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Transvesical intussusception ureterectomy
TRANSVESICAL ROGER
INTUSSUSCEPTION
GOODFRIEND,
Los Gatos,
M.D.
California
Nephroureterectomy remains the treatment of choice for transitional cell carcinoma of the kidney except when the lesion is small, low grade, and noninvasive. Transvesical intussusception ureterectomy shortens and simplifies this operation.1.2 Following a flank nephrectomy, the remaining ureter is sutured to a ureteral catheter which has been threaded down the ureter into the bladder. The bladder is then opened through a small cystostomy incision. Traction on the catheter causes the ureter to intussuscept, thereby permitting extraction of the entire ureter which is then excised together with a bladder cuff. This report describes modifications in the technique that will facilitate the procedure and assure total ureteral resection. Procedure A 7-F silk-woven ureteral catheter is cystoscopically placed into the renal pelvis prior to surgery and taped to a Foley catheter. Following nephrectomy, a heavy suture is passed through both sides of the ureter and through the eye of the catheter tip. Traction on the ureteral
FIGURE 1. (A) Ureteral catheter sutured to ureter; (B) intussusception started; and (C) intussusception progresses easily once started.
catheter by the operating room nurse reaching under the drapes causes the ureter to invaginate. If this does not occur, the ureter is fixed in position with right angle clamps applied on each side about 2 cm from the cut end (Fig. 1). Gentle traction is applied to the ureteral catheter from below, at the same time invaginating the open end of the ureter with forceps. Once this intussusception process is initiated, the remainder of the operation proceeds easily. The ureter should not be freed up initially as mentioned in previous articles. With continued traction, the ureter will disappear into the depths of the wound by progressive intussusception. The surgeon follows the ureter down, lightly grasping the ureter as it disappears and freeing it from its areolar attachments. When the ureter has intussuscepted below the level of the iliac vessels, the flank wound is closed and the patient placed in the supine position. The bladder is filled through the Foley catheter and a small cystostomy done. The ureter is found exiting via the urethra or lying in the bladder, It is then grasped and pulled into the bladder for
l’ ‘\‘, I :; _ \
414
URETERECTOMY
:
UROLOGY
;
APRIL 1983 !
VOLUlfE
XXI. h’UMBER 4
Comment
FICVRE: 2.
Remainder
of ureter being withdrawn
into bladder.
the remainder of its length (Fig. 2). This fact is verified by observing the inverted cone of the ureter tenting the vesical mucosa surrounding the orifice. If this tenting is not observed, it means the ureteral extraction is incomplete and further traction is required. A large clamp placed at the base of the cone will insure inclusion of a cuff of vesical mucosa when the ureter is excised. If preferred, an incision may be made for a wider cuff. The orifice is then closed with reabsorbable sutures encompassing mucosa and underlying muscle. The Foley catheter is left inI place and the cystostomy closed. If a 7-F catheter cannot be inserted cystoscopically, a smaller catheter may be used. A 7F catheter can then be sutured to the smaller one following nephrectomy. The 7-F catheter is threaded through the ureter by pulling on the smaller one until it appears in the urethra. Silkwoven large catheters are advisable because the sutures fixing the ureter can tear easily through a small (disposable catheter.
Previous authors have recommended that the catheter be placed down the ureter into the bladder, the wound closed, and then the cystostomy done. However. I have found that unless the intussusception is started from above, traction on the ureteral catheter mav cause the ureter to be pulled down upon -itself with an “accordion-like” effect and prevent intussusception. This is why the ureteral catheter must be placed cystoscopically into the renal pelvis prior to surgery and the flank wound not closed until the intussuscepted ureter is pulled below the iliac vessels. Also it is not always possible to introduce a catheter into the bladder from above. Freeing the ureter initially, as suggested by others merely makes the “accordion-like” result more probable. Intussusception of the ureter is facilitated by leaving ureteral attachments in place and freeing them as the intussusception progresses. Retroperitoneal lower ureteral dissection can be difficult, especially in obese patients. This method obviates this problem. Bleeding has not been a factor to date in reported cases. Addendum An additional operation was done on a solitary kidney with extensive transitional cell carcinoma. Instead of a suprapubic cystostom); the ureter was excised by using a 24-F resectoscope and the knife electrode. It was simple to obtain a cuff around the ureter: traction on the ureter facilitated this. 777 Pollard Road, Los Gatos, California
Suite 8 95030
AC:KSO~\'LEI)GSIE:ST: To Dr. T. Sullivan for his collaboration and Annette Goodfriend for the dramings.
INTUSSUSCEPTION
GOODFRIEND,
Los Gatos,
M.D.
California
Nephroureterectomy remains the treatment of choice for transitional cell carcinoma of the kidney except when the lesion is small, low grade, and noninvasive. Transvesical intussusception ureterectomy shortens and simplifies this operation.1.2 Following a flank nephrectomy, the remaining ureter is sutured to a ureteral catheter which has been threaded down the ureter into the bladder. The bladder is then opened through a small cystostomy incision. Traction on the catheter causes the ureter to intussuscept, thereby permitting extraction of the entire ureter which is then excised together with a bladder cuff. This report describes modifications in the technique that will facilitate the procedure and assure total ureteral resection. Procedure A 7-F silk-woven ureteral catheter is cystoscopically placed into the renal pelvis prior to surgery and taped to a Foley catheter. Following nephrectomy, a heavy suture is passed through both sides of the ureter and through the eye of the catheter tip. Traction on the ureteral
FIGURE 1. (A) Ureteral catheter sutured to ureter; (B) intussusception started; and (C) intussusception progresses easily once started.
catheter by the operating room nurse reaching under the drapes causes the ureter to invaginate. If this does not occur, the ureter is fixed in position with right angle clamps applied on each side about 2 cm from the cut end (Fig. 1). Gentle traction is applied to the ureteral catheter from below, at the same time invaginating the open end of the ureter with forceps. Once this intussusception process is initiated, the remainder of the operation proceeds easily. The ureter should not be freed up initially as mentioned in previous articles. With continued traction, the ureter will disappear into the depths of the wound by progressive intussusception. The surgeon follows the ureter down, lightly grasping the ureter as it disappears and freeing it from its areolar attachments. When the ureter has intussuscepted below the level of the iliac vessels, the flank wound is closed and the patient placed in the supine position. The bladder is filled through the Foley catheter and a small cystostomy done. The ureter is found exiting via the urethra or lying in the bladder, It is then grasped and pulled into the bladder for
l’ ‘\‘, I :; _ \
414
URETERECTOMY
:
UROLOGY
;
APRIL 1983 !
VOLUlfE
XXI. h’UMBER 4
Comment
FICVRE: 2.
Remainder
of ureter being withdrawn
into bladder.
the remainder of its length (Fig. 2). This fact is verified by observing the inverted cone of the ureter tenting the vesical mucosa surrounding the orifice. If this tenting is not observed, it means the ureteral extraction is incomplete and further traction is required. A large clamp placed at the base of the cone will insure inclusion of a cuff of vesical mucosa when the ureter is excised. If preferred, an incision may be made for a wider cuff. The orifice is then closed with reabsorbable sutures encompassing mucosa and underlying muscle. The Foley catheter is left inI place and the cystostomy closed. If a 7-F catheter cannot be inserted cystoscopically, a smaller catheter may be used. A 7F catheter can then be sutured to the smaller one following nephrectomy. The 7-F catheter is threaded through the ureter by pulling on the smaller one until it appears in the urethra. Silkwoven large catheters are advisable because the sutures fixing the ureter can tear easily through a small (disposable catheter.
Previous authors have recommended that the catheter be placed down the ureter into the bladder, the wound closed, and then the cystostomy done. However. I have found that unless the intussusception is started from above, traction on the ureteral catheter mav cause the ureter to be pulled down upon -itself with an “accordion-like” effect and prevent intussusception. This is why the ureteral catheter must be placed cystoscopically into the renal pelvis prior to surgery and the flank wound not closed until the intussuscepted ureter is pulled below the iliac vessels. Also it is not always possible to introduce a catheter into the bladder from above. Freeing the ureter initially, as suggested by others merely makes the “accordion-like” result more probable. Intussusception of the ureter is facilitated by leaving ureteral attachments in place and freeing them as the intussusception progresses. Retroperitoneal lower ureteral dissection can be difficult, especially in obese patients. This method obviates this problem. Bleeding has not been a factor to date in reported cases. Addendum An additional operation was done on a solitary kidney with extensive transitional cell carcinoma. Instead of a suprapubic cystostom); the ureter was excised by using a 24-F resectoscope and the knife electrode. It was simple to obtain a cuff around the ureter: traction on the ureter facilitated this. 777 Pollard Road, Los Gatos, California
Suite 8 95030
AC:KSO~\'LEI)GSIE:ST: To Dr. T. Sullivan for his collaboration and Annette Goodfriend for the dramings.