Vol. 113,
THE JOURNAL OF UROLOGY
Printed in
Copyright© 1975 by The Williams & Wilkins Co.
COMPLICATIONS OF TRANSURETEROURETEROSTOMY RICHARD M. EHRLICH
AND
DONALD G. SKINNER
From the Department of Surgery, Division of Urology, University of California School of Medicine, Los Angeles, California
Transureteroureterostomy is an accepted and valuable procedure in reconstructive urologic surgery. Although conceived in 1894 by Boari and Casati 1 and first performed in 1935 by Higgins 2 Hodges and associates 3 are credited with the first large series of successful results and have been its strongest proponents. More than 200 cases have now been reported. The procedure has been remarkably free of complications and prompted Hodges and associates to state in 1963 that, "The point needs re-emphasis that 32 normal ureters entering this series remained 32 normal ureters at the conclusion". 3 Ten years later, in updating this series, Udall and associates concluded that, "Apprehension concerning the safety of the recipient ureter seems unwarranted". 4 We herein report 5 cases of transureteroureterostomy in which damage to the recipient and/or donor ureter necessitated major reconstructive efforts in these gravely ill patients. CASE REPORTS
Case 1. R. W., a 59-year-old man, underwent left hemicolectomy for suspected neoplasia in March 1972. Diverticulitis was found but the lower left ureter was inadvertently severed below the iliac vessels, A primary ureteral anastomosis was done but urinary leakage resulted. Two weeks later a left-to-right transureteroureterostomy was performed but retroperitoneal extravasation continued (fig. 1, A and B), Gram-negative sepsis, bilateral Pseudomonas pneumonia and abdominal distension developed and the patient was transferred to our medical center. Bilateral hydronephrosis and fistulization of urine into the small bowel were found. Emergency bilateral nephrostomy and tracheostomy were performed, The urinary leakage continued and at a second operation complete anastomotic disruption Accepted for publication October 25, 197 4. Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974. Supported in part by the University Medical Research Foundation and the Kennedy Foundation. 1 Boari et Casati: Contribute sperimentale alla plastica dell uretere (communicazione all academica delle). Scienze Med. et Nat. di Terrara Maggio, 1894. 2 Higgins, C. C.: Transuretero-ureteral anastomosis: report of a clinical case. J. Urol., 34: 349, 1935. 'Hodges, C. V., Moore, R. J., Lehman, T. H. and Behnam, A. M.: Clinical experiences with transureteroureterostomy. J. Urol., 90: 552, 1963. 'Udall, D. A., Hodges, C. V., Pearse, H. M. and Burns, A. B.: Transureteroureterostomy. Experience in pediatric patient. Urology, 2: 401, 1973.
and severe fibrosis were found. The left ureter was ligated and a primary right ureteroureterostomy was performed. The anastomotic site is narrowed and mild hydronephrosis of kidney persists (fig. 1, C). A left nephrectomy was performed later since the patient was too ill physically and emotionally to withstand further reconstruction. The total hospitalization was 5 months and it took more than a year to get the patient into satisfactory condition. Case 2, J. J., a 44-year-old woman, underwent an abdominal hysterectomy for benign disease in September 1972. The left ureter was injured and a left-to-right transureteroureterostomy was performed. Despite ureteral stents postoperatively retroperitoneal urinary leakage resulted and the patient became septic with bilateral pneumonia, bilateral hydronephrosis and a cutaneous fistula. She was transferred to our center and an emergency tracheostomy and bilateral tomies were performed. It was anticipated an exploration of the retroperitoneal area and recon struction using the intestinal tract would be necessary but during a 3-month period the ceased and the nephrostomies were removed. A stricture of the transureteroureterostomy site subsequently developed and mild bilateral dronephrosis, recurrent urinary infections and renal cortical loss resulted (fig. 2, A). In June 1974 an extensive vesico-psoas hitch was performed with resection of the strictured area and separate reanastomosis of both ureters to the bladder (fig, 2, B). The patient is clinically well at the present time, Case 3. P. J., a 62-year-old man, underwent a sigmoid resection for carcinoma of the colon. All lymph nodes were negative. The left ureter was severed at the time and a left-to-right transureteroureterostomy was performed. The ureter was widely mobilized and severe deviation to the midline was necessary to accomplish the anastomosis. The patient was then transferred to our center with retroperitoneal urinary leakage, bilateral hydronephrosis and sepsis. Bilateral nephrostomies and ligation of the donor left ureter were performed. A stricture of the right ureter developed and hydronephrosis persisted, A right ileal ureter was constructed since the ureter was encased in dense fibrous tissue which obviated the ability to perform a ureteral anastomosis. At a second operation a left nephrectomy was performed since the clinical condition of the patient contraindicated further reconstructive efforts. The patient is
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FIG. 1. Case 1. A, IVP reveals bilateral hydronephrosis and retroperitoneal extravasation. B, right retrograde pyelogram demonstrates extreme medial deviation of recipient ureter and extravasation of contrast medium. C, mild right hydronephrosis remains 2 years after unsuccessful transureteroureterostomy. Left kidney has been removed.
COMPLICATIONS OF TRANSURETEROURETEROSTOMY
469
Fm. 2. Case 2. A, bilateral hydroureteronephrosis secondary to stricture at anastomotic site. B, extensive vesico-psoas hitch. Extent to which bladder can be successfully mobilized and remain functional is shown.
stable with normal renal function in the solitary right kidney. Case 4. A. D., a 59-year-old woman, underwent a sigmoid resection for primary adenocarcinoma of the colon in January 1973. Inadvertently, an 8 cm. segment of ureter was resected. Urologic consultation was obtained. Both ureters were successfully mobilized and a left-to-right transureteroureterostomy was performed. Medial deviation of the right ureter was necessary because of the short length of the left ureter. The postoperative course was complicated by urinary leakage and progressive bilateral hydroureteronephrosis (fig. 3, A). Attempts to pass a catheter from below were not successful and the patient was taken back to the operating room 24 days postoperatively, after 18 hours of anuria. Bilateral nephrostomies were done, the stenotic anastomosis was resected, the left ureter was ligated and a primary right ureteroureterostomy was performed. A ureteral stricture subsequently developed at the anastomotic site (fig. 3, B). Numerous attempts to dilate this stricture were unsuccessful and a right ileal ureter was necessary 6 months later to re-establish urinary continuity (fig. 3, C). Six weeks postoperatively a left nephrectomy was done. Subsequently, the patient has done well with normal renal function and serum electrolyte values. Case 5. E. K., a 52-year-old man, underwent an
aorto-iliac endarterectomy in July 1973 for occlusive peripheral vascular disease. The right ureter was injured at the time of operation and primarily repaired. A week postoperatively urine began to leak from the drain site. Although ureteral catheters were passed on 2 occasions and left in place for 3 and 10 days, respectively, they were unsuccessful and urine leakage continued. Six weeks later a right-to-left transureteroureterostomy was performed. The patient did well for 1 month but an anastomotic cutaneous fistula developed through the abdominal incision and he was referred to our center for management (fig. 4, A). Progressive right hydroureteronephrosis developed (fig. 4, B) but, fortunately, a left retrograde pyelogram revealed narrowing at the site of anastomosis but there was no left ureteral leakage or significant proximal hydronephrosis (fig. 4, C). A right ilea! ureter was finally necessary to re-establish urinary continuity. This procedure was successfully performed 3 ½ months after the initial operation, and the patient has remained asymptomatic during the ensuing 6 months (fig. 4, D). DISCUSSION
There have been few reported complications of transureteroureterostomy. Only 1 death directly attributable to intraperitoneal leakage has been cited and this was in a child with a transureteroureterostomy in conjunction with a cu-
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FIG. 3. Case 4. A, 30-minute IVP 2 weeks after left-to-right transureteroureterostomy demonstrates leakage from anastomosis (arrow) with proximal hydronephrosis. Note that some contrast medium can be seen in distal right ureter. B, right nephrostogram 5 months after right ureteroureterostomy demonstrates persistent stricture of proximal ureter. C, 15-minute IVP 6 months following reconstruction with ilea! ureter. Note prompt function of right kidney with excellent drainage via ilea! ureter.
COMPLICATIONS OF TRANSURETEROURETEROSTOMY
taneous ureterostomy. 5 Of the patients reported Udall and associates 2 died postoperatively 1 died of a myocardial infarction and 1 of mycotic sepsis associated with advanced neoplasia. 6 Smith and associates reported 1 death from a myocardial infarction and urinary extravasation. 7 Extensive carcinoma was the cause of 2 other deaths 5 and 11 months after a successful transureteroureterostomy. 3 Reported postoperative morbidity has also been minimal. Of the 67 cases reported on by Udall and associates pyelonephritis developed in 8 patients and 8 had prolonged leakage, only 1 of whom had complete anastomotic disruption. 6 In the adults, hydronephrosis of the donor kidney was progressive in 5 cases-1 caused by scarring, 1 owing to malignant obstruction and 3 caused by vesicoureteral reflux. Prolonged urinary drainage following transureteroureterostomy was also noted by several authors.'· 7 - 9 Damage to the normal recipient ureter has not been observed. 6 • s- 11 However, 3 patients with a dilated ureter preoperatively had progressive hydronephrosis owing to an uncorrected distal lesion. 5 From the aforementioned data there can be little question that in more than 200 reported cases minimal morbidity has resulted. Our 5 patients (4 of whom underwent transureteroureterostomy elsewhere) represent the first reported problems with the recipient ureterorenal table). Recipient unit: Ilea! ureters, 2 Hydronephrosis, 1 Ureteral stricture. 1 Donor unit: Nephrectomies, 3 Ilea! ureter, 1Hydronephrosis. 1
Two ileal ureters were required to restore anatomic continuity and 1 ureteral stricture with mild hydronephrosis in a solitary kidney remains. Of the 2 patients with hydronephrosis of the recipient kidney, 1 recently underwent reanastomosis of the 5 Halpern, G. N ., King, L. R. and Belman, A. B.: Transureteroureterostomy in children. J. Urol., 109: 504, 1973. 'Udall, D. A., Hodges, C. V., Pearse, H. M. and Burns, A. B.: Transureteroureterostomy: a neglected procedure. J. Urol., 109: 817, 1973. 7 Smith, R. B., Harbach, L. B., Kaufman, J. J. and Goodwin, 'vV. E.: Crossed ureteroureterostomy: variation of uses. J. Urol., 106: 204, 1971. 8 Schmidt, J. D., Flocks, R. H. and Arduino, L.: Transureteroureterostomy in the management of distal ureter al disease. J. Urol., 108: 204, 1972. 9 Zincke, H. and Malek, R. S.: Experience with cutaneous and transureteroureterostomy. J. Urol., lH: 760, 1974. 10 Jacobs, D., Politano, V. A. and Harper, J. M.: Experiences with transureteroureterostomy. J. Urol., 97: 1013, 1967. 11 Hecker, G. N. and Ocker, J. M., Jr.: Why transureteroureterostomy? J. Urol., 108: 710, 1972.
471
ureter to the bladder after an extensive vesicopsoas hitch and the other is being followed conser vatively in the hope that progression does not occur. Of the affected donor ureterorenal units, 3 nephrectomies were performed since the were too ill to consider further reconstructive efforts. The kidneys that were removed had been normal before the problems caused the transureteroureterostomy. One successful ileaI ureter has been performed on a donor kidney and 1 hydronephrotic donor kidney remains further operation may be needed. The aforementioned complications have 2 common denominators, namely poor blood supply and anastomotic tension. It has been emphasized that it is essential to accomplish the anastomosis with out tension and it is critical to have an blood supply accompany the transplanted ureter." We fully endorse this concept. In cases 3 and mobilization of the recipient ureter from its bed and wide medial deviation no doubt contributed to anastomotic disruption and stricture. The donor ureter must be free of tension and allowed to lie in a gentle unobstructed course. A tangential rather than perpendicular anastomosis is preferred and the donor ureter should be cut obliquely and/or spatulated. If the donor ureter cannot easily reach the unmobilized believe that alternative forms of reconstruction are mandatory and urge that transureteroureteros-tomy not be performed. We further emphasize that if the blood questionable the procedure should be The use of stents is optional but a poorly or non-functioning stent may lead to tions. In such instances early removal is mamfa .. tory. The judicious performance of a especially in a cancer patient, may represBnt conservative rather than radical treatment. Cases 3 and 4 are instances, in retrospect, when tomy would have been a wiser alternative. In cases 1, 2, 3 and 4 nephrostomies were used an attempt to salvage donor kidneys. In cases 1, and 4 the ureters were ligated below since diversion will not usually divert the urine pletely. Further reconstructive efforts using the intestinal tract were contemplated but the were too ill to withstand this approach and, nephrectomies were performed. However, the ciple of preliminary nephrostomy drainage lower ureteral ligation is sound and shouid borne in mind in difficult management situations. A sixth case has been encountered m which prolonged urinary leakage finally resolved but mild hydronephrosis still exists. Medial ent ureteral deviation was the problem. We believe that donor phrostomy as a proximal safety valve tributed to resolution of the leakage. Adequate retroperitoneal drainage is of importance even if the anastomosis appears to
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FIG. 4. Case 5. A, IVP and cutaneous sinogram 1 month post-transureteroureterostomy demonstrate cutaneous fistula connecting with anastomosis and hydronephrotic right kidney (arrow). B, 45-minute IVP 2 months following transureteroureterostomy demonstrates progressive hydronephrosis of right kidney but good function and drainage from left. C, left retrograde pyelogram before reconstruction demonstrates narrowing at site of anastomosis but no leakage or significant obstruction. D, IVP 2 weeks post-reconstruction demonstrates resolution ofright hydronephrosis and excellent drainage into bladder. Note near absence of contrast from right ileal ureter.
COMPLICATIONS OF TRANSURETEROURETEROSTOMY
watertight at the time of operation. Urinary infection is probably not an absolute contraindication to performance of a transureteroureterostomy, 6 • 11 although preoperative eradication is preferred. High dose pelvic irradiation, calculous disease and retroperitoneal fibrosis are justified contraindications. Reflux or distal obstruction of the recipient ureter is also a contraindication since multiple complications have been reported in this setting.'· 6 Despite these difficult management problems we do not wish to suggest that transureteroureterostomy be abandoned. However, we emphasize that in our 5 patients an alternative and safer operative method was available at the initial procedure to obviate disastrous complications. For example in all but case 4 a vesico-psoas hitch could easily have been done, thus eliminating any possible damage to the recipient ureterorenal unit. This operative technique has not received the attention it deserves. By mobilization of the bladder and take down of the opposite vesical pedicle, adequate length can be obtained to bridge all but the most extensive ureteral defects. 12 · 13 We believe it is simple, safe and highly satisfactory in these settings. The fact that an extensive vesico-psoas hitch was successfully performed to overcome obstruction at the transureteroureterostomy site in case 2 readily demonstrates that this procedure could have been used initially, at the time of ureteral injury, much lower in the pelvis. A Boari flap, alone or in conjuction with a vesico-psoas hitch, can also be done, and Thomp12 Turner Warwick, R. and Worth, P.H. L.: The psoas bladder-hitch procedure for the replacement of the lower third of the ureter. Brit. J. Urol., 41: 701, 1969. 13 Ehrlich, R. M., Skinner, D. G. and Melman, A.: The versatility of the vesico-psoas hitch. In preparation.
473
son and Ross recently emphasized the value of this technique in a long-term followup of 23 Autotransplantation recently received consider able attention and will no doubt be performed increasing frequency in the future. 1 ' - 20 it will probably be limited to those surgeons vascular experience and not used in cases with preoperative infection or in gynecologic trauma. SUMMARY
Five cases were presented of serious tions associated with transureteroureterostomy, Until now the operation has been reported to be virtually free of difficulties. Poor blood anastomotic tension were responsible for the failures. These factors plus alternative methods of diversion in difficult situations are discussed. "Thompson, I. M. and Ross, G., Jr.: Long-term sul ts of bladder flap repair of uretera! injuries. J. Urol Hl: 483, 1974. 15 Marshall, V. F., Whitsell, J., McGovern, J. H. and Miscall, B. G.: The practicality of renal autotransplantation in humans. J.A.M.A., 196: 1154, 1966. 16 Martinez-Pineiro, J. A. and Sicilia, L. S.: Kidm,y autotransplantation for the treatment of renal artery stenosis: report of two cases. J. Urol., Hl8: 35, 1972. 17 Lim, R. C., Jr., Eastman, A. B. and Blaisdell, F. W .. Renal autotransplantation. Adjunct to repair of renal vascular lesions. Arch. Surg., W5: 847, 1972. 18 Rhame, R. C.: Application of renal autotransplanta tion to the treatment of simultaneous bilateral ureteral tumours. Brit. J. Urol., 45: 388, 1973. 19 Clune, G. J. A., Hartley, L. C. J., Collins, G. M. and Gordon, R. D.: Renovascular hypertension: the renal autotransplantation. Brit. J. Surg., 60: 20 Orcutt, T. W., Foster, J. H., Richie, R J. P. and Warner, H. E.: Bilateral ex vivo renal reconstruction with autotransplantation. J.A.M.A., 493, 1974.
THE JOURNAL OF UROLOGY
Printed in
Copyright© 1975 by The Williams & Wilkins Co.
COMPLICATIONS OF TRANSURETEROURETEROSTOMY RICHARD M. EHRLICH
AND
DONALD G. SKINNER
From the Department of Surgery, Division of Urology, University of California School of Medicine, Los Angeles, California
Transureteroureterostomy is an accepted and valuable procedure in reconstructive urologic surgery. Although conceived in 1894 by Boari and Casati 1 and first performed in 1935 by Higgins 2 Hodges and associates 3 are credited with the first large series of successful results and have been its strongest proponents. More than 200 cases have now been reported. The procedure has been remarkably free of complications and prompted Hodges and associates to state in 1963 that, "The point needs re-emphasis that 32 normal ureters entering this series remained 32 normal ureters at the conclusion". 3 Ten years later, in updating this series, Udall and associates concluded that, "Apprehension concerning the safety of the recipient ureter seems unwarranted". 4 We herein report 5 cases of transureteroureterostomy in which damage to the recipient and/or donor ureter necessitated major reconstructive efforts in these gravely ill patients. CASE REPORTS
Case 1. R. W., a 59-year-old man, underwent left hemicolectomy for suspected neoplasia in March 1972. Diverticulitis was found but the lower left ureter was inadvertently severed below the iliac vessels, A primary ureteral anastomosis was done but urinary leakage resulted. Two weeks later a left-to-right transureteroureterostomy was performed but retroperitoneal extravasation continued (fig. 1, A and B), Gram-negative sepsis, bilateral Pseudomonas pneumonia and abdominal distension developed and the patient was transferred to our medical center. Bilateral hydronephrosis and fistulization of urine into the small bowel were found. Emergency bilateral nephrostomy and tracheostomy were performed, The urinary leakage continued and at a second operation complete anastomotic disruption Accepted for publication October 25, 197 4. Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974. Supported in part by the University Medical Research Foundation and the Kennedy Foundation. 1 Boari et Casati: Contribute sperimentale alla plastica dell uretere (communicazione all academica delle). Scienze Med. et Nat. di Terrara Maggio, 1894. 2 Higgins, C. C.: Transuretero-ureteral anastomosis: report of a clinical case. J. Urol., 34: 349, 1935. 'Hodges, C. V., Moore, R. J., Lehman, T. H. and Behnam, A. M.: Clinical experiences with transureteroureterostomy. J. Urol., 90: 552, 1963. 'Udall, D. A., Hodges, C. V., Pearse, H. M. and Burns, A. B.: Transureteroureterostomy. Experience in pediatric patient. Urology, 2: 401, 1973.
and severe fibrosis were found. The left ureter was ligated and a primary right ureteroureterostomy was performed. The anastomotic site is narrowed and mild hydronephrosis of kidney persists (fig. 1, C). A left nephrectomy was performed later since the patient was too ill physically and emotionally to withstand further reconstruction. The total hospitalization was 5 months and it took more than a year to get the patient into satisfactory condition. Case 2, J. J., a 44-year-old woman, underwent an abdominal hysterectomy for benign disease in September 1972. The left ureter was injured and a left-to-right transureteroureterostomy was performed. Despite ureteral stents postoperatively retroperitoneal urinary leakage resulted and the patient became septic with bilateral pneumonia, bilateral hydronephrosis and a cutaneous fistula. She was transferred to our center and an emergency tracheostomy and bilateral tomies were performed. It was anticipated an exploration of the retroperitoneal area and recon struction using the intestinal tract would be necessary but during a 3-month period the ceased and the nephrostomies were removed. A stricture of the transureteroureterostomy site subsequently developed and mild bilateral dronephrosis, recurrent urinary infections and renal cortical loss resulted (fig. 2, A). In June 1974 an extensive vesico-psoas hitch was performed with resection of the strictured area and separate reanastomosis of both ureters to the bladder (fig, 2, B). The patient is clinically well at the present time, Case 3. P. J., a 62-year-old man, underwent a sigmoid resection for carcinoma of the colon. All lymph nodes were negative. The left ureter was severed at the time and a left-to-right transureteroureterostomy was performed. The ureter was widely mobilized and severe deviation to the midline was necessary to accomplish the anastomosis. The patient was then transferred to our center with retroperitoneal urinary leakage, bilateral hydronephrosis and sepsis. Bilateral nephrostomies and ligation of the donor left ureter were performed. A stricture of the right ureter developed and hydronephrosis persisted, A right ileal ureter was constructed since the ureter was encased in dense fibrous tissue which obviated the ability to perform a ureteral anastomosis. At a second operation a left nephrectomy was performed since the clinical condition of the patient contraindicated further reconstructive efforts. The patient is
467
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FIG. 1. Case 1. A, IVP reveals bilateral hydronephrosis and retroperitoneal extravasation. B, right retrograde pyelogram demonstrates extreme medial deviation of recipient ureter and extravasation of contrast medium. C, mild right hydronephrosis remains 2 years after unsuccessful transureteroureterostomy. Left kidney has been removed.
COMPLICATIONS OF TRANSURETEROURETEROSTOMY
469
Fm. 2. Case 2. A, bilateral hydroureteronephrosis secondary to stricture at anastomotic site. B, extensive vesico-psoas hitch. Extent to which bladder can be successfully mobilized and remain functional is shown.
stable with normal renal function in the solitary right kidney. Case 4. A. D., a 59-year-old woman, underwent a sigmoid resection for primary adenocarcinoma of the colon in January 1973. Inadvertently, an 8 cm. segment of ureter was resected. Urologic consultation was obtained. Both ureters were successfully mobilized and a left-to-right transureteroureterostomy was performed. Medial deviation of the right ureter was necessary because of the short length of the left ureter. The postoperative course was complicated by urinary leakage and progressive bilateral hydroureteronephrosis (fig. 3, A). Attempts to pass a catheter from below were not successful and the patient was taken back to the operating room 24 days postoperatively, after 18 hours of anuria. Bilateral nephrostomies were done, the stenotic anastomosis was resected, the left ureter was ligated and a primary right ureteroureterostomy was performed. A ureteral stricture subsequently developed at the anastomotic site (fig. 3, B). Numerous attempts to dilate this stricture were unsuccessful and a right ileal ureter was necessary 6 months later to re-establish urinary continuity (fig. 3, C). Six weeks postoperatively a left nephrectomy was done. Subsequently, the patient has done well with normal renal function and serum electrolyte values. Case 5. E. K., a 52-year-old man, underwent an
aorto-iliac endarterectomy in July 1973 for occlusive peripheral vascular disease. The right ureter was injured at the time of operation and primarily repaired. A week postoperatively urine began to leak from the drain site. Although ureteral catheters were passed on 2 occasions and left in place for 3 and 10 days, respectively, they were unsuccessful and urine leakage continued. Six weeks later a right-to-left transureteroureterostomy was performed. The patient did well for 1 month but an anastomotic cutaneous fistula developed through the abdominal incision and he was referred to our center for management (fig. 4, A). Progressive right hydroureteronephrosis developed (fig. 4, B) but, fortunately, a left retrograde pyelogram revealed narrowing at the site of anastomosis but there was no left ureteral leakage or significant proximal hydronephrosis (fig. 4, C). A right ilea! ureter was finally necessary to re-establish urinary continuity. This procedure was successfully performed 3 ½ months after the initial operation, and the patient has remained asymptomatic during the ensuing 6 months (fig. 4, D). DISCUSSION
There have been few reported complications of transureteroureterostomy. Only 1 death directly attributable to intraperitoneal leakage has been cited and this was in a child with a transureteroureterostomy in conjunction with a cu-
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FIG. 3. Case 4. A, 30-minute IVP 2 weeks after left-to-right transureteroureterostomy demonstrates leakage from anastomosis (arrow) with proximal hydronephrosis. Note that some contrast medium can be seen in distal right ureter. B, right nephrostogram 5 months after right ureteroureterostomy demonstrates persistent stricture of proximal ureter. C, 15-minute IVP 6 months following reconstruction with ilea! ureter. Note prompt function of right kidney with excellent drainage via ilea! ureter.
COMPLICATIONS OF TRANSURETEROURETEROSTOMY
taneous ureterostomy. 5 Of the patients reported Udall and associates 2 died postoperatively 1 died of a myocardial infarction and 1 of mycotic sepsis associated with advanced neoplasia. 6 Smith and associates reported 1 death from a myocardial infarction and urinary extravasation. 7 Extensive carcinoma was the cause of 2 other deaths 5 and 11 months after a successful transureteroureterostomy. 3 Reported postoperative morbidity has also been minimal. Of the 67 cases reported on by Udall and associates pyelonephritis developed in 8 patients and 8 had prolonged leakage, only 1 of whom had complete anastomotic disruption. 6 In the adults, hydronephrosis of the donor kidney was progressive in 5 cases-1 caused by scarring, 1 owing to malignant obstruction and 3 caused by vesicoureteral reflux. Prolonged urinary drainage following transureteroureterostomy was also noted by several authors.'· 7 - 9 Damage to the normal recipient ureter has not been observed. 6 • s- 11 However, 3 patients with a dilated ureter preoperatively had progressive hydronephrosis owing to an uncorrected distal lesion. 5 From the aforementioned data there can be little question that in more than 200 reported cases minimal morbidity has resulted. Our 5 patients (4 of whom underwent transureteroureterostomy elsewhere) represent the first reported problems with the recipient ureterorenal table). Recipient unit: Ilea! ureters, 2 Hydronephrosis, 1 Ureteral stricture. 1 Donor unit: Nephrectomies, 3 Ilea! ureter, 1Hydronephrosis. 1
Two ileal ureters were required to restore anatomic continuity and 1 ureteral stricture with mild hydronephrosis in a solitary kidney remains. Of the 2 patients with hydronephrosis of the recipient kidney, 1 recently underwent reanastomosis of the 5 Halpern, G. N ., King, L. R. and Belman, A. B.: Transureteroureterostomy in children. J. Urol., 109: 504, 1973. 'Udall, D. A., Hodges, C. V., Pearse, H. M. and Burns, A. B.: Transureteroureterostomy: a neglected procedure. J. Urol., 109: 817, 1973. 7 Smith, R. B., Harbach, L. B., Kaufman, J. J. and Goodwin, 'vV. E.: Crossed ureteroureterostomy: variation of uses. J. Urol., 106: 204, 1971. 8 Schmidt, J. D., Flocks, R. H. and Arduino, L.: Transureteroureterostomy in the management of distal ureter al disease. J. Urol., 108: 204, 1972. 9 Zincke, H. and Malek, R. S.: Experience with cutaneous and transureteroureterostomy. J. Urol., lH: 760, 1974. 10 Jacobs, D., Politano, V. A. and Harper, J. M.: Experiences with transureteroureterostomy. J. Urol., 97: 1013, 1967. 11 Hecker, G. N. and Ocker, J. M., Jr.: Why transureteroureterostomy? J. Urol., 108: 710, 1972.
471
ureter to the bladder after an extensive vesicopsoas hitch and the other is being followed conser vatively in the hope that progression does not occur. Of the affected donor ureterorenal units, 3 nephrectomies were performed since the were too ill to consider further reconstructive efforts. The kidneys that were removed had been normal before the problems caused the transureteroureterostomy. One successful ileaI ureter has been performed on a donor kidney and 1 hydronephrotic donor kidney remains further operation may be needed. The aforementioned complications have 2 common denominators, namely poor blood supply and anastomotic tension. It has been emphasized that it is essential to accomplish the anastomosis with out tension and it is critical to have an blood supply accompany the transplanted ureter." We fully endorse this concept. In cases 3 and mobilization of the recipient ureter from its bed and wide medial deviation no doubt contributed to anastomotic disruption and stricture. The donor ureter must be free of tension and allowed to lie in a gentle unobstructed course. A tangential rather than perpendicular anastomosis is preferred and the donor ureter should be cut obliquely and/or spatulated. If the donor ureter cannot easily reach the unmobilized believe that alternative forms of reconstruction are mandatory and urge that transureteroureteros-tomy not be performed. We further emphasize that if the blood questionable the procedure should be The use of stents is optional but a poorly or non-functioning stent may lead to tions. In such instances early removal is mamfa .. tory. The judicious performance of a especially in a cancer patient, may represBnt conservative rather than radical treatment. Cases 3 and 4 are instances, in retrospect, when tomy would have been a wiser alternative. In cases 1, 2, 3 and 4 nephrostomies were used an attempt to salvage donor kidneys. In cases 1, and 4 the ureters were ligated below since diversion will not usually divert the urine pletely. Further reconstructive efforts using the intestinal tract were contemplated but the were too ill to withstand this approach and, nephrectomies were performed. However, the ciple of preliminary nephrostomy drainage lower ureteral ligation is sound and shouid borne in mind in difficult management situations. A sixth case has been encountered m which prolonged urinary leakage finally resolved but mild hydronephrosis still exists. Medial ent ureteral deviation was the problem. We believe that donor phrostomy as a proximal safety valve tributed to resolution of the leakage. Adequate retroperitoneal drainage is of importance even if the anastomosis appears to
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FIG. 4. Case 5. A, IVP and cutaneous sinogram 1 month post-transureteroureterostomy demonstrate cutaneous fistula connecting with anastomosis and hydronephrotic right kidney (arrow). B, 45-minute IVP 2 months following transureteroureterostomy demonstrates progressive hydronephrosis of right kidney but good function and drainage from left. C, left retrograde pyelogram before reconstruction demonstrates narrowing at site of anastomosis but no leakage or significant obstruction. D, IVP 2 weeks post-reconstruction demonstrates resolution ofright hydronephrosis and excellent drainage into bladder. Note near absence of contrast from right ileal ureter.
COMPLICATIONS OF TRANSURETEROURETEROSTOMY
watertight at the time of operation. Urinary infection is probably not an absolute contraindication to performance of a transureteroureterostomy, 6 • 11 although preoperative eradication is preferred. High dose pelvic irradiation, calculous disease and retroperitoneal fibrosis are justified contraindications. Reflux or distal obstruction of the recipient ureter is also a contraindication since multiple complications have been reported in this setting.'· 6 Despite these difficult management problems we do not wish to suggest that transureteroureterostomy be abandoned. However, we emphasize that in our 5 patients an alternative and safer operative method was available at the initial procedure to obviate disastrous complications. For example in all but case 4 a vesico-psoas hitch could easily have been done, thus eliminating any possible damage to the recipient ureterorenal unit. This operative technique has not received the attention it deserves. By mobilization of the bladder and take down of the opposite vesical pedicle, adequate length can be obtained to bridge all but the most extensive ureteral defects. 12 · 13 We believe it is simple, safe and highly satisfactory in these settings. The fact that an extensive vesico-psoas hitch was successfully performed to overcome obstruction at the transureteroureterostomy site in case 2 readily demonstrates that this procedure could have been used initially, at the time of ureteral injury, much lower in the pelvis. A Boari flap, alone or in conjuction with a vesico-psoas hitch, can also be done, and Thomp12 Turner Warwick, R. and Worth, P.H. L.: The psoas bladder-hitch procedure for the replacement of the lower third of the ureter. Brit. J. Urol., 41: 701, 1969. 13 Ehrlich, R. M., Skinner, D. G. and Melman, A.: The versatility of the vesico-psoas hitch. In preparation.
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son and Ross recently emphasized the value of this technique in a long-term followup of 23 Autotransplantation recently received consider able attention and will no doubt be performed increasing frequency in the future. 1 ' - 20 it will probably be limited to those surgeons vascular experience and not used in cases with preoperative infection or in gynecologic trauma. SUMMARY
Five cases were presented of serious tions associated with transureteroureterostomy, Until now the operation has been reported to be virtually free of difficulties. Poor blood anastomotic tension were responsible for the failures. These factors plus alternative methods of diversion in difficult situations are discussed. "Thompson, I. M. and Ross, G., Jr.: Long-term sul ts of bladder flap repair of uretera! injuries. J. Urol Hl: 483, 1974. 15 Marshall, V. F., Whitsell, J., McGovern, J. H. and Miscall, B. G.: The practicality of renal autotransplantation in humans. J.A.M.A., 196: 1154, 1966. 16 Martinez-Pineiro, J. A. and Sicilia, L. S.: Kidm,y autotransplantation for the treatment of renal artery stenosis: report of two cases. J. Urol., Hl8: 35, 1972. 17 Lim, R. C., Jr., Eastman, A. B. and Blaisdell, F. W .. Renal autotransplantation. Adjunct to repair of renal vascular lesions. Arch. Surg., W5: 847, 1972. 18 Rhame, R. C.: Application of renal autotransplanta tion to the treatment of simultaneous bilateral ureteral tumours. Brit. J. Urol., 45: 388, 1973. 19 Clune, G. J. A., Hartley, L. C. J., Collins, G. M. and Gordon, R. D.: Renovascular hypertension: the renal autotransplantation. Brit. J. Surg., 60: 20 Orcutt, T. W., Foster, J. H., Richie, R J. P. and Warner, H. E.: Bilateral ex vivo renal reconstruction with autotransplantation. J.A.M.A., 493, 1974.
