureter is brought through the tunnel to the point where the spatulated ureter is anastomosed to the mucosa, as was described in the original technique (Fig. 5). 4. The muscle layer is repaired (Fig. 6). This modification can provide an excellent tunnel to prevent reflux and still avoid the angulation and constriction that results in obstruction (Fig. 7). The angle at which the ureter
UROLOGY
i AUGUST1992
/ VOLUME40.NUMBER2
FIGURE 8. Placement of temporary ureteral stent and the ‘Z” stitch closure after its removal.
enters the bladder wall is determined by surgical insertion of a clamp, which allows better control than with the Lich or Gregoir procedure. A suitable tunnel length can be obtained with a small incision, and there are no stitches at the entry of the ureter that may cause obstruction. It is important to perform a generous
173
Ochsner Clinic
submucosal dissection to avoid obstruction of the ureter when closing the muscle layer. Finally, we recommend placing a red rubber catheter as a temporary ureteral stent. The catheter is attached to a small trocar and exited through the bladder several centimeters distal to the ureteroneocystostomy site. This temporary stent may help ensure patency and avoid obstruction. The stent can be easily pulled out at the end of the procedure, and the exit site can be closed with a simple “Z” stitch (Fig. 8).
1. Lich R, Howerton L, and Davis L: Recurrent urosepsis in children. I Urol86: 554 (1961). 2. Gr&ir W, and Van‘Rege’morterG: Le reflux v&co-ureteral congenital, Urol Int 18: 122 (1964). 3. Gregoir W: Le traitement chirurigical du reflux v&cou&&l congenital, Acta Chir Belg 63: 431 (1964). 4. Gregoir W, and Schulman CC: Die extravesikale Antirefluxplastik, Urologe A 16: 124 (1977).
174
UROLOGY
1514 Jefferson Highway New Orleans, Louisiana 70121 (DR. HUSSEY) References
/
AUGUST 1992
/
VOLUME 40, NUMBER 2
WORKSHOP
A MODIFICATION OF EXTRAVESICAL URETERONEOCYSTOSTOMY IN KIDNEY TRANSPLANTATION J. FREDY ABED, M.D. JOHN L. HUSSEY, M.D. From the Department of Surgery, Division of Transplantation, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, Louisiana Several ureteral reimplantation procedures have been used to create a ureteroneocystostomy. These are usually performed in renal transplantation, for which a quick, safe, and reliable technique is highly desirable. Lich, Howerton, and Davis’ and Gregoir and Van Regemorter2s3 originated the extravesical ureteroneocystostomy commonly used today. In this technique, the muscularis of the bladder is incised for about 4 cm and the mucosa is opened for 1 cm at the distal angle of the incision. The ureter is anastomosed to the mucosa, and the muscle layer is closed over the terminal ureter, keeping this portion in a submucosal tunnel (Fig. 1). In terms of antireflux therapy, Gregoir’s technique has a failure rate of 4.5 percent, either because of obstruction or persistent reflux.4 Failure to create an adequate length of submucosal tunnel can result in reflux. Obstruction
may occur because of angulation of the ureter at its entry into the bladder wall or because of compression as it enters into the tunnel (Fig. 2). It is difficult to know how much of the extravesical ureter is compressed by closing the
FIGURE 2. Angulation
of ureter at its entry into bladder wall. Proximity of last stitch to ureteral entrance.
FICURE~. FIGURE1.
172
Standard Lich-Gregoir technique.
Margin of submucosal dissection around
incision.
UROLOGY
/ AUGUST1992
/ VOLUME40,NUMBER2
FIGURE 4.
Tunnel
between
incision and ureteral
entrance.
Ureteral entry is 1.0-l .5 cm distant FIGURE 6. from bladder incision. Muscle layer is closed and ureter remains unobstructed in tunnel free of stitches.
FIGURE 7. Our modification, indicating position of ureter as it enters bladder wall.
FIGURE5.
Anastomosis of ureter to mucosa.
bladder muscle, as the angulation of the ureter depends on how it enters the bladder wall and on how close to the entry the proximal stitch is placed. We propose the following modifications: 1. After the muscularis is incised, a submucosal dissection is performed (Fig. 3). 2. A 2.0-cm submucosal tunnel is created by inserting a hemostat and gently spreading at the proximal corner of the incision and exiting 1.52.0 cm proximal to the incision through a separate “stab incision” (Fig. 4). 3. The distal ureter is brought through the tunnel to the point where the spatulated ureter is anastomosed to the mucosa, as was described in the original technique (Fig. 5). 4. The muscle layer is repaired (Fig. 6). This modification can provide an excellent tunnel to prevent reflux and still avoid the angulation and constriction that results in obstruction (Fig. 7). The angle at which the ureter
UROLOGY
i AUGUST1992
/ VOLUME40.NUMBER2
FIGURE 8. Placement of temporary ureteral stent and the ‘Z” stitch closure after its removal.
enters the bladder wall is determined by surgical insertion of a clamp, which allows better control than with the Lich or Gregoir procedure. A suitable tunnel length can be obtained with a small incision, and there are no stitches at the entry of the ureter that may cause obstruction. It is important to perform a generous
173
Ochsner Clinic
submucosal dissection to avoid obstruction of the ureter when closing the muscle layer. Finally, we recommend placing a red rubber catheter as a temporary ureteral stent. The catheter is attached to a small trocar and exited through the bladder several centimeters distal to the ureteroneocystostomy site. This temporary stent may help ensure patency and avoid obstruction. The stent can be easily pulled out at the end of the procedure, and the exit site can be closed with a simple “Z” stitch (Fig. 8).
1. Lich R, Howerton L, and Davis L: Recurrent urosepsis in children. I Urol86: 554 (1961). 2. Gr&ir W, and Van‘Rege’morterG: Le reflux v&co-ureteral congenital, Urol Int 18: 122 (1964). 3. Gregoir W: Le traitement chirurigical du reflux v&cou&&l congenital, Acta Chir Belg 63: 431 (1964). 4. Gregoir W, and Schulman CC: Die extravesikale Antirefluxplastik, Urologe A 16: 124 (1977).
174
UROLOGY
1514 Jefferson Highway New Orleans, Louisiana 70121 (DR. HUSSEY) References
/
AUGUST 1992
/
VOLUME 40, NUMBER 2