|Year : 2009 | Volume
| Issue : 2 | Page : 47-51
Laparoscopic ureteroneocystostomy for management of lower ureteric strictures
Aman Gupta, Punit Bansal, MK Bera, Anup Kumar Kundu, Aradhana Kalra, Mukesh Kumar Vijay, Arindham Dutta, Suresh Singla, Punit Tiwari
Department of Urology, IPGMER, SSKM Hospital , Kolkata - 20, India
|Date of Submission||22-Mar-2009|
|Date of Acceptance||08-May-2009|
|Date of Web Publication||26-Sep-2009|
54, Panchdeep Apartments, Vikas Puri, New Delhi - 110 018.
| Abstract|| |
Aim: We assessed the results of laparoscopic transperitoneal ureteroneocystostomy with or without a psoas hitch for management of lower ureteral strictures.
Materials and Methods: Between October 2005 and August 2008, 16 patients with lower ureteric strictures underwent laparoscopic ureteroneocystostomy with or without a psoas hitch. Etiology of strictures was gynecological surgery in 11, surgery for stone disease in 3, ureterovaginal fistula in 1 and primary obstructive megaureter in 1. Transperitoneal 3- or 4-port laparoscopic ureteroneocystostomy was performed with or without psoas hitch.
Results: All operations were successfully completed without any need for conversion to open. Mean operative time was 171.56 min (range 130 to 260 min), mean blood loss was 93.44 cc (range 30 to 200 cc) and total hospital stay was 3.73 days (range 3 to 6 days). Mean time to resume oral intake was 12.5 h (range 8 to 22 h). Mean follow-up period was 21.83 months (range 6-39 months). Postoperative follow-up investigations revealed successful outcome in all 16 patients, success being defined as relief of symptoms and radiological improvement, irrespective of the refluxing status. Non-refluxing status was achieved in 15 out of 16 patients as determined by micturition cystography.
Conclusions: Laparoscopic ureteroneocystostomy is a safe and effective procedure, with inherent advantages of laparoscopic surgery.
Keywords: Laparoscopy, ureteric stricture, ureteroneocystostomy
|How to cite this article:|
Gupta A, Bansal P, Bera M K, Kundu AK, Kalra A, Vijay MK, Dutta A, Singla S, Tiwari P. Laparoscopic ureteroneocystostomy for management of lower ureteric strictures. Urol Ann 2009;1:47-51
|How to cite this URL:|
Gupta A, Bansal P, Bera M K, Kundu AK, Kalra A, Vijay MK, Dutta A, Singla S, Tiwari P. Laparoscopic ureteroneocystostomy for management of lower ureteric strictures. Urol Ann [serial online] 2009 [cited 2018 Jan 22];1:47-51. Available from: http://www.urologyannals.com/text.asp?2009/1/2/47/56044
| Introduction|| |
Ureteral strictures may result from various causes, including endoscopic urological procedures, stone passage, tuberculosis, endometriosis, malignancies, primary obstructive megaureter, radiation therapy and open and laparoscopic surgery (urological , vascular, gynecological). 
Traditionally, open ureteric reimplantation with or without psoas hitch has been the gold standard for such strictures.  However, as the urologists' experience with laparoscopy grows, there has been a dramatic increase in the laparoscopic applications for management of diseases of the ureter. The various conditions where laparoscopic procedures have been used for benign conditions of the ureter are primary vesicoureteral reflux,  retrocaval ureter, retroperitoneal fibrosis, ureteroureterostomy, ureteroneocystostomy and transureteroureterostomy.
Ureteroneocystostomy in adults is indicated in the management of distal ureteric strictures or ureteral obstruction and ureteral injury as a result of gynecological or pelvic surgery. Excellent results have been reported in the treatment of secondary ureteral strictures due to perforations following ureteroscopy as well as in gynecological cases where infiltrative ureteral endometriosis or inadvertent ureteral injuries necessitate distal ureteral resection and reimplantation. ,,,
We present our experience with laparoscopic ureteroneocystostomy for the management of lower ureteric strictures.
| Materials and Methods|| |
A total of 16 patients underwent transperitoneal laparoscopic ureteral reimplantation for lower ureteric strictures at our institute between October 2005 and August 2008. Etiology of strictures were open abdominal hysterectomy in 4, laparoscopic abdominal hysterectomy in 2, transabdominal excision of uterine fibroid in 3, excision of tubo-ovarian mass in 2, open ureterolithotomy for lower ureteric stone in 1, ureterorenoscopic lithotripsy for lower ureteric stone in 2, ureterovaginal fistula in 1 and primary obstructive megaureter in 1. All patients were referred to our referral institute from other centers. The mean time period between surgery and referral was 4.2 months. Previous diversion in the form of percutaneous nephrostomy was performed in 8 out of 16 patients before referral. Four patients had failed attempts at endoscopic management of stricture before referral.
All patients underwent intravenous pyelography for anatomical study of pelviureteric system and DTPA renal scan as a baseline function and assess salvageability of the kidney. Peroperative retrograde pyelography along with on table nephrotomogram (where proximally diverted) were performed to assess exact length and location of the stricture. Mean stricture length was found to be 2.06 cm (range 1.5 to 3).
The nonrefluxing-modified Lich-Gregoir onlay technique was used for the ureteroneocystostomy. All patients were catheterized per-urethrally at the beginning of the procedure after administration of general anesthesia. Procedures were performed in supine position, with table tilted at 15-30 degree of Trendelenburg to allow overlying bowel to fall away. Pneumoperitoneum was created using Veress needle. A 10 mm camera port was inserted at umbilicus and two secondary ports (one 5 mm and one 10 mm) were inserted in midclavicular line on either side, just below the level of the umbilicus. The posterior peritoneum over the iliac vessels was incised on the ipsilateral side and the ureter was dissected up to the stricture segment with care taken to preserve the periureteral tissue. The distal ureter was clipped and the normal healthy proximal part was spatulated in the 6 o'clock position. In none of the cases was ureter so much dilated as to require tapering. The bladder was filled with 150 cc of sterile saline and adequately mobilized. Psoas hitch was required in 12 out of 16 patients. In four cases psoas hitch was not required, where stricture was lowered down, and anastomosis could be performed without tension. The etiology in these four cases was post-ureterorenoscopic lithotripsy in 2, primary obstructive megaureter in 1 and stricture secondary to uterine fibroid excision in 1. Stricture length in each of these four cases was 1.5 cm. The detrusor was incised using electrocautery over posterolateral aspect followed by opening of the bladder mucosa at a distal-most part of the incision by scissors. The ureter was anastomosed to the bladder mucosa using 4-0 Vicryl sutures. Before completion of anastomosis, a double J stent was inserted in all cases from the site of anastomosis in an antegrade manner over the guidewire. The edges of the detrusor muscle were approximated over the ureter to create the submucosal tunnel. The repair was then tested by bladder filling and direct laparoscopic visualization for any leaks. A pelvic drain was used in all the cases. Nephrostomy tube, where present, was clamped after surgery. Per-urethral catheter was removed on postoperative day one in all the cases. The pelvic drain was removed when drainage was less than 50 cc. Drain was removed by postoperative day 2 in all cases. Nephrostomy was removed after removal of the drain. The double-J stent was removed at 6 weeks postoperative period. Intravenous pyelogram and DTPA scan were performed 3 months after removal of the double-J stent. A voiding cystourethrogram (VCUG) was also performed over three months to assess reflux status. Subsequently, the patients were examined at 6-monthly intervals with ultrasonography at each visit for 2 years, and a repeat intravenous pyelography and renal scan at 1 year to detect any late development of stricture. All patients had a successful outcome, success being defined as symptomatic and radiological improvement irrespective of the reflux status.
| Results|| |
The laparoscopy procedure was performed successfully in all 16 patients without need to conversion. Mean patient age was 28 years (range 24 to 38 years). The operative time ranged from 130 to 260 min (mean 171.56 min), the mean stricture length was 2.06 cm (range 1.5 to 3 cm). The blood loss ranged from 30 to 200 min. Mean time to resume oral intake was 12.5 h (8-22 h) and mean hospital stay was 3.73 days (range 3 to 6 days) [Table 1].
Follow-up revealed successful outcome in all 16 cases and a non-refluxing status in 15 out of 16 cases. Mean follow-up period was 21.83 months (range 6 to 39 months). None of the cases developed an anastomotic stricture till the time of follow-up. No major complication was encountered in any of the cases. Minor complication in the form of port-site infection was observed in one case, which responded to antibiotics. Results are depicted in [Table 2].
| Discussion|| |
Ureteral reimplantation is most often performed in the adult population for diseases or traumas of the lower ureter that results in ureteric obstruction.  Laparoscopic ureteroneocystostomy was first described in children by Ehrlich et al, for high-grade vesicoureteral reflux.  The first laparoscopic ureteroneocystostomy in adults was reported by Reddy and Evans for the treatment of 1 cm distal ureteral stricture that developed as a delayed complication of transurethral resection of prostate. 
Open surgery for the reconstruction of lower ureter has been traditionally described as a Gold Standard for management of lower ureteric obstruction. However, open surgery has its disadvantages of greater morbidity, longer convalescence period and prolonged hospitalization compared to laparoscopic surgery. Although technically demanding, with increasing experience in laparoscopic procedures, laparoscopic reimplantation has become a feasible option for management of such strictures. Minimally invasive procedures like balloon dilatation and endoincision of stricture are also treatment options for small length of the ureteric strictures. Balloon dilatation alone has a moderate success rate in resolving ureteric strictures and often requires repeat dilatations.  Acucise; is also an option, and Preminger et al reported a success rate of 58% in the management of distal ureteric strictures using the Acucise;. 
Laparoscopic surgery has the advantages of less pain, early ambulation and rapid convalescence compared to open surgery, while the disadvantage is the longer operative time. , There are various techniques available for ureteroneocystostomy, which in general have a high success rate of 92 to 98%. ,,,,,,, The Lich-Gregoir extravesical approach is the most commonly performed laparoscopic procedure for the treatment of ureteroneocystostomy. ,, When an adequate lower ureter length is not available, the vesico-psoas hitch is an option. The psoas hitch is a reliable adjunctive procedure that promotes tension-free repair.  For a successful outcome, it is important to avoid tension, ureteral torsion and angulation. It is better to mobilize the bladder for a psoas hitch rather than perform extensive ureteral mobilization to preserve ureteral vascularity. Care is taken to preserve periureteral blood supply and avoid thermal injury from overly aggressive use of coagulation. Anastomosis in adults may be performed in a refluxing or non-refluxing manner, with no long-term consequences for clinical outcomes or renal function.  We chose to perform a non-refluxing procedure, because a potential disadvantage of the refluxing anastomosis may be a proclivity toward recurrent pyelonephritis. The procedure was successfully performed laparoscopically in all 16 patients without the need to conversion, with a mean operative time of 171.56 min (range 130 to 260 min) and a mean blood loss of 93.44 cc (range 30 to 200). Mean time to resume oral intake was 12.5 h (8-22 h) and all patients were discharged after a mean hospital stay of 3.73 days (range 3 to 6 days). Mean follow-up period was 21.83 months (range 6 to 39), with a successful outcome in all 16 cases and a non-refluxing status in 15 out of 16 cases. None of the cases developed anastomotic stricture till the time of follow-up. No major complication was encountered in any of the cases. Minor complication in the form of port-site infection was observed in one case, which responded to antibiotics.
Similar results were seen in a study by Modi et al, who performed laparoscopic ureteroneocystostomy for post-hysterectomy ureterovaginal fistula. 
Rassweiler et al compared laparoscopic and open ureteroneocystostomy procedure.  In their laparoscopic group, all patients underwent a vesico-psoas hitch or Boari flap and none had urinary leakage, while 2 in the open group with ureteroneocystostomy had urinary leakage. The laparoscopic group had a lesser analgesic drug requirement, shorter hospitalization and more rapid recovery.
Four of our patients had a previous failed attempt of endo-dilatation for stricture before being referred to us. Given the need for repeated dilatations for strictures managed by balloon dilatation, this may not be a feasible option in the patients we are dealing with, who have limited access to referral health centers.
Recurrent stricture usually develops within 1 year posttreatment. In their 20-year experience with managing ureteral strictures, Selzman and Spirnak observed only a 11% stricture rate after 1 year at an average follow-up of 8.5 years.  At an average follow-up of 21.83 months (range 6 to 39 months), none of our patients developed a stricture. We follow up our patients with intravenous pyelography along with DTPA scan at 1 year and with ultrasonography 6-monthly thereafter, at least for 2 years, and perform further investigations only if there is a clinical or sonological evidence of obstruction. Only 1 patient (male) had Grade 1 vesicoureteral reflux on voiding urethrocystogram at 3 months. This patient was followed with urine culture performed every 3 month. Patient did not develop urinary tract infection till this time over a follow-up period of 11 months.
Given the fact that indications for ureteral reimplantation vary and that reimplantations are sometimes performed at the same setting of other gynecologic procedures, such as hysterectomies, data on operative times, blood loss and postoperative hospitalization are difficult to compare.  In general, laparoscopic ureteroneocystostomy takes 3-4 h (3.5-4.5 h) with an estimated blood loss of <50 cc. ,, Patients can expect minimal postoperative pain, a short convalescence and excellent urologic outcomes.
| Conclusions|| |
Laparoscopic ureteroneocystostomy is not only feasible for management of lower ureteric strictures, but also has the advantages of early ambulation, rapid convalescence and shorter hospital stay, with equivalent functional outcomes compared to open surgery. The principles of laparoscopic approach for management of lower ureteric strictures are similar to those of open surgery. Although the acceptance of ureteral surgery trails that of ablative surgeries like radical nephrectomy and nephroureterectomy, the minimally invasive approach to the ureter has become a powerful tool in urologist's armamentarium.
| Abbreviations and Acronyms Used|| |
TAH - Total abdominal hysterectomy, Lap TAH - Laparoscopic total abdominal hysterectomy, POM - Primary obstructive megaureter, URSL - Ureterorenoscopic lithotripsy
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[Table 1], [Table 2]