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Transureterocalicostomy: An Alternative Internal Diversion Technique
0022-5347/95/1532-0404$03.00/0 Vol. 153, 404-406, February 1995 Printed in U.S.A.
JOURNAL OF UROLCGY Copyright 0 1995 by AMERICAN UROLOGICAL ASSOCIATION, INC.
THE
TRANSURETEROCALICOSTOMY: AN ALTERNATIVE INTERNAL DIVERSION TECHNIQUE FRANCISCO TIBOR DRNES, ARTUR HENRIQUE BRIT0
AND
RAUL CUTAIT
From the Departments of Urology and Surgery, Hospital Sirio-Libanes, S&J Paula, Brazil
ABSTRACT
We report a case of an infiltrating retroperitoneal tumor that completely enveloped and obstructed the mid third of the lef%ureter. After resection of the tumor, including a 10 cm. long segment of ureter, the upper left ureter was successfully diverted to the upper calix of the right ectopic kidney (transureterocalicostomy). To our knowledge our report represents the first case of such surgery. KEY WORDS:ureteral neoplasms, urinary diversion, kidney ealices, ureterostomy
Transureteroureterostomy is a well known procedure for internal urinary diversion in cases of loss of the lower ureteral segment. Preconditions for success are adequate length of the donor ureter to reach the contralateral ureter as well as normal anatomy of this receptor unit. We report a case in which transureteroureterostomy was anatomically impossible due to an ectopic receptor kidney. Urinary diversion was successfully accomplished by transureterocalicostmy. CASE REPORT
E. S. H., a 65-year-old white woman, underwent partial sigmoidectmy 1year previously due to sigmoid cancer. Surgery was uneventful and resulted in apparent control of disease. Colonoscopy and abdominal ultrasound were normal 8 months postoperatively. Although the patient was completely asymptomatic, abdominal computerized tomography and magnetic resonance imaging 2 months later revealed a 5 cm. retroperitoneal tumor infiltrating the left psoas muscle at the level of L5-S1 with moderate left hydronephrosis due to ureteral obstruction. The right kidney was well functioning but ectopic, located a t the level of M-Sl, and malrotated with anteriorized pelvis and calices. Since no other tumors were noted in the abdomen or thorax, surgical removal of the mass was indicated. Preoperative retrograde pyelography confirmed tumoral infiltration of the mid portion of the left ureter that almost completely obstructed it. Laparotomy was performed through a left pararectal incision. After freeing the left colon, the tumor was seen completely enveloping the left ureter and the ipsilateral common iliac vessels, and was adherent to the psoas muscle. To allow complete resection of this mass the psoas muscle was deeply incised, and the ureter was sectioned above and below the tumor with a margin almost 3 cm. above the tumor. The iliac vessels were carefully separated from the mass. At the completion of dissection the ureter was missing a mid portion almost 10 cm. long. Frozen section of both ureteral stumps showed no tumoral residue but the distance between them precluded any attempt a t primary end-to-end reanastomosis. The need for postoperative radiotherapy was considered, and the possibilities of left renal autotransplantation to the iliac fossa and ileal interposition were discarded since the autotransplanted kidney and ileal segment would probably lie in the irradiation field. Transureteroureterostomy was not feasible since the right kidney was ectopic and the left ureter could not reach the short right ureter. Left nephrectomy seemed to be Accepted for publication April 8, 1994.
the option but on inspecting the right malrotated kidney it was noted that its uppermost medial calk was superficial with almost no overlying parenchyma. Although the proximal end of the transected left ureter could not initially reach this calk, the procedure was accomplished without tension after adequate downward mobilization and fixation of the left kidney. It is important t o note that even after this maneuver the upper left ureter could not reach the lower left segment (with a gap of almost 5 cm.) or the right ureter. After incising the upper right calix a 6F multi-perforated ureteral stent was inserted, directed downward by a guide wire into the bladder and exteriorized through the urethra. The other end of the stent was pushed into the left ureter up to the renal pelvis. End-to-side anastomosis between the left spatulated ureter and the right upper calix was then performed with interrupted 4-zero catgut. The anastornotic site and tumoral bed were covered by peritoneum, both areas were drained with large Penrose drains exteriorized through the flank and the incision was closed. The ureteral stent was tied to a Foley catheter inserted in the bladder. Convalescence was uneventful. On postoperative day 12 retrograde pyelography through the stent showed a patent ureterocaliceal anastomosis without extravasation (fig. 1). The stent and Foley catheter were removed and the patient resumed normal voiding. Excretory urography 6 weeks later showed mild dilatation of the left kidney with normal function (fig. 2). The patient then underwent a 6-week course of radiation to the tumoral bed. Ultrasound and computerized tomography 2 and 6 months after radiotherapy showed improvement in the dilatation of the left kidney without evidence of local tumor recurrence. The patient has remained asymptomatic. DISCUSSION
Traumatic and iatrogenic lesions of the ureter have been treated with different techniques of reconstruction according to the type, level and extension of the ureteral injury as well as the presence of local urinary extravasation and infection. The same guidelines generally are used when a ureteral segment must be removed due to intrinsic disease (stricture or tumor) or extrinsic involvement (tumor, fibrosis or abscess).' Recent advances in endourological techniques using flexible ureteroscopes and nonreacting ureteral catheters have obviated the need for open surgery but there are still some situations when ureteral resection is inevitable. Such operations in the lower third of the ureter cause no special difficulty to the urologist since the bladder is near and, if straightforward ureterovesical reimplantation is not possi-
404
TRANSURETEROCALICOSTOMY
FIG. 1. Anteroposterior ( A ) and lateral (arrows).
views of postoperative retrograde
FIG. 2. Excreto urography demonstrates normal function and mild calicectasis o?left kidney.
ble, other techniques, such as the psoas hitch with O r without the Boari flap, enable reanastomosis of the ureter to the bladder.' When the upper ureteral segment is damaged it can be treated by pyeloureteral reanastomosis with or with-
405
show patent anastomosis without leakage
out concomitant renal mobilization and nephropexy. When much of the renal pelvis or upper ureter is involved in fibrosis, ureterocalicostomy can be performed, depending on the ability t o expose and suture the lower caliceal wall without tension t o the healthy ~ r e t e r . ~ The mid section of the ureter is the most problematic segment. Whenever ipsilateral ureteroureterostomy is not possible due to the extent of the resected segment, even after extensive renal mobilization, ileal interposition must be p e r f ~ r m e d . ~If. residual upper ureter is available, transureteroureterostomy can be an adequate alternative.6 Kidney autotransplantation remains an exceptional disproportionate alternative in such cases to be used when the aforementioned operations are technically impossible and kidney preservation is mandatory.' Ipsilateral nephrectomy is the treatment of choice when the contralateral kidney is normal and life expectancy is short due to old age or concurrent malignancy. In our case primary ipsilateral ureteroureterostomy and transureteroureterostomy were impossible due to the extent of the resected segment. The need for subsequent radiotherapy precluded ileal interposition and renal autotransplantation. Due to concurrent malignancy, nephrectomy could have been an adequate alternative since the contralateral kidney, although ectopic, had normal function. We preferred transureterocalicostomy since the right kidney had a favorable pyelocaliceal anatomy with a superficial upper calix, and there was no need for extensive dissection of an otherwise normal kidney. Criticism regarding possible damage of the receptor calix and its consequences on the function of the ipsilateral healthy kidney would not apply to our case since the calix was superficial. Therefore, if the anastomosis failed due to stricture or dehiscence, there would be no significant consequences to the receptor kidney. In the case of transureteroureterostomy the kidney would be more endangered since ureteral leakage could cause stenosis and function loss. Success in our case was also ensured by the optimal conditions in which the ureterocaliceal anastomosis was performed, that is without tension and with adequate drainage. In an exceptional circumstance this simple procedure proved to be a worthwhile alternative to nephrectomy.
406
TRANSURETEROCALICOSTOMY REFERENCES
~ M. c,,~ x n g , ~K. s, ~and 0lsson, ~ C,, A.: Ureteral reconstruction and bypass: experience with ileal interposition, the Boari flap-psoas hitch and renal autotransplantation. J . Urol., IAR. 3n i w n. --.--, 2. Olsson, C. A. and Norlen, L. J.: Combined Boari bladder flappsoas hitch procedure in ureteral replacement. Scand. J. Urol. Nephrol., 20 279,1986. 3. Mollard, P., Mouriquand, P., Joubert, P. and Pouyau, A,: Ureterocalicostomy for hydronephrosis caused by junction disease in children and adolescents. Apropos of 35 cases. Chir. Ped., 1, B
-
-
--I
31: 87. 1990. A.J., Colodny, A. H., Bauer, S. B. and Retik, A. B.: The use of bowel interposed between proximal and distal ureter in urinary tract reconstruction. J. Urol., 134: 737, 1985. 5. Martinez-Sagarra, J. M., Amon Sesmero, J . H., Santos Lago, J., Estebanez Zarranz, J., Amogarcia, A. and Rodriguez Toves, A,: Ureteroplastias ileales. Arch. Esp. Urol., 45: 961, 1992. 6. Baert, L. and Claes, H.: A retroperitoneal approach for transureteroureterostomy: a neglected and forgotten procedure. Acta Urol. Belg., 5 8 51, 1990.
4. Casale,
JOURNAL OF UROLCGY Copyright 0 1995 by AMERICAN UROLOGICAL ASSOCIATION, INC.
THE
TRANSURETEROCALICOSTOMY: AN ALTERNATIVE INTERNAL DIVERSION TECHNIQUE FRANCISCO TIBOR DRNES, ARTUR HENRIQUE BRIT0
AND
RAUL CUTAIT
From the Departments of Urology and Surgery, Hospital Sirio-Libanes, S&J Paula, Brazil
ABSTRACT
We report a case of an infiltrating retroperitoneal tumor that completely enveloped and obstructed the mid third of the lef%ureter. After resection of the tumor, including a 10 cm. long segment of ureter, the upper left ureter was successfully diverted to the upper calix of the right ectopic kidney (transureterocalicostomy). To our knowledge our report represents the first case of such surgery. KEY WORDS:ureteral neoplasms, urinary diversion, kidney ealices, ureterostomy
Transureteroureterostomy is a well known procedure for internal urinary diversion in cases of loss of the lower ureteral segment. Preconditions for success are adequate length of the donor ureter to reach the contralateral ureter as well as normal anatomy of this receptor unit. We report a case in which transureteroureterostomy was anatomically impossible due to an ectopic receptor kidney. Urinary diversion was successfully accomplished by transureterocalicostmy. CASE REPORT
E. S. H., a 65-year-old white woman, underwent partial sigmoidectmy 1year previously due to sigmoid cancer. Surgery was uneventful and resulted in apparent control of disease. Colonoscopy and abdominal ultrasound were normal 8 months postoperatively. Although the patient was completely asymptomatic, abdominal computerized tomography and magnetic resonance imaging 2 months later revealed a 5 cm. retroperitoneal tumor infiltrating the left psoas muscle at the level of L5-S1 with moderate left hydronephrosis due to ureteral obstruction. The right kidney was well functioning but ectopic, located a t the level of M-Sl, and malrotated with anteriorized pelvis and calices. Since no other tumors were noted in the abdomen or thorax, surgical removal of the mass was indicated. Preoperative retrograde pyelography confirmed tumoral infiltration of the mid portion of the left ureter that almost completely obstructed it. Laparotomy was performed through a left pararectal incision. After freeing the left colon, the tumor was seen completely enveloping the left ureter and the ipsilateral common iliac vessels, and was adherent to the psoas muscle. To allow complete resection of this mass the psoas muscle was deeply incised, and the ureter was sectioned above and below the tumor with a margin almost 3 cm. above the tumor. The iliac vessels were carefully separated from the mass. At the completion of dissection the ureter was missing a mid portion almost 10 cm. long. Frozen section of both ureteral stumps showed no tumoral residue but the distance between them precluded any attempt a t primary end-to-end reanastomosis. The need for postoperative radiotherapy was considered, and the possibilities of left renal autotransplantation to the iliac fossa and ileal interposition were discarded since the autotransplanted kidney and ileal segment would probably lie in the irradiation field. Transureteroureterostomy was not feasible since the right kidney was ectopic and the left ureter could not reach the short right ureter. Left nephrectomy seemed to be Accepted for publication April 8, 1994.
the option but on inspecting the right malrotated kidney it was noted that its uppermost medial calk was superficial with almost no overlying parenchyma. Although the proximal end of the transected left ureter could not initially reach this calk, the procedure was accomplished without tension after adequate downward mobilization and fixation of the left kidney. It is important t o note that even after this maneuver the upper left ureter could not reach the lower left segment (with a gap of almost 5 cm.) or the right ureter. After incising the upper right calix a 6F multi-perforated ureteral stent was inserted, directed downward by a guide wire into the bladder and exteriorized through the urethra. The other end of the stent was pushed into the left ureter up to the renal pelvis. End-to-side anastomosis between the left spatulated ureter and the right upper calix was then performed with interrupted 4-zero catgut. The anastornotic site and tumoral bed were covered by peritoneum, both areas were drained with large Penrose drains exteriorized through the flank and the incision was closed. The ureteral stent was tied to a Foley catheter inserted in the bladder. Convalescence was uneventful. On postoperative day 12 retrograde pyelography through the stent showed a patent ureterocaliceal anastomosis without extravasation (fig. 1). The stent and Foley catheter were removed and the patient resumed normal voiding. Excretory urography 6 weeks later showed mild dilatation of the left kidney with normal function (fig. 2). The patient then underwent a 6-week course of radiation to the tumoral bed. Ultrasound and computerized tomography 2 and 6 months after radiotherapy showed improvement in the dilatation of the left kidney without evidence of local tumor recurrence. The patient has remained asymptomatic. DISCUSSION
Traumatic and iatrogenic lesions of the ureter have been treated with different techniques of reconstruction according to the type, level and extension of the ureteral injury as well as the presence of local urinary extravasation and infection. The same guidelines generally are used when a ureteral segment must be removed due to intrinsic disease (stricture or tumor) or extrinsic involvement (tumor, fibrosis or abscess).' Recent advances in endourological techniques using flexible ureteroscopes and nonreacting ureteral catheters have obviated the need for open surgery but there are still some situations when ureteral resection is inevitable. Such operations in the lower third of the ureter cause no special difficulty to the urologist since the bladder is near and, if straightforward ureterovesical reimplantation is not possi-
404
TRANSURETEROCALICOSTOMY
FIG. 1. Anteroposterior ( A ) and lateral (arrows).
views of postoperative retrograde
FIG. 2. Excreto urography demonstrates normal function and mild calicectasis o?left kidney.
ble, other techniques, such as the psoas hitch with O r without the Boari flap, enable reanastomosis of the ureter to the bladder.' When the upper ureteral segment is damaged it can be treated by pyeloureteral reanastomosis with or with-
405
show patent anastomosis without leakage
out concomitant renal mobilization and nephropexy. When much of the renal pelvis or upper ureter is involved in fibrosis, ureterocalicostomy can be performed, depending on the ability t o expose and suture the lower caliceal wall without tension t o the healthy ~ r e t e r . ~ The mid section of the ureter is the most problematic segment. Whenever ipsilateral ureteroureterostomy is not possible due to the extent of the resected segment, even after extensive renal mobilization, ileal interposition must be p e r f ~ r m e d . ~If. residual upper ureter is available, transureteroureterostomy can be an adequate alternative.6 Kidney autotransplantation remains an exceptional disproportionate alternative in such cases to be used when the aforementioned operations are technically impossible and kidney preservation is mandatory.' Ipsilateral nephrectomy is the treatment of choice when the contralateral kidney is normal and life expectancy is short due to old age or concurrent malignancy. In our case primary ipsilateral ureteroureterostomy and transureteroureterostomy were impossible due to the extent of the resected segment. The need for subsequent radiotherapy precluded ileal interposition and renal autotransplantation. Due to concurrent malignancy, nephrectomy could have been an adequate alternative since the contralateral kidney, although ectopic, had normal function. We preferred transureterocalicostomy since the right kidney had a favorable pyelocaliceal anatomy with a superficial upper calix, and there was no need for extensive dissection of an otherwise normal kidney. Criticism regarding possible damage of the receptor calix and its consequences on the function of the ipsilateral healthy kidney would not apply to our case since the calix was superficial. Therefore, if the anastomosis failed due to stricture or dehiscence, there would be no significant consequences to the receptor kidney. In the case of transureteroureterostomy the kidney would be more endangered since ureteral leakage could cause stenosis and function loss. Success in our case was also ensured by the optimal conditions in which the ureterocaliceal anastomosis was performed, that is without tension and with adequate drainage. In an exceptional circumstance this simple procedure proved to be a worthwhile alternative to nephrectomy.
406
TRANSURETEROCALICOSTOMY REFERENCES
~ M. c,,~ x n g , ~K. s, ~and 0lsson, ~ C,, A.: Ureteral reconstruction and bypass: experience with ileal interposition, the Boari flap-psoas hitch and renal autotransplantation. J . Urol., IAR. 3n i w n. --.--, 2. Olsson, C. A. and Norlen, L. J.: Combined Boari bladder flappsoas hitch procedure in ureteral replacement. Scand. J. Urol. Nephrol., 20 279,1986. 3. Mollard, P., Mouriquand, P., Joubert, P. and Pouyau, A,: Ureterocalicostomy for hydronephrosis caused by junction disease in children and adolescents. Apropos of 35 cases. Chir. Ped., 1, B
-
-
--I
31: 87. 1990. A.J., Colodny, A. H., Bauer, S. B. and Retik, A. B.: The use of bowel interposed between proximal and distal ureter in urinary tract reconstruction. J. Urol., 134: 737, 1985. 5. Martinez-Sagarra, J. M., Amon Sesmero, J . H., Santos Lago, J., Estebanez Zarranz, J., Amogarcia, A. and Rodriguez Toves, A,: Ureteroplastias ileales. Arch. Esp. Urol., 45: 961, 1992. 6. Baert, L. and Claes, H.: A retroperitoneal approach for transureteroureterostomy: a neglected and forgotten procedure. Acta Urol. Belg., 5 8 51, 1990.
4. Casale,