Transureteroureterostomy - Indications and Contraindications

Introduction

Higgins introduced transureteroureterostomy in 1935. Transureteroureterostomy was used in the treatment of urinary tract disorders in children and adult age groups. But it posed a risk to the opposite, nondiseased ureter and kidney. Hence transureteroureterostomy is not frequently performed. Instead, transureteroureterostomy is performed in lower ureter damage (iatrogenic or traumatic), lower ureteric strictures, pelvic radiation cases of bladder flap or psoas hitch, or failed ureteric reimplantation. In addition, transureteroureterostomy is used in cases of dilated ureters (posterior urethral valves, neurogenic bladder, large bladder diverticula) and cases of the incontinent bladder (neurogenic or myogenic bladder). Here the lower ureter is used as a continent-catheterized stoma.

What Is Transureteroureterostomy?

Transureteroureterostomy is a surgical procedure used for urinary reconstruction. In this technique, one ureter is joined to the other across the middle. This procedure offers individuals an adjunct to procedures like urostomy appliances (bags used to collect urine outside the body) or internal urinary stents. This procedure is common in conditions of distal ureteral obstruction. Transureteroureterostomy procedures are used in uni-diversion cases where the pelvis is avoided because of previous trauma, radiation therapy, or surgery. In some conditions, transureteroureterostomy is combined with cutaneous ureterostomy.

Knowing the Anatomy of the Ureter:

The ureters are located in the retroperitoneum and help transport urine from the kidneys to the bladder. They are divided into three segments:

• The proximal ureter extends from the ureteropelvic junction to the area crossing the sacroiliac joint.

• The middle ureter extends from the bony pelvis and iliac vessels.

• The distal or pelvic ureter extends from the iliac vessels to the border.

Because of the complex anatomy of the ureters, they are prone to risks during surgical procedures. The left ureteropelvic junction is posterior to the duodenal-pelvic junction and the pancreas. The right ureteropelvic link is posterior to the duodenum and lateral to the inferior vena cava. As the ureters move downward, they lie on the psoas muscle and pass medially to the sacroiliac joints. They oscillate laterally at the ischial spines and then pass medially to penetrate the base of the bladder. The inferior mesenteric artery and sigmoid vessels cross the left ureter anteriorly. The right colic and ileocolic vessels cross the right ureter. When the ureters enter the pelvis, they move anterior to the iliac vessels and posterior to the gonadal vessels. In females, the ureter is posterior to the ovaries and lateral to the infundibulopelvic ligament. It moves posterior to the broad ligament and lateral to the uterus. The uterine arteries move at the ureterovesical junction. The ureter is crossed by the umbilical ligament in males and passes below the vas deferens.

What Are the Requirements for Transureteroureterostomy?

Requirements for transureteroureterostomy include a redeemable ipsilateral kidney with a normal functioning ureter next to the defective portion. The recipient ureter should have free drainage and must be involved with any condition that may put both kidneys at risk postoperatively. The principle of transureteroureterostomy is to restore ureteral continuity by bringing the ureter across the midline and connecting it to the contralateral ureter. This is done in a side-to-side or end-to-side manner. Transureteroureterostomy can be performed in cases of solitary kidneys with a normal ureteral stump.

What Are the Indications of Transureteroureterostomy?

The primary motive of transureteroureterostomy is to reestablish nonobstructive and non-refluxing drainage of the ureter. In children, transureteroureterostomy is performed to recover a failed ureteral reimplantation or in conjunction with the urinary diversion for cutaneous ureterostomy. Transureteroureterostomy is employed for urinary diversion and in cases of urinary reservoir construction, as transureteroureterostomy requires only one ureter reimplantation. Transureteroureterostomy is also used in adjunct with reimplantation of the recipient ureter. Many of these cases required suturing or tapering with a psoas hitch or bladder augmentation. Transureteroureterostomy is performed simultaneously in cases of complications or abnormal bladder reimplantation.

Indications for Psoas Hitch:

Psoas hitch is a technique used for traversing the defect in the lower third of the ureter. Indications for technique include:

• Failed ureteroneocystostomy.

• Segmental resection of the distal ureteral tumor.

• Distal ureteral injury.

• Ureteral fistulae were secondary to pelvic surgery.

Indications for Boari Flap:

Boari flap is used as an adjunct to primary ureteroneocystostomy. The technique is used when there is limited ureteral mobility or when the defective segment of the ureter is too long. Boari flaps can traverse a defect of 10 cm to 15 cm long. In addition, a spiral bladder flap is constructed to reach the renal pelvis in a few cases.

What Is the Epidemiology of Transureteroureterostomy?

There are a total of 600 cases reported so far. The number is less because most cases go unreported in the scientific literature. The highest number of issues were registered in England with benign and malignant diseases which affected the distal ureter. In the cases reported, many complications were due to the common ureter distal to the transureteroureterostomy. Transient leaks occurred in 6 percent of the individuals. Hence there should be an emphasis on ensuring a normal accepting ureter distal to the transureteroureterostomy. Conditions like stone disease, medicinal disease, and chronic renal insufficiency involve risk to both upper units. These conditions are a contradiction to transureteroureterostomy.

What Is the Etiology of Transureteroureterostomy?

Medical conditions that require performing transureteroureterostomy are:

• Pelvic malignancies.

• Trauma.

• Vesicoureteral reflux (backward urine flow from the bladder to the ureter).

• Exstrophy (a rare condition where the bladder develops outside the fetus's body).

• Amyloidosis (abnormal protein buildup in the organs).

• Malakoplakia (an inflammatory condition caused due to the bactericidal effect of the macrophages).

• Leukoplakia involves segments of the ureter.

What Is the Presentation of Cases Requiring Transureteroureterostomy?

Individuals with intrinsic and extrinsic ureteral obstruction require transureteroureterostomy. The individual may complain of fever, malaise, flank pain, or sepsis or may even be completely asymptomatic. Investigations such as ultrasound or computed tomography demonstrate unilateral or bilateral hydronephrosis.

What Are the Contraindications for Transureteroureterostomy?

Transureteroureterostomy Contraindication involves diseases affecting the kidneys and mid or proximal ureters. The diseases are:

• Genitourinary tuberculosis.

• A long history of renal calculi.

• Retroperitoneal fibrosis.

• Transitional cell carcinoma.

• Vesicoureteral reflux in the recipient ureter.

• A luminal discrepancy in the ureters.

• In cases where psoas hitch or board flap can be performed.

Conclusion

Transureteroureterostomy is a urinary reconstruction procedure used when other conventional techniques are impossible. Transureteroureterostomy is a useful procedure if performed precisely and provides a good prognosis. In addition, prompt follow-up care can reduce morbidity and mortality.