Ureteral Reconstruction

Methods Used in Ureteral Reconstruction

There are six primary methods used in ureteral reconstruction:

1. Cystoscopy with Ureteral Dilation and Stent Placement: Ideal for patients not suited for definitive repair. This procedure involves placing stents, which need regular replacement due to encrustation and occlusion.

2. Ureter Reimplantation: This surgery reroutes the ureter above the obstruction and repositions it into a new location in the bladder, avoiding complex bladder and bowel reconstruction. It is suitable for lower ureter problems but not for upper obstructions.

3. Psoas Hitch/Boari Flap Repair: This method is for extensive ureter injuries higher in the pelvis. It involves moving the upper ureter and bladder towards the injured side, fixing the bladder in position by “hitching” it to the psoas muscle. Sometimes, a bladder flap is used to bridge the distance. A potential complication is temporary bladder frequency and urgency, which can be managed with medication.

4. End-to-End Repair (Uretero-ureterostomy): Uretero-ureterostomy (UU) involves removing the diseased section of the ureter, freeing up the remaining length for mobility, and sewing the cut ends together. This technique is suitable only for short sections of the ureter, as longer strictures and blockages cannot be repaired this way. The advantages include avoiding complex procedures, maintaining normal anatomy, and achieving long-term success and patency.

5. Ureter Cross Over (Trans Uretero-ureterostomy): Transuretero-ureterostomy (Trans UU) bypasses the distal ureter by crossing the affected ureter over the body’s midline and connecting it to the healthy ureter on the opposite side. This approach is beneficial for patients with a history of complicated pelvic surgery, making other surgical techniques challenging.

6. Ileal Ureter (Bowel Interposition): This method uses a section of the small bowel to replace longer segments of the damaged ureter. It’s reserved for patients with extensive ureteral issues who haven’t found relief from more conservative treatments. Post-surgery, patients may notice cloudy urine or mucus, as the bowel section replaces part of the urinary tract.

7. Ureteral repair with grafts: In certain obstructive problems of ureter, specially with recurrent strictures, or longer gaps between healthy ends of the ureter, we would use grafts such as buccal mucosal grafts from patient’s mouth to reconstruct the ureter. We do this in laparoscopic robotic or open abdominal approach. Your urologist will discuss with you the preoperative and postoperative stages of this surgery.

8. Kidney auto-transplantation: In patients who have very long strictures of ureter, one option is repositioning the kidney to lower in the pelvis and connecting the kidney to the pelvic vasculature. This is a complex surgery and requires ureteral and vascular reconstruction.