Vol. 117, ,January

'rHE ,Jol.;R'...JAL OF UROLOGY

Copyright© 1977 by The \Villia.ms &

Co.

l~inted in U.S.A.

COMPLICATIONS WITH TRANSURETEROURETER0STOJ\1Y IVAN L. SANDOZ, DAVID P. PAULL

AND

CURTIS A. MACFARLANE

ABSTRACT

Of our 23 patients who underwent transureteroureterostomy 4 sustained injury to the recipient ureter. This complication has been feared but seldom reported. The complications are discussed and factors in technique possibly relating to the failures are considered. Despite our experience we continue to regard the operation as an excellent means of urinary diversion for patients with unilateral lower ureteral lesions. Transureteroureterostomy was conceived prior to the turn of the century by Boari 1 and was first performed in 1927 by Higgins. 2 The first successful large series was reported in 1963 by Hodges and associates. 3 Since that time the procedure has gained increasing acceptance and more than 200 cases have been reported. Complications have been so few that published series provide the reader with an overwhelming confidence in the safety and success of the operation. Injury to the normal recipient ureter has been feared but seldom reported. In updating their series in 1973 Udall and associates stated that, "Apprehension concerning the safety of the recipient ureter seems unwarranted".• In 1975 Brannan also concluded that, "the fear of injury to the healthy kidney is without foundation". 5 Unfortunately, our experience and that of others indicate that complications involving the recipient ureter can occur. In 1975 Ehrlich and Skinner reported 5 cases of serious anastomotic disruption resulting in multiple corrective procedures, the loss of 3 donor kidneys and serious injury to 4 recipient ureters. 6 Of these 2 had ileal ureter replacement, 1 has a persistent mild ureteral stricture and 1 required extensive vesicopsoas hitch. In our own series of 23 transureteroureterostomies 4 patients sustained serious complications of the recipient ureter. Of these 3 ultimately had excellent results after prolonged morbidity and a series of operations. However, 1 patient died and the death was partially owing to the complications arising from the procedure. ·As the indications and enthusiasm for transureteroureterostomy increase more complications can be expected. INDICATIONS AND ANALYSIS

The 23 operations were performed between 1960 and 1975. All cases were followed to a conclusion in terms of stable upper tracts on serial excretory urograms Patients ranged in age from 3 to 79 years. Indications for the included Qtr,"t"'"''Q reflux and surgical injury. Stricture. There were 12 cases of distal ureteral strictures: 4 congenital and 8 post-surgical. Of the latter 8 cases 3 were caused by distal ureterolithotomy, 2 after ureteroneocystostomy, 1 after hysterectomy, and 1 each after transurethral prostatectomy and transurethral resection of a bladder tumor with early use of thio-tepa instillation. Reflux. There were 6 cases of unilateral reflux. These included 3 failures after ureteroneocystostomy, and 1 each after ureterolithotomy, a ureterocele operation and diminutive bladder following segmental resection. Surgical injury. There were 5 cases of acute surgical injury. Three occurred after a hysterectomy (2 distal third, 1 middle Accepted for publication June 18, 1976. Read at annual meeting of Western Section, American Urological Association, Coronado, California, February 22-26, 1976. 39

third), 1 incident to a difficult radical retropubic prostatectomy and 1 after a colon resection. There were no cutaneous ureterostomies in our series. Only 1 patient had had previous radiotherapy and pelvic malignancy and he had no complications after the transureteroureterostomy. Major ureterocutaneous fistulas (persisting more than 10 days) developed in 4 cases. One ceased spontaneously 14 days postoperatively and another ceased after cystoscopic placement of a ureteral catheter. Of the remaining 2 cases 1 eventually required nephrectomy of the donor (diseased) unit and the other required bilateral nephrostomy. An attempt was made to correlate complications with the presence of preoperative or postoperative urinary infection, suture n,aterial and method (interrupted or continuous suture) used for anastomosis but no consistent association could be made. Of the 3 surgeons involved we each had at least 1 of the 4 major complications. Despite the serious complications 22 of the 23 cases achieved excellent results. CASE REPORTS

Case 1. D. E. W., 3385, had right ureteral duplication with hydronephrosis and reflux in both segments secondary to a ureterocele operation done in 1948. In 1964, when the patient was 46 years old, he had the following combined operations: excision of a bladder diverticulum, Y-V plasty of the bladder neck, ipsilateral right ureteroureterostomy and right-to-left transureteroureterostomy. Postoperatively, there was a prolonged urinary fistula but this sealed spontaneously after 3 weeks. Thereafter, there was evidence of progressive right hydronephrosis and recurrent sepsis owing to a stricture of the common right ureter at the transureteroureterostomy anastomotic siteo A right nephrectomy was accomplished 4 months after the transureteroureterostomy. Nephrectomy was done through the flank and as much of the right ureter that could be reached through this approach was resected. Between 1964 and 1968 serial IVPs were done, showing persistent mild left ureteral stricture with mild obstruction to drainage at the old transureteroureterostomy site. Ureteral dilatations were done periodically. In 1970 a 1 cm. ureteral diverticulum became evident at the site of the old transureteroureterostomy anastomosis (fig. 1). Because of recurrent bacteriuria and the assumption that this small diverticulum was a reservoir of infection exploration of the old transureteroureterostomy site was done. Retroperitoneal fibrosis, extending several centimeters above and below the transureteroureterostomy site, produced the ureteral stricture. The left ureter was freed, the diverticulum was excised and an intubated ureterostomy was done in situ. IVPs after removal of the splinting tube and treatment of infection reveRled an excellent result without residual obstruction. There has been no further urinary tract infection.

40

SANDOZ, PAULL AND MACFARLANE

Case 2. A. S. B., 10-665, a 54-year-old man, had a lower left ureterolithotomy on November 26, 1969, following an unsuccessful cystoscopic manipulation for a distal left ureteral stone. Persistent urinary leakage developed and exploration 14 days later revealed complete obstruction of the distal left ureter. The ureter was edematous, friable and bathed by infected urine. A left-to-right transureteroureterostomy was accomplished but a 100 per cent urinary fistula occurred after this procedure (fig. 2, A). The fistula persisted despite cystoscopic placement of a ureteral catheter. On December 31 the transureteroureterostomy anastomotic site was explored. The recipient right ureter was totally strictured immediately distal to the transureteroureterostomy suture line that had become partially separated accounting for the fistula. It was necessary to resect a segment of the recipient right ureter and do an end-to-end ureteroureterostomy. The left-to-right transureteroureterostomy was repeated at a higher level on the right ureter. All suture lines were splinted with 8F tubes.

Fm. 1. Case 1. Retrograde ureterogram 6 years after right nephrectomy for transureteroureterostomy failure shows recipient ureteral stricture and diverticulum.

Postoperatively, continued extravasation about the left ureteral splinting tube occurred and, therefore, bilateral nephrostomy was done on January 21, 1970. The patient was discharged from the hospital shortly thereafter. On March 17 antegrade pyelograms still showed some extravasation at the site of the transureteroureterostomy anastomosis. By April the anastomoses had healed completely and it was possible to remove the nephrostomy tubes. An IVP in October showed normally functioning renal units and no evidence of obstruction (fig. 2, B). IVPs in 1972 continued to be normal and there has been no recurrence of stone formation or infection. Case 3. M. J. M., 80-35, a 15-year-old boy, had a congenital distal stricture of the left ureter with grade III hydroureter and hydronephrosis (fig. 3, A). On the right side there was complete ureteral duplication with the 2 ureters joining intramurally at the bladder. There was no reflux. The ureter draining the right upper segment was selected as the recipient ureter and a left-to-right transureteroureterostomy was done on November 3, 1967. Postoperatively, there was no urinary fistula. Followup IVPs on February 22, 1968 demonstrated marked obstruction of the recipient right upper ureteral segment and persistent hydronephrosis and hydrometer on the left side (fig. 3, B). Exploration approximately 4 months after the original procedure demonstrated dense retroperitoneal fibrosis about the anastomotic site, extending in both directions for 2 to 3 cm. The ureters were dissected free and the transureteroureterostomy anastomotic site was resected, including a portion of the strictured recipient ureter. An end-to-end ureteroureterostomy of the right superior segment ureter was done and a left-toright transureteroureterostomy was repeated at a higher level on the recipient ureter. Ureteral splints were used. Followup IVPs demonstrated complete resolution of the hydronephrosis and hydrometer of the right upper segment. The right lower ureteral segment was never affected adversely. The left hydronephrosis and hydrometer showed relief of the obstruction and prompt drainage (fig. 3, C). These findings were stable for 1 ½ years, at which time the boy injured the left kidney in a football game. Left nephrectomy was necessary because of marked hemorrhage. No problem has as yet developed from the short left ureteral stump attached to the right ureter. Case 4. W. H., 89-62, a 66-year-old man, underwent radical retropubic prostatectomy for stage A carcinoma of the prostate on July 25, 1968. The procedure was complicated by marked adhesion of the bladder to the rectum and left pelvic side walls, this being the result of a distal ureterolithotomy with extrava-

Fm. 2. Case 2. A, persistent extravasation 21 days after transureteroureterostomy owing to recipient ureteral stricture. B, late IVP demonstrates eventual excellent result.

C0i\1PLICATI01'!S WTffi TRANSURETEROURETEROSTOMY

41

FIG. 3. Case 3. A, delayed drainage film shows distal left ureteral stricture. B, IVP 4 months after transureteroureterostomy shows obstruction of recipient right superior segment ureter and increased obstruction on left side. C, eventual good result after repeat transureteroureterostomy.

FIG. 4. Case 4. A, antegrade pyelogram through left nephrostomy 16 days after left-to-right transureteroureterostomy. Left nephrostomy drains right kidney as well but little urine reaches bladder owing to recipient ureteral stricture. Contrast medium in bladder is from simultaneous cystogram. B, detail of recipient ureteral stricture.

sation and sepsis many years earlier. The plane between the bladder and seminal vesicles on the left side could not be established and the left ureter was transected the dissection even though it contained a left ureteral catheter. The distal left ureter was so adherent to the pelvic side walls that it could not be safely mobilized to allow reimplantation into the bladder. Therefore, a left-to-right transureteroureterostomy was accomplished. Splints were not used. One day postoperatively the patient locked himself in the bathroom and pulled out all the tubes, including the Foley urethral catheter through the vesicourethral anastomosis. Despite replacement of the catheter the patient became oliguric and rapidly uremic. Infusion pyelograms demonstrated partial bilateral ureteral obstruction at the transureteroureterostomy site. On July 28 a left nephrostomy was accomplished. The patient remained extremely belligerent and confused owing in part to his alcoholic history. On July 31, despite restraints, he managed to pull out the left nephrostomy tube. Surgical nephrostomy was repeated. Surprisingly, the left nephrostomy also drained the

right kidney via the patent transureteroureterostomy anastomosis. Approximately 2 weeks later left antegrade pyelograms demonstrated patency of the transureteroureterostomy anastomosis but poor drainage down the recipient ureter (fig. 4, A). A right retrograde ureterogram demonstrated a stricture of the recipient ureter immediately below the transureteroureterostomy anastomotic site (fig. 4, B). At exploration the anastomosis between the 2 ureters was patent to 12F but the segmental stricture of the recipient ureter immediately below the anastomotic site measured only 1 mm. in diameter. A ureteroplasty was done and the recipient ureter was intubated. The left side continued to drain by nephrostomy. The patient progressed well for the first 5 days but then a series of complications developed and led to his death. These complications included progressive jaundice, gastrointestinal hemorrhage and sepsis in the lungs, kidneys and liver. He died 5 weeks after the last operation. At autopsy the ureteral anastomoses were intact and patent. A fulminant hepatitis, pneumonia and microabscesses in the left kidney were present.

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SANDOZ, PAULL AND MACFARLANE DISCUSSION

In light of our experience and that of Ehrlich and Skinner it is apparent that complications of the recipient ureter represent a definite hazard to transureteroureterostomy. It is not our intent to suggest that transureteroureterostomy be discarded. The operation has great merit and should be part of the repertoire of all urological surgeons. When confronted with distal ureters that are diseased, fibrotic, strictured, edematous and friable from extravasation, or associated with pelvic sepsis, transureteroureterostomy is often the procedure of choice. It allows the surgeon the luxury of working in a virgin field with normal tissue. However it should be undertaken with caution a1:_ci_cmly after theilie~~Ciluari.fliiiLandveslco:Jiliili~. h i ~ e beenconsidered seriously._In retrospect, case 1 should not have had a transureteroureterostomy but rather a primary nephrectomy since the donor kidney initially was moderately hydronephrotic and pyelonephritic from chronic massive reflux. Proximal ureteroureterostomy of a duplicated donor ureter immediately prior to transureteroureterostomy, as was done in case 1, is a relative contraindication because of the likelihood of interference with the blood supply of the distal donor ureter. Also, increased pressure within the donor ureters owing to edema at the transureteroureterostomy site would increase the likelihood of extravasation at the ureteroureterostomy. The usual contraindications to transureteroureterostomy are extensive pelvic irradiation, residual fa.Iculuiaisease i°ueiTher_J..idu-ey, reflux-or ai.staLJ2arTial obstructTon-oCfne :recfrifent_ureter and retroperitoneal fibro~is with the attendant problems of reducecrvascular supply. To__this.,.._smLlv..ould..add-as a relatE,e _CO!!_traindication )Ilarked di~arfu in size_of tJ1L2 ureters0 _ A slender thin-walled 5F recipient ureter may not adapt well to a thick-walled dilated tortuous donor ureter. Cases 1 and 3 would fall into this category. Pre-existing urinary infection should be treated vigorously before the operation but of itself is not an absolute contraindication to transureteroureterostomy. The technique of transureteroureterostomy has been described sufficiently by Hodges and others.•-• Emphasis has been placed on the necessity of having a good blood supply to the tip of the transplanted ureter and on the avoidance of anastomotic tension. We believe that these criteria were well met in our 4 cases of failure. Therefore, in the hope of avoiding future complications, other points in technique may bear repeating and clarification. 1) The ideal site for an anastomosis is 2 to 4 cm. above the pelvic orirn-S-inceuieters·are at 'tfos-poinf> ii{d .the rec1pfent ureter nas--a straignt course. A ·ureteral a;;-;;:stomosis mar the iliac vesseTsincYeasesTh.e1ikelihood of stricture owing to angulation and increased tension. To assure adequate exposure of that portion of the recipient ureter, the abdominal incision should be extended superiorly even though the original problem may be in the deep pelvis. 2) The_recipient ureterotomy must b,f_at les1fil,1.5 cm JQ!lg_ and maae i

Complications with transureteroureterostomy.

Vol. 117, ,January 'rHE ,Jol.;R'...JAL OF UROLOGY Copyright© 1977 by The \Villia.ms & Co. l~inted in U.S.A. COMPLICATIONS WITH TRANSURETEROURETER...
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