0022-5347/79/1214-0518$02.00/0 Vol. 121, April Printed in U. S .A .

THE JOURNAL OF UROLOGY

Copyright © 1979 by The Williams & Wilkins Co.

TANDEM TRANSURETEROURETEROSTOMY FRANCIS A. DETURE* AND BIRDWELL FINLAYSON From the Department of S urgery (Urology) , Un ive rsity of Florida, Gainesville, Florida

ABSTRACT

A case of bilateral hydronephrosis after transureteroureterostomy is reported. Management of such complications may be difficult and should include innovative ureteral salvage based upon fundamental principles ofureteral surgery. Concern that transureteroureterostomy would jeopardize normal renal units and ureters has been alleviated by reports of efficacy with relatively low morbidity . 1- 3 However, Ehrlich and Skinner,• and Sandoz and associates• have reported occasional serious morbidity, damage to the normal renal unit and mortality. Transureteroureterostomies have been used with end cutaneous ureterostomy and ureteroenteric anastomosis. 3• 6 Ureteroureterostomy with unilateral nephrostomy has been reported as a rapid method of urinary diversion ,7 and transureteropyelostomy" and transpyeloureterostomy" bave been described. However, more complex combinations of ureteral rearrangement have not been emphasized. Herein we report on the use of such complex ureteral combinations in bridging multiple ureteral deficits. CASE REPORT

A 62-year-old white woman, STH 22-48-49, received 5,000 rad external total pelvic irradiation plus 2,000 rad intrauterine radium for stage II epidermoid carcinoma of the right lateral vaginal fornix in the spring of 1973. An excretory urogram (IVP) was normal. The patient tolerated this radiation and did well until December when she returned with fever, chills, right costovertebral pain and dysuria. An Escherichia coli urinary infection was treated with ampicillin with relief of symptoms. In January 1974 an IVP showed a normal left kidney and ureter but there was delayed excretion of contrast material on the right side and grade 2 hydroureteronephrosis to the ureterovesical junction on delayed films . A right retrograde pyelogram demonstrated a 1 cm. long stenosis of the distal right ureter. This was believed to be secondary to post-radiation fibrosis or recurrent tumor and the cause of the obstruction. The patient returned in April 1974, complaining of fullness in the right flank without systemic or voiding symptoms. Physical examination suggested a right flank mass and the patient had right costovertebral angle tenderness. An IVP showed a progression of the obstruction to the distal right ureter (fig. 1, A ). Urine remained infected with E. coli, Enterococcus and Klebsiella. The distal right ureter was explored through a midline lower abdominal incision. A tensely dilated right ureter, approximately 4 times the normal diameter, was found above a dense fibrosis encasing the distal right ureter but biopsy of this area showed no tumor. A rightto-left transureteroureterostomy was done . The patient had copius and prolonged Penrose urinary drainage for approximately 1 month. Subsequently, she complained of right costovertebral angle fullness and pain. In August, because of progressive now bilateral flank symptoms, persistent urinary tract infections and IVP evidence of progressive hydroureteronephrosis bilaterally (fig. 1, B), a left retrograde pyelogram was done. A 1½ cm. segment of stenotic left ureter involving

the anastomotic site was seen and the right ureter appeared obstructed 2 cm. above the anastomosis (fig. 1, C). The transureteroureterostomy anastomosis was explored but there was still no evidence of residual tumor. The right ureter was tensely dilated to its tunnel through the sigmoid mesentery wherein it was densely encased in scar. A 6 cm. segment of the left mid ureter from 2 cm. below the anastomosis to 3 cm. above it was fibrotic and, therefore, was resected. The distal left ureter, although friable and encased in mi1d fibrosis , was left undisturbed. The left proximal ureter was dissected to the level of the renal pelvis and the left kidney was mobilized but this did not allow sufficient gain in ureteral length to bridge the defect. The right kidney was mobilized as well. Bilateral nephrostomy tubes were placed through anterior pyelotomies. A new tunnel was made through the sigmoid mesentery to allow transfer of the right ureter to the left retroperitoneum. The end of the right ureter and the end of the distal left ureter were spatulated and an end-to-end ureteroureterostomy was done. Because of the friability of the distal left ureter interrupted 4-zero chromic sutures were used rather than a watertight closure. Approximately 4 cm. above this anastomosis a ureterotomy was made on the anteromedial aspect of the right ureter and the end of the proximal left ureter was anastomosed to this with a running, watertight suture of 4-zero chromic. Before this anastomosis was completed an SF silicone ureteral stent was placed to bridge both anastomoses and also pass into the bladder. The relationship of the ureters· in the completed anastomosis is shown in figure 2. Both anterior pyelotomies for the placement of nephrostomy tubes and both anastomoses were drained via Penrose drains. Postoperatively, none of the Penrose drains leaked significantly and after antegrade nephrostograms 10 days later failed to demonstrate extravasation of dye these drains were removed. The ureteral stent was removed cystoscopically 24 days postoperatively. Thereafter, antegrade pyelography repeatedly demonstrated free drainage of the upper tracts (fig. 3, A) . However, it was not until February 1975, 6 months postoperatively, that the patient could tolerate having both nephrostomy tubes clamped simultaneously for long intervals. In March both nephrostomy tubes were removed. During the intervening 3 years the patient has had infrequent urinary tract infections. Renal function has remained normal and stable. The left kidney is normal except for a cortical scar at the site of the nephrostomy tube. There is stable calicectasis on the right side. The right kidney has extensive old cortical thinning but has not atrophied further (fig. 3, B). Also, it has been 5 years since the radiotherapy for epidermoid carcinoma of the vagina and there is no evidence of recurrent disease.

Accepted for publication August 11 , 1978. * Requests for reprints: Department of Surgery (Urology), Box J. 247, College of Medicine, University of Florida, Gainesville, Florida 32610.

518

COMMENT

Alternatives were considered for bridging the ureteral defects in this case. On the right side ureteral mobilization with primary reimplantation of the distal ureter could not be

TANDEM TRANSURETEROURETEROSTOMY

519

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accomplished because of insufficient ureteral length. The prior pelvic radiation prevented bladder mobilization for a psoas hitch or a Boari flap. The left mid ureteral deficit could not be made up for by renal mobilization. Small bowel interposition was discarded because the alternatives were using a segment of bowel on each side, a transureteroureterostomy into the proximal left ureter above a bowel segment or a right-to-left

2

transureteroenterostomy. Also, we did not wish to do a diversion that would require a permanent appliance. The most fitting alternative seemed to be the tandem transureteroureterostomy. It could certainly be argued that the initial right-to-left transureteroureterostomy failed because of the prior radiation effect upon the distal ureters and that because of this a similar procedure should not have been

520

DETURE AND FINLAYSON

Fm. 3

done. However, Sandoz and associates, in reporting their complications with transureteroureterostomy, have indicated that for anastomotic strictures resection of the strictured portion of the recipient ureter, with end-to-end ureteroureterostomy and then repeat transureteroureterostomy above the ureteroureterostomy is feasible. 5 Uehling had a case of a fused pelvic kidney drained by 3 ureters that all entered into a cloacal structure for which a transuretero-uretero-ureterostomy ending as a cutaneous ureterostomy was done. 10 Although the occasion to use a tandem transureteroureterostomy is rare the urologist should be cognizant of this as an alternative in difficult circumstances and consider unusual ureteral combinations based upon accepted surgical principles. REFERENCES 1. Udall, D. A., Hodges, C. V., Pearse, H. M. and Burns, A. B.:

Transureteroureterostomy: a neglected procedure. J. Urol., 109: 817, 1973. 2. Halpern, G. N., King, L. R. and Belman, A. B.: Transureterou-

reterostomy in children. J. Urol., 109: 504, 1973. 3. Brannan, W.: Useful applications of transureteroureterostomy in adults and children. J. Urol., 113: 460, 1975. 4. Ehrlich, R. M. and Skinner, D. G.: Complications of transureteroureterostomy. J. Urol., 113: 467, 1975. 5. Sandoz, I. L., Paull, D. P. andMacFarlane, C. A.: Complications with transureteroureterostomy. J. Urol., 117: 39, 1977. 6. Schmidt, J. D., Flocks, R.H. and Arduino, L.: Transureteroureterostomy in the management of distal ureteral disease. J. Urol., 108: 204, 1972. 7. Wechsler, M., Romas, N. and Rudin, L.: Ureteroureterostomy and unilateral nephrostomy. Alternate rapid method of diversion. Urology, 7: 366, 1976. 8. Moore, T. D.: Transureteropyelostomy and transuretero-ureterostomy: the indications and operative technique. J. Urol., 60: 859, 1948. 9. Hodges, C. V., Moore, R. J., Lehman, T. H. and Behman, A. M.: Clinical experiences with transureteroureterostomy. J. Urol., 90: 552, 1963. 10. Uehling, D. T.: Transuretero-uretero-ureterostomy for pelvic kidney. J. Urol., 111: 825, 1974.

Tandem transureteroureterostomy.

0022-5347/79/1214-0518$02.00/0 Vol. 121, April Printed in U. S .A . THE JOURNAL OF UROLOGY Copyright © 1979 by The Williams & Wilkins Co. TANDEM TR...
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