Surg Illustrated

SURGERY ILLUSTRATED
BARRY

Surgical Atlas
Transureteroureterostomy
JOHN M. BARRY
The Oregon Health & Science University, Portland, Oregon, USA

ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com

INDICATIONS • DeBakey ‘Atraugrip’ vascular tissue forceps.

• Lahey/Sweet gallbladder duct forceps,
The indication for transureteroureterostomy 19 cm.
is to bypass a distal ureter without • Potts-style scissors with short blades and
compromising the recipient ureter with semi-sharp tips.
disease from the donor renal unit. It is • Thin vascular needle holders.
useful in patients who have had previous • 5/0 double-armed monofilament
pelvic surgery that would make a absorbable sutures.
ureteroneocystostomy with a psoas hitch, • Soft suction drain.
with or without a bladder flap procedure, • Y-connector system for intraoperative
difficult or inadvisable. The procedure is bladder irrigation and drainage.
not recommended under the following • Double-pigtail stent with thread left on
circumstances: chronic pyelonephritis, renal bladder/distal end.
calculus disease, previous ureteric trauma • Cysto-urethroscopy set-up with two open-
with scar, idiopathic retroperitoneal fibrosis, ended ureteric catheters to accept guidewires
fibrosis following previous aortoiliac vascular (optional).
surgery, high-dose radiation therapy, • Foley catheter that will comfortably fit the
urosepsis, uroepithelial tumours, pelvic urethra after calibration with bougie à boule.
visceral tumours with ureteric involvement, or • Sequential calf-compression devices.
inadequate ureteric length for a tension-free
anastomosis. The procedure is useful when SPECIFIC PATIENT PREPARATION
the better of the two ureters is reimplanted
into the bladder. When a normal ureter • Treat urinary tract infection if present.
remains after nephrectomy, a • Bowel preparation if the patient has bowel
transureteroureterostomy will provide dysfunction, infrequent bowel movements, or
drainage for the remaining kidney when its prior abdominal surgery.
ureter is diseased. The procedure is of • Antibiotic administration within 30 min of
value when the smaller of two ureters is procedure.
anastomosed to the larger one, which is then • Calf sequential compression devices to
used to bridge the abdominal wall and form a prevent deep venous thrombosis.
stoma.
SPECIFIC PATIENT POSITIONING
SPECIFIC EQUIPMENT/MATERIALS
• Lithotomy position for cystoscopy and
• Basic Bookwalter table-fixed retractor. bilateral ureteric catheterizations (optional).
• Basic laparotomy set. • After cystoscopy and bilateral ureteric
• Headlight. catheterization, extended supine position
• Magnification if the patient is small. with a break in the table just above the iliac
• Morse-Andrews suction tube. crest.

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BARRY

Figure 1

Cystoscopy is performed and open-ended

ureteric catheters placed. The ureteric
catheters are brought out alongside the Foley
catheter and each connected to its own
drainage system; they will be removed later.
The patient is placed supine, slightly
hyperextended, sequential calf-compression
devices applied (not shown), and the Foley
catheter attached to a Y-connector,
connected to an irrigation/drainage system so
that the anaesthetist can drain and fill the
bladder during surgery. The patient is
prepared and draped for a vertical midline
incision that will be extended as much as
necessary to comfortably perform the
procedure.

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Figure 2

Enough adhesions are taken down to allow

the Bookwalter retractor to be placed; the
Bookwalter ring is positioned 4–5 cm above
skin level. When the abdominal wall retractors
are placed, this creates intra-abdominal space
to pack the intestines out of the way. The
posterior peritoneum is incised as would be
done for a retroperitoneal lymphadenectomy.
This will expose both ureters. If they are not
easily seen, suspicious structures can be
plucked and observed for peristalsis, or the
previously placed ureteric stents palpated.

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BARRY

Figure 3

The donor ureter is traced into the pelvis, and

as much peri-ureteric tissue as possible is left
with the ureter to provide blood supply. The
catheter in the donor ureter is withdrawn
from below. The donor ureter is ligated distally
and divided proximal to the ligature. The
ureter is spatulated on its medial surface to
create a 2-cm opening and tagged with a stay
suture that will be used for gentle traction.
The donor ureter is dissected proximally. The
gonadal vessels are divided between ligatures
so they will swing medially with the donor
ureter. (If the patient has had previous
vasectomies, he will probably develop
testicular atrophy on the side of the donor
ureter.)

The donor ureter is swung over the great

vessels towards the recipient ureter. The
donor ureter is passed cephalad or caudad to
the inferior mesenteric artery depending on
which will bring the donor ureter closer to the
recipient ureter with no tension. If necessary,
a plane lateral to the recipient ureter is
opened, and the ureter is teased medially
towards the donor ureter until they meet with
no tension.

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Figure 4

A, 5/0 monofilament stay sutures are placed

side-by-side in the recipient ureter at the
proposed longitudinal ureterotomy.

The recipient ureter is incised with a #15

blade and the incision is extended with Potts-
style scissors to match the opening in the
donor ureter; 5/0 absorbable monofilament
sutures are placed at either end of the
recipient ureterotomy and into the heel and
toe of the donor ureter.

B, The posterior wall of the donor ureter is

sewn to the medial wall of the recipient ureter
from inside the lumen. The recipient ureteric
catheter is withdrawn by an unscrubbed
assistant until the open end appears in the
half-completed anastomosis. A guidewire is a b
passed into the end of the recipient ureteric
catheter and withdrawal of the ureteric
catheter is completed.

A double-pigtail stent is passed over the wire

into the bladder. A suture is left on the distal
curl in case the curl later retracts up the
ureter. The wire is removed and the position of
the distal curl confirmed when the
anaesthetist fills the bladder through the Y-
connector hook-up by clamping the outflow
catheter and opening the inflow tube.

A guidewire is passed through a side hole in

the double-pigtail stent to straighten the
proximal curl, and the proximal stent is passed
up the donor ureter into the renal pelvis. The
guide wire is removed.

C, The ureteric anastomosis is completed with

the running 5/0 monofilament absorbable
suture. c d

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BARRY

Figure 5

A soft suction drain is placed in the

retroperitoneum and brought out lateral to
the colon through a stab wound lateral to the
abdominal incision. The posterior peritoneal
incision is closed with running 3/0 absorbable
suture. The intestines are allowed to return to
their natural positions. The midline incision is
closed with interrupted far-far-near-near 0
monofilament absorbable sutures. If epidural
catheter analgesia will not be used, the
wound is injected with a long-acting local
anaesthetic such as ropivacaine. Scarpa’s
fascia is closed with running 3/0 absorbable
suture. The skin is closed with a running 4–0
absorbable subcuticular suture. Adhesive
strips are applied across the suture line. Dry
dressings are placed over the wound and the
drainage tube. The Y-connector is removed
and the Foley catheter is connected to a urine
drainage bag.

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CARE AFTER SURGERY of a transureteroureterostomy. Some Although transureteroureterostomy may

surgeons will prefer to avoid ureteric seldom be indicated, it is a good procedure to
Patient-controlled intravenous analgesia is catheterization for ureteric identification and have available.
used. The Foley catheter is removed in a day or rely on simple observation and diuresis to
two when the patient can void or resume identify the ureters. Text from this paper originally appeared in
intermittent catheterization. If epidural ‘Atlas of Surgical Techniques in Urology’, ed.
analgesia is used, urethral catheter removal is Dissecting clamps like the Lahey/Sweet E.D. Whitehead; pp. 370–371. Copyright:
delayed for ≥ 6 h after the epidural has been gallbladder duct forceps have longitudinal Lippincott Williams & Wilkins, 1998.
discontinued. rather than cross serrations and do not get Reproduced with permission.
caught on tissues during dissection.
The wound dressing is removed 2 days after Correspondence: John M. Barry, The Oregon
surgery. The adhesive strips will come off Skin closure with an absorbable subcuticular Health & Science University, Portland, Oregon,
several days later with a bath or shower. The suture is more comfortable for the patient USA.
sequential calf compression devices are than skin staples, clips or nonabsorbable e-mail: barryj@ohsu.edu
removed when the patient is ambulating. The sutures any of which must be removed later.
suction drain is removed when the drainage is
< 50 mL/24 h. In ª 6 weeks, the patient has One of our more disappointing cases was
baseline renal ultrasonography and the donor ureteric obstruction that occurred as a REFERENCES
double-pigtail ureteric stent removed via child grew and the ureter became trapped
flexible cystoscopy in the clinic 10 min after under the inferior mesenteric artery. 1 Barry JM. Transureteroureterostomy. In
instilling a urethral anaesthetic. Whitehead ED ed. Atlas of Surgical
Techniques in Urology. Philadelphia: WB
CLOSING COMMENTS Saunders, 1997: 369–72
SURGEON TO SURGEON 2 Sharpe BW. Trans-uretero-ureteral
Material has been used freely, and with anastomosis. Ann Surg 1906; 44: 687–
The Y-connector system can be used to fill permission, from a previous publication [1]. 707
the bladder to consider the option of The procedure was described in dogs and 3 Higgins CC. Transuretero-ureteral
ureteroneocystostomy with or without a cadavers nearly 100 years ago [2], and anastomosis: Report of a clinical case.
psoas hitch or bladder flap procedure, instead reported in a patient 70 years ago [3]. J Urol 1935; 34: 349–55

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