- Email: [email protected]
Ureterocalicostomy: An Alternative to Nephrectomy
Vol. 115, May Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
URETEROCALICOSTOMY: AN ALTERNATIVE TO NEPHRECTOMY N. JAMES HAWTHORNE,* HORST ZINCKE
AND
PANAYOTIS P. KELALIS
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
Ureterocalicostomy is a procedure with limited indications but with important application in the infrequent patient in whom the more desirable methods of creating unobstructed ureteropelvic drainage cannot be used. Three children are described in whom successful ureterocalicostomy was performed. The most common· condition in which ureterocalicostomy has been useful is in the obstructed and scarred, intrarenal pelvis in which a classic type ofureteropyelostomy is not possible. The most important technical consideration seems to be sufficient amputation of the lower pole renal cortex in order to free the ureterocaliceal anastomosis from the surrounding cortical tissue. The 3 cases illustrate the difficult situations in which ureterocalicostomy may be indicated and the value of this procedure in preserving maximal renal function in children. In 1947 Neuwirt reported on the successful implantation of the ureter of a solitary kidney into the lower calix of the renal pelvis. 1 The limited reports of this operation reflect the infrequency of its indication and perhaps the difficulties and frustrations often associated with the complicated conditions in which ureterocalicostomy becomes necessary. The extensive report by Couvelaire and associates in 1964 was the first comprehensive discussion of this procedure. 2 Such a discussion is not available in English. Herein we describe 3 children in whom ureterocalicostomy was performed and review the available literature. CASE REPORTS
Case 1. A 14-year-old boy was in a motorcycle accident in June 1973 and sustained extensive abdominal injuries on the right side. The upper right ureter was severed but this was not recognized at exploratory laparotomy. Flank pain and abdominal swelling ensued after 3 weeks. Exploration of the right flank revealed severe inflammatory reaction around the kidney and ureter, and extravasated urine. The severed ureter was separated from the renal pelvis by about 3 cm. and was so indurated that dissection was not possible. After sufficient kidney mobilization, an anastomosis of the ureter to the inferior calix of the kidney was performed over a 6F red rubber catheter. Tension on the anastomosis was not excessive but because of the fragile edematous condition of the ureter, the surgeon left the lower pole cortex around the anastomosis rather than amputate it in order to provide reinforcement of the suture line. The stenting catheter was removed 6 weeks later. Soon delay in emptying developed, which led to progressive hydronephrosis. The patient was referred to the Mayo Clinic after placement of a nephrostomy tube. An excretory urogram (IVP) showed hydronephrosis (fig. 1, A) and retrograde ureterograms demonstrated the area of stricture at the ureterocaliceal anastomosis. In October the right kidney was re-explored. Despite a tremendous amount of perirenal inflammatory reaction, the appearance of the kidney was excellent. Stricturing of the intrarenal portion of the ureter was noted. The small and intrarenal pelvis and shortened ureter precluded ureteropyelostomy. Therefore, the spatulated ureter was anastomosed to the infundibulum of the lower calix without undue tension over a 16F whistle-tip catheter after the lower pole was amputated. A nephrostomy catheter was placed. Accepted for publication August 15, 1975. * Requests for reprints: Section of Publications, Mayo Clinic, 200
First St., S.W., Rochester, Minnesota 55901.
The stent was removed 3 weeks postoperatively. Although a nephrostogram showed a patent anastomosis, it failed to function when the nephrostomy tube was clamped. A retrograde ureteral catheter was left in place for 11 days, after which both it and the nephrostomy tube were removed without difficulty. The patient has been asymptomatic and IVP 3 and 18 months postoperatively showed regression of the hydronephrosis and prompt drainage via the ureterocaliceal anastomosis (fig. 1, B). Case 2. A 5-year-old boy was referred to the Mayo Clinic in May 1974 for renal failure. He was pallid, edematous and lethargic. Blood pressure was 170/120 mm. Hg, plasma urea level 249 mg. per dl. and creatinine level 9.6 mg. per dl. Infusion IVPs showed bilateral pyelocaliectasis and suggested ureteropelvic obstruction (fig. 2, A). The boy had undergone bilateral ureteroneocystostomy in April 1973 for enuresis and vesicoureteral reflux. Revision of the ureterovesical junctions had been performed a month later when obstruction developed. Bilateral ureteropelvic obstruction was diagnosed several months later and a right dismembered pyeloplasty was done in January 1974. However, the patient's condition continued to worsen. Emergency decompression of both kidneys was performed by nephrostomy and a simultaneous ureteropyelostomy was done on the right side. After resolution of the renal failure, roentgenographic contrast studies were done, which showed the small contracted left renal pelvis with the ureter ending blindly outside the hilus (fig. 2, B). Further operation was undertaken in July. The left ureter was traced to the renal hilus where it was obliterated. The renal pelvis was scarred and intrarenal, precluding any reconstructive procedure. The upper pole of the kidney was atrophic, necessitating partial nephrectomy. The lower pole was amputated to reveal the lower calix. The ureter was spatulated and anastomosed to the lower calix over a 12F ureteral catheter and nephrostomy was done. The left ureteral stent was removed and the left nephrostomy tube was clamped without difficulty 17 days postoperatively. A nephrostogram showed rapid complete flow of contrast medium from the calices to the bladder (fig. 2, C) and the nephrostomy tube was removed. The child has been free of symptoms and an IVP 6 months postoperatively showed prompt function and drainage of the remaining left renal unit (fig. 2, D). Case 3. A 5-year-old girl was first seen at the Mayo Clinic in August 1974 with obstruction of the left kidney and a nephrostomy. A bilateral ureteroneocystostomy had been performed 5 months previously for vesicoureteral reflux and persistent
583
i ! '
584
HAWTHORNE, ZINCKE AND KELALIS
FIG. 1. Case 1. A, admission IVP demonstrates right hydronephrosis. Right ureter was never opacified. B, IVP 18 months postoperatively shows regression of hydronephrosis and prompt drainage of kidney.
was performed over a 12F whistle-tip catheter after enough of the lower pole cortex was removed to expose the inferior calix. A nephrostomy tube was placed. The postoperative course was complicated by fever and purulent drainage around the nephrostomy tube. Culture of the drainage material yielded Candida albicans. A perirenal abscess was drained by reopening the previous flank incision. Establishment of physiologic urine drainage was considered mandatory and, thus, secondary left ureteroneocystostomy was performed after resection of the lower occluded portion of the ureter. The ureteral stent was removed 20 days postoperatively and the nephrostomy tube was clamped and subsequently removed. When the child was discharged from the hospital the serum creatinine level was 0.95 mg. per dl. and the urine was uninfected. IVP 8 months later showed prompt, bilateral excretion with good drainage on the operated side (fig. 3, B). DISCUSSION
A variety of excellent and established techniques for restoring the continuity of the obstructed ureteropelvic junction or upper ureter is available to the surgeon. Occasionally, or even rarely, these techniques cannot be applied. The non-diseased portion of the ureter is not long enough to reach the pelvis or the pelvis is inaccessible because of some combination of peripelvic scarring, intrarenal location or an interfering vascular pedicle. Various techniques have been applied when a reanastomosis is prevented by insufficient length of ureter, including autotransplantation of the kidney and interposition of an ileal segment. When the pelvis cannot be adequately approached and dissected, only nephrectomy or permanent nephrostomy may be considered. Ureterocalicostomy is an important alternative in these patients. When evaluating the applicability of ureterocalicostomy the urologist must first consider the patient's age, general physical condition and ability to tolerate a postoperative course that is more difficult than that after simple nephrectomy. The 3 children whom we have described were in good general health and had long life expectancy, making preservation of maximal renal function imperative. The kidney to be preserved by ureterocalicostomy should have sufficient functional mass to
FIG. 2. Case 2. A, admission infusion IVP shows poor function and marked bilateral hydronephrosis. Ureters were never opacified. B, simultaneous nephrostogram and retrograde ureterogram. Two nephrostomy tubes were required to drain kidney. Ureter ends blindly outside hilus. C, nephrostogram after ureterocalicostomy demonstrates rapid complete emptying of pelvis. D, IVP 6 months postoperatively shows prompt function and complete drainage.
infection. Obstruction developed at the site of both anastomoses, necessitating insertion of ureteral catheters by an open procedure. After removal of the catheters the right side drained well but the obstruction of the lower left ureter continued and drainage with a nephrostomy tube became necessary. Serum creatinine level was normal. The urine from the nephrostomy tube was infected and a nephrostogram showed ureteropelvic obstruction as well as complete ureterovesical junction obstruction (fig. 3, A). At exploration through a flank incision the ureter was identified and traced to the region of the pelvis, which was intrarenal. Considerable peripelvic inflammation and narrowing of the upper ureter made ureteropyelostomy technically not feasible. A ureterocaliceal anastomosis
FIG. 3. Case 3. A, admission nephrostogram demonstrates ureteropelvic and complete ureterovesical junction obstructions. B, IVP 8 months postoperatively shows regression of pyelocaliectasis and prompt drainage by ureterocalicostomy.
URETER0CAL1C0STOrvrz
make the '-'"J~,.~,H worthwhile. This evaluation often must be made at operation. The contralateral kidney must be evaluated for its capacity to perform total renal function and for the likelihood of its involvement by the primary pathologic process. The most commonly reported underlying pathologic conditions that necessitate ureterocalicostomy, including renal lithiasis, congenital ureteropelvic junction obstruction and, in Europe, renal tuberculosis, have a high incidence of bilaterality. Neuwirt performed the first ureterocalicostomy by simply pulling the splayed ureter through the cortex into the calix and suturing the ureter to the capsule. 1 However, the lower pole cortex was markedly thinned. \Vhen Jameson and associates performed ureterocalicostomy without amputation of a more normal lower cortical pole, scarring and contracture developed, resulting in obstruction. 3 Exploration revealed the obstruction to be in the intrarenal ureteral segment and was caused by fibrosis of the cortex, the ureterocaliceal anastomosis itself being patent. Their reoperation with the anastomosis performed after amputation of the lower pole was successful. Similarly, the first ureterocalicostomy performed on our case 1 was done without amputation of the lower pole. Reoperation after obstruction developed revealed that fibrosis of the cortex obstructed the intrarenal ureter and the reanastomosis was successful after amputation of the lower pole. Various methods of anastomosis of the ureter to the calix have been described. Although the most simple, Neuwirt's method is limited (as noted previously) and might not create the desired dependent anastomosis. 1 Jameson and associates bivalved the ureter and anastomosed the 2 flaps to the calix over a ureteral stent but made no attempt to achieve a watertight closure. 3 Some have created a direct end-to-end anastomosis and still others have sutured the ureter to the calix and the renal capsule. The principles that have been used by one of us (P. P. K.) in performing ureterocalicostomy are 1) amputation of sufficient lower pole cortex to free the ureter from entrapment contracting fibrosis of the cortex and 2) tangential sectioning of the calix and splaying of the ureter to create a maximally patent anastomosis and a non-circumferential suture line. A retrograde ureteral catheter is placed cystoscopically to aid in
the identification of the ureteL The catheter is replaced and the anastomosis is performed over a ureteral stent of sufficient caliber in combination with nephrostomy drainage (fig. 4). The largest series of ureterocalicostomies encountered is that of Couvelaire and associates. 2 That report included 8 patients with ureteropelvic obstruction secondary to operation for renal stones, 2 with primary ureteropelvic obstruction, 3 with pelvic stenosis owing to tuberculosis and 1 with a horseshoe kidney complicated by pyelocaliectasis. Many of these patients had complex problems and some had undergone multiple surgical procedures. There were 4 failures. In the discussion of the failures Couvelaire and associates concluded that the most important factor contributing to failure was inadequate freeing of the anastomosis from the surrounding tissue of the lower pole cortex. Michalowski and associates described 10 patients who underwent ureterocalicostomy. 4 Of these patients 5 had congenital ureteropelvic obstruction as the underlying disease and 5 had nephrolithiasis. Good results were reported in 6 patients (as judged by IVP), although only 1 ultimately underwent nephrectomy. They did not speculate on the reasons for the less than satisfactory results. We found 50 cases of ureterocalicostomy reported in the available literature. 1 • 1 4 Of these cases 36 apparently had successful results. Eight ureterocalicostomies were performed on patients who were in the first 2 decades of life. Our limited experience and the previously reported experience with ureterocalicostomy indicate that this procedure can be performed successfully even when complicated by prior renal operation. The likelihood of success seems comparable to that in other secondary operations on the obstructed ureteropelvic junction. With careful surgical technique and rigid adherence to the principle of removal of cortical tissue from the ureterocaliceal anastomosis, the likelihood of creating unobstructed drainage of the upper collecting system is good. REFERENCES
Neuwirt, K.: Implantation of the ureter into the lower calyx of the renal pelvis. In: VII Congres de la Societe Internationale d'Urologie, part 2, pp. 253-255, 1947. 2. Couve!aire, R., Auvert, J., Moulonguet, A., Cukier, J. and Leger, P.: Implantations et anastomoses uretero-calicielles: techniques et indications. J. Urol. Nephrol., 70: 437, 1964. 3. Jameson, S. G., McKinney, J. S. and Rushton, J. F.: Ureterocalyostomy: a new surgical procedure for correction of ureteropelvic stricture associated with an intrarenal pelvis. J. Urol., 1.
77: 135, 1957. 4. Michalowski, E., Modelski, W. and Kmak, A.: Die End-zu-End-
5.
6.
7. 8.
9.
10. 11. ,
FIG. 4. Representation of method of ureterocalicostomy. A, lower pole cortex is removed to expose inferior calix and free anastomotic site. B, ureter sectioned obliquely and spatulated. C, anastomosis performed over stenting catheter.
Anastomose zwischen dem unteren Nieren-kelch und Hamleiter (Ureterocalicostomie). Z. Urol. Nephrol., 63: 1, 1970. Chauvin, H.-F. and Famarier, G.: Resu!tat mediat d'une anastomose uretero-ca!icielle pour tuberculose renale. J. Urol. Nephrol., 67: 545, 1961. Grasset, D.: Speleotomie polaire superieure et implantation uretero-calicielle inferieure droites pour stenose pye!ique bacillaire. J. Uro!. Nephrol., 74: 87, 1968. Macaulay, R. J., Jr.: Ureterocalyceal anastomosis: case report. J. Urol., 90: 40, 1963. Moloney, G. E.: Avulsion of the renal pelvis treated by ureterocalycostomy. Brit. J. Urol., 42: 519, 1970. Mochalova, T. P.: 0 peresadke mochetochnika v nizhniuiu chashechku pri posttuberku!eznykh stenozakh prilokhanochnogo otdela mochetochnika. Urol. Nefrol., 38: 32, 1973. Proca, E.: On a case of uretero-calyceal anastomosis. Rom. Med. Rev., 15: 51, 1971. Puigvert, A. and Ponce de Leon, I.: Ureterocaliostomla en el
tratameinto de la tuberculosis renal. Arch. Esp. Urol., 18: 1, 1965. 12. Scarabelli, L.: A proposito dell'uretero-calico-anastomosi. Contributo casistico. Minerva Chir., 23: 729, 1968. 13. Singer, J.: Ureterocalyostomy: a case report and discussion. Brit. J. Urol., 34: 178, 1962.
r.
586
HAWTHORNE, ZINCKE AND KELALIS
14. Wesolowski, S.: Corrective operative procedure after unsuccessful pelvi-ureteric plastic surgery. Brit. J. Urol., 43: 679, 1971.
COMMENT
We recently used this surgical maneuver in a patient who had complete stricture of the proximal ureter, extending up into the intrarenal ureteropelvic junction. The thin parenchyma in the lower
pole ensured us a good ureterocaliceal anastomosis without danger of stricturing from thick scarred renal parenchyma. This innovative surgical technique should be part of the urological surgeon's armamentarium but used in only the rare selective cases.
Martin G. McLaughlin The Johns Hopkins Hospital Baltimore, Maryland
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
URETEROCALICOSTOMY: AN ALTERNATIVE TO NEPHRECTOMY N. JAMES HAWTHORNE,* HORST ZINCKE
AND
PANAYOTIS P. KELALIS
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
Ureterocalicostomy is a procedure with limited indications but with important application in the infrequent patient in whom the more desirable methods of creating unobstructed ureteropelvic drainage cannot be used. Three children are described in whom successful ureterocalicostomy was performed. The most common· condition in which ureterocalicostomy has been useful is in the obstructed and scarred, intrarenal pelvis in which a classic type ofureteropyelostomy is not possible. The most important technical consideration seems to be sufficient amputation of the lower pole renal cortex in order to free the ureterocaliceal anastomosis from the surrounding cortical tissue. The 3 cases illustrate the difficult situations in which ureterocalicostomy may be indicated and the value of this procedure in preserving maximal renal function in children. In 1947 Neuwirt reported on the successful implantation of the ureter of a solitary kidney into the lower calix of the renal pelvis. 1 The limited reports of this operation reflect the infrequency of its indication and perhaps the difficulties and frustrations often associated with the complicated conditions in which ureterocalicostomy becomes necessary. The extensive report by Couvelaire and associates in 1964 was the first comprehensive discussion of this procedure. 2 Such a discussion is not available in English. Herein we describe 3 children in whom ureterocalicostomy was performed and review the available literature. CASE REPORTS
Case 1. A 14-year-old boy was in a motorcycle accident in June 1973 and sustained extensive abdominal injuries on the right side. The upper right ureter was severed but this was not recognized at exploratory laparotomy. Flank pain and abdominal swelling ensued after 3 weeks. Exploration of the right flank revealed severe inflammatory reaction around the kidney and ureter, and extravasated urine. The severed ureter was separated from the renal pelvis by about 3 cm. and was so indurated that dissection was not possible. After sufficient kidney mobilization, an anastomosis of the ureter to the inferior calix of the kidney was performed over a 6F red rubber catheter. Tension on the anastomosis was not excessive but because of the fragile edematous condition of the ureter, the surgeon left the lower pole cortex around the anastomosis rather than amputate it in order to provide reinforcement of the suture line. The stenting catheter was removed 6 weeks later. Soon delay in emptying developed, which led to progressive hydronephrosis. The patient was referred to the Mayo Clinic after placement of a nephrostomy tube. An excretory urogram (IVP) showed hydronephrosis (fig. 1, A) and retrograde ureterograms demonstrated the area of stricture at the ureterocaliceal anastomosis. In October the right kidney was re-explored. Despite a tremendous amount of perirenal inflammatory reaction, the appearance of the kidney was excellent. Stricturing of the intrarenal portion of the ureter was noted. The small and intrarenal pelvis and shortened ureter precluded ureteropyelostomy. Therefore, the spatulated ureter was anastomosed to the infundibulum of the lower calix without undue tension over a 16F whistle-tip catheter after the lower pole was amputated. A nephrostomy catheter was placed. Accepted for publication August 15, 1975. * Requests for reprints: Section of Publications, Mayo Clinic, 200
First St., S.W., Rochester, Minnesota 55901.
The stent was removed 3 weeks postoperatively. Although a nephrostogram showed a patent anastomosis, it failed to function when the nephrostomy tube was clamped. A retrograde ureteral catheter was left in place for 11 days, after which both it and the nephrostomy tube were removed without difficulty. The patient has been asymptomatic and IVP 3 and 18 months postoperatively showed regression of the hydronephrosis and prompt drainage via the ureterocaliceal anastomosis (fig. 1, B). Case 2. A 5-year-old boy was referred to the Mayo Clinic in May 1974 for renal failure. He was pallid, edematous and lethargic. Blood pressure was 170/120 mm. Hg, plasma urea level 249 mg. per dl. and creatinine level 9.6 mg. per dl. Infusion IVPs showed bilateral pyelocaliectasis and suggested ureteropelvic obstruction (fig. 2, A). The boy had undergone bilateral ureteroneocystostomy in April 1973 for enuresis and vesicoureteral reflux. Revision of the ureterovesical junctions had been performed a month later when obstruction developed. Bilateral ureteropelvic obstruction was diagnosed several months later and a right dismembered pyeloplasty was done in January 1974. However, the patient's condition continued to worsen. Emergency decompression of both kidneys was performed by nephrostomy and a simultaneous ureteropyelostomy was done on the right side. After resolution of the renal failure, roentgenographic contrast studies were done, which showed the small contracted left renal pelvis with the ureter ending blindly outside the hilus (fig. 2, B). Further operation was undertaken in July. The left ureter was traced to the renal hilus where it was obliterated. The renal pelvis was scarred and intrarenal, precluding any reconstructive procedure. The upper pole of the kidney was atrophic, necessitating partial nephrectomy. The lower pole was amputated to reveal the lower calix. The ureter was spatulated and anastomosed to the lower calix over a 12F ureteral catheter and nephrostomy was done. The left ureteral stent was removed and the left nephrostomy tube was clamped without difficulty 17 days postoperatively. A nephrostogram showed rapid complete flow of contrast medium from the calices to the bladder (fig. 2, C) and the nephrostomy tube was removed. The child has been free of symptoms and an IVP 6 months postoperatively showed prompt function and drainage of the remaining left renal unit (fig. 2, D). Case 3. A 5-year-old girl was first seen at the Mayo Clinic in August 1974 with obstruction of the left kidney and a nephrostomy. A bilateral ureteroneocystostomy had been performed 5 months previously for vesicoureteral reflux and persistent
583
i ! '
584
HAWTHORNE, ZINCKE AND KELALIS
FIG. 1. Case 1. A, admission IVP demonstrates right hydronephrosis. Right ureter was never opacified. B, IVP 18 months postoperatively shows regression of hydronephrosis and prompt drainage of kidney.
was performed over a 12F whistle-tip catheter after enough of the lower pole cortex was removed to expose the inferior calix. A nephrostomy tube was placed. The postoperative course was complicated by fever and purulent drainage around the nephrostomy tube. Culture of the drainage material yielded Candida albicans. A perirenal abscess was drained by reopening the previous flank incision. Establishment of physiologic urine drainage was considered mandatory and, thus, secondary left ureteroneocystostomy was performed after resection of the lower occluded portion of the ureter. The ureteral stent was removed 20 days postoperatively and the nephrostomy tube was clamped and subsequently removed. When the child was discharged from the hospital the serum creatinine level was 0.95 mg. per dl. and the urine was uninfected. IVP 8 months later showed prompt, bilateral excretion with good drainage on the operated side (fig. 3, B). DISCUSSION
A variety of excellent and established techniques for restoring the continuity of the obstructed ureteropelvic junction or upper ureter is available to the surgeon. Occasionally, or even rarely, these techniques cannot be applied. The non-diseased portion of the ureter is not long enough to reach the pelvis or the pelvis is inaccessible because of some combination of peripelvic scarring, intrarenal location or an interfering vascular pedicle. Various techniques have been applied when a reanastomosis is prevented by insufficient length of ureter, including autotransplantation of the kidney and interposition of an ileal segment. When the pelvis cannot be adequately approached and dissected, only nephrectomy or permanent nephrostomy may be considered. Ureterocalicostomy is an important alternative in these patients. When evaluating the applicability of ureterocalicostomy the urologist must first consider the patient's age, general physical condition and ability to tolerate a postoperative course that is more difficult than that after simple nephrectomy. The 3 children whom we have described were in good general health and had long life expectancy, making preservation of maximal renal function imperative. The kidney to be preserved by ureterocalicostomy should have sufficient functional mass to
FIG. 2. Case 2. A, admission infusion IVP shows poor function and marked bilateral hydronephrosis. Ureters were never opacified. B, simultaneous nephrostogram and retrograde ureterogram. Two nephrostomy tubes were required to drain kidney. Ureter ends blindly outside hilus. C, nephrostogram after ureterocalicostomy demonstrates rapid complete emptying of pelvis. D, IVP 6 months postoperatively shows prompt function and complete drainage.
infection. Obstruction developed at the site of both anastomoses, necessitating insertion of ureteral catheters by an open procedure. After removal of the catheters the right side drained well but the obstruction of the lower left ureter continued and drainage with a nephrostomy tube became necessary. Serum creatinine level was normal. The urine from the nephrostomy tube was infected and a nephrostogram showed ureteropelvic obstruction as well as complete ureterovesical junction obstruction (fig. 3, A). At exploration through a flank incision the ureter was identified and traced to the region of the pelvis, which was intrarenal. Considerable peripelvic inflammation and narrowing of the upper ureter made ureteropyelostomy technically not feasible. A ureterocaliceal anastomosis
FIG. 3. Case 3. A, admission nephrostogram demonstrates ureteropelvic and complete ureterovesical junction obstructions. B, IVP 8 months postoperatively shows regression of pyelocaliectasis and prompt drainage by ureterocalicostomy.
URETER0CAL1C0STOrvrz
make the '-'"J~,.~,H worthwhile. This evaluation often must be made at operation. The contralateral kidney must be evaluated for its capacity to perform total renal function and for the likelihood of its involvement by the primary pathologic process. The most commonly reported underlying pathologic conditions that necessitate ureterocalicostomy, including renal lithiasis, congenital ureteropelvic junction obstruction and, in Europe, renal tuberculosis, have a high incidence of bilaterality. Neuwirt performed the first ureterocalicostomy by simply pulling the splayed ureter through the cortex into the calix and suturing the ureter to the capsule. 1 However, the lower pole cortex was markedly thinned. \Vhen Jameson and associates performed ureterocalicostomy without amputation of a more normal lower cortical pole, scarring and contracture developed, resulting in obstruction. 3 Exploration revealed the obstruction to be in the intrarenal ureteral segment and was caused by fibrosis of the cortex, the ureterocaliceal anastomosis itself being patent. Their reoperation with the anastomosis performed after amputation of the lower pole was successful. Similarly, the first ureterocalicostomy performed on our case 1 was done without amputation of the lower pole. Reoperation after obstruction developed revealed that fibrosis of the cortex obstructed the intrarenal ureter and the reanastomosis was successful after amputation of the lower pole. Various methods of anastomosis of the ureter to the calix have been described. Although the most simple, Neuwirt's method is limited (as noted previously) and might not create the desired dependent anastomosis. 1 Jameson and associates bivalved the ureter and anastomosed the 2 flaps to the calix over a ureteral stent but made no attempt to achieve a watertight closure. 3 Some have created a direct end-to-end anastomosis and still others have sutured the ureter to the calix and the renal capsule. The principles that have been used by one of us (P. P. K.) in performing ureterocalicostomy are 1) amputation of sufficient lower pole cortex to free the ureter from entrapment contracting fibrosis of the cortex and 2) tangential sectioning of the calix and splaying of the ureter to create a maximally patent anastomosis and a non-circumferential suture line. A retrograde ureteral catheter is placed cystoscopically to aid in
the identification of the ureteL The catheter is replaced and the anastomosis is performed over a ureteral stent of sufficient caliber in combination with nephrostomy drainage (fig. 4). The largest series of ureterocalicostomies encountered is that of Couvelaire and associates. 2 That report included 8 patients with ureteropelvic obstruction secondary to operation for renal stones, 2 with primary ureteropelvic obstruction, 3 with pelvic stenosis owing to tuberculosis and 1 with a horseshoe kidney complicated by pyelocaliectasis. Many of these patients had complex problems and some had undergone multiple surgical procedures. There were 4 failures. In the discussion of the failures Couvelaire and associates concluded that the most important factor contributing to failure was inadequate freeing of the anastomosis from the surrounding tissue of the lower pole cortex. Michalowski and associates described 10 patients who underwent ureterocalicostomy. 4 Of these patients 5 had congenital ureteropelvic obstruction as the underlying disease and 5 had nephrolithiasis. Good results were reported in 6 patients (as judged by IVP), although only 1 ultimately underwent nephrectomy. They did not speculate on the reasons for the less than satisfactory results. We found 50 cases of ureterocalicostomy reported in the available literature. 1 • 1 4 Of these cases 36 apparently had successful results. Eight ureterocalicostomies were performed on patients who were in the first 2 decades of life. Our limited experience and the previously reported experience with ureterocalicostomy indicate that this procedure can be performed successfully even when complicated by prior renal operation. The likelihood of success seems comparable to that in other secondary operations on the obstructed ureteropelvic junction. With careful surgical technique and rigid adherence to the principle of removal of cortical tissue from the ureterocaliceal anastomosis, the likelihood of creating unobstructed drainage of the upper collecting system is good. REFERENCES
Neuwirt, K.: Implantation of the ureter into the lower calyx of the renal pelvis. In: VII Congres de la Societe Internationale d'Urologie, part 2, pp. 253-255, 1947. 2. Couve!aire, R., Auvert, J., Moulonguet, A., Cukier, J. and Leger, P.: Implantations et anastomoses uretero-calicielles: techniques et indications. J. Urol. Nephrol., 70: 437, 1964. 3. Jameson, S. G., McKinney, J. S. and Rushton, J. F.: Ureterocalyostomy: a new surgical procedure for correction of ureteropelvic stricture associated with an intrarenal pelvis. J. Urol., 1.
77: 135, 1957. 4. Michalowski, E., Modelski, W. and Kmak, A.: Die End-zu-End-
5.
6.
7. 8.
9.
10. 11. ,
FIG. 4. Representation of method of ureterocalicostomy. A, lower pole cortex is removed to expose inferior calix and free anastomotic site. B, ureter sectioned obliquely and spatulated. C, anastomosis performed over stenting catheter.
Anastomose zwischen dem unteren Nieren-kelch und Hamleiter (Ureterocalicostomie). Z. Urol. Nephrol., 63: 1, 1970. Chauvin, H.-F. and Famarier, G.: Resu!tat mediat d'une anastomose uretero-ca!icielle pour tuberculose renale. J. Urol. Nephrol., 67: 545, 1961. Grasset, D.: Speleotomie polaire superieure et implantation uretero-calicielle inferieure droites pour stenose pye!ique bacillaire. J. Uro!. Nephrol., 74: 87, 1968. Macaulay, R. J., Jr.: Ureterocalyceal anastomosis: case report. J. Urol., 90: 40, 1963. Moloney, G. E.: Avulsion of the renal pelvis treated by ureterocalycostomy. Brit. J. Urol., 42: 519, 1970. Mochalova, T. P.: 0 peresadke mochetochnika v nizhniuiu chashechku pri posttuberku!eznykh stenozakh prilokhanochnogo otdela mochetochnika. Urol. Nefrol., 38: 32, 1973. Proca, E.: On a case of uretero-calyceal anastomosis. Rom. Med. Rev., 15: 51, 1971. Puigvert, A. and Ponce de Leon, I.: Ureterocaliostomla en el
tratameinto de la tuberculosis renal. Arch. Esp. Urol., 18: 1, 1965. 12. Scarabelli, L.: A proposito dell'uretero-calico-anastomosi. Contributo casistico. Minerva Chir., 23: 729, 1968. 13. Singer, J.: Ureterocalyostomy: a case report and discussion. Brit. J. Urol., 34: 178, 1962.
r.
586
HAWTHORNE, ZINCKE AND KELALIS
14. Wesolowski, S.: Corrective operative procedure after unsuccessful pelvi-ureteric plastic surgery. Brit. J. Urol., 43: 679, 1971.
COMMENT
We recently used this surgical maneuver in a patient who had complete stricture of the proximal ureter, extending up into the intrarenal ureteropelvic junction. The thin parenchyma in the lower
pole ensured us a good ureterocaliceal anastomosis without danger of stricturing from thick scarred renal parenchyma. This innovative surgical technique should be part of the urological surgeon's armamentarium but used in only the rare selective cases.
Martin G. McLaughlin The Johns Hopkins Hospital Baltimore, Maryland