Ureteral Stricture

Ureteral strictures may result from a variety of causes, including stone passage, endoscopic urologic procedures, radiation therapy, open or laparoscopic surgery, and penetrating traumatic injuries. The incidence of ureteral strictures has increased in recent years, largely as a result of the introduction and widespread use of upper urinary tract endoscopy. Several factors may contribute to the development of ureteral strictures following ureteroscopy, which may be seen in as many as 3% to 11% of patients. These include stone impaction, relative ischemia, often because of the use of larger instruments for prolonged intervals, ureteral injury with extravasation of urine, and direct mechanical or thermal trauma. Ureteral injury leading to stricture, fistula formation, or obstruction may also be seen following a variety of open surgical procedures, including abdominal and vaginal hysterectomy, repair of vascular lesions, and pelvic exploration in patients with prostate, colon, and rectal malignancies.

Although the need for surgical repair of a ureteral injury may be immediately evident in some cases, many patients with ureteral obstruction and/or fistulas do not present until weeks or months following surgery. In particular, ureteral strictures that result from endoscopic manipulation of the upper urinary tract may not be noted for prolonged intervals because of the slow development of ureteral fibrosis. The presentation of patients with ureteral strictures is variable and may range from acute flank pain with sepsis and pyelonephritis to the incidental finding of hydronephrosis in an asymptomatic individual. As a result, the initial evaluation and treatment of patients with suspected ureteral obstruction must be tailored to the clinical situation.

DIAGNOSIS

A variety of diagnostic procedures are available to evaluate patients suspected to have ureteral strictures. Those patients presenting with acute pain and/or upper urinary tract infection will likely require immediate decompression of the obstructed kidney by internal (ureteral stent) or external (percutaneous nephrostomy) drainage. In these cases, immediate or delayed radiographic imaging of the affected renal unit may be performed in an antegrade or retrograde fashion. Those patients not requiring immediate intervention may be evaluated by intravenous pyelography (IVP), renal scintigraphy or computerized tomographic (CT) scanning. Advantages of an IVP include the ability to assess renal function as well as the level and degree of obstruction. Nuclear studies provide limited anatomic detail but allow for a more precise quantification of renal function and drainage. CT scans provide an assessment of perirenal and periureteral structures, which may be important in some patients with ureteral strictures.

INDICATIONS FOR SURGERY

The indications for surgical management of ureteral strictures, disruptions, and fistulas are dependent on the etiology of the lesion and the clinical situation. Ureteral disruption that results from external violence will generally require immediate repair. Similarly, iatrogenic injuries to the ureter noted during open pelvic or abdominal surgery should be repaired without delay. In contrast, initial attempts at conservative or endoscopic management of patients with ureteral injuries detected several days or weeks following surgery may be appropriate in some cases. Ureteral strictures that result from upper urinary tract endoscopy may be managed successfully with endoscopic dilation and/or incision (endoureterotomy) , with open surgical repair reserved for patients with recurrent obstruction.

ALTERNATIVE THERAPY

Many patients with ureteral strictures can be successfully managed using a variety of endourologic methods. Balloon dilation via a percutaneous, antegrade, or transurethral, retrograde approach is generally simple to perform with little risk of significant morbidity. Alternatively, full-thickness endoscopic incision of the stricture (endoureterotomy) followed by stent placement may have a higher long-term success rate than dilation but entails a greater risk of vascular and/or intestinal injury. In general, endourologic techniques appear to be most successful in patients with short, nonirradiated strictures of the distal ureter. Overall, an initial attempt at endoscopic management is appropriate in most patients with ureteral strictures because the potential morbidity and the recovery period are generally less with these procedures. In addition, a failed endoscopic procedure does not appear to jeopardize the success of subsequent open surgical repairs. Finally, some patients with complex ureteral strictures and/or disruption may be best managed by nephrectomy or cutaneous ureterostomy. This approach may be particulary appropriate in those with significant comorbid disease or patients in whom a urine leak could be disastrous, such as those with vascular grafts in the area of the ureteral injury.

SURGICAL TECHNIQUE

Ureteroureterostomy

This procedure is most appropriate in patients with short ureteral strictures involving the abdominal ureter (superior to the bifurcation of the iliac vessels). In addition, direct anastomosis of the ureter can be performed in patients with intraoperative injuries and those with ureteral damage secondary to external violence. If ureteroureterostomy is to be performed as a separate procedure, a flank, anterolateral, or midline approach is appropriate based on the level of the ureteral injury. In general, an incision that allows for renal mobilization is helpful in case additional ureteral length is necessary.

Initially, the ureter is identified through either an extraperitoneal or intraperitoneal approach. If the ureter is difficult to locate, it can be reliably found as it crosses the bifurcation of the common iliac artery. In patients who have undergone previous surgery or those with severe ureteral distortion, the ureter may be confused with other structures such as the gonadal vein. Careful dissection and aspiration with a small needle may be helpful in such cases. Once identified, the ureter is freed by blunt and sharp dissection with abundant soft tissue left surrounding the structure. It is essential to avoid damage to the ureteral adventitia because this may lead to ischemia and poor healing of the anastomosis. In cases in which the ureter has been surgically transected or completely divided by a penetrating knife or gunshot wound, both ends of the ureter must be identified.

In patients with ureteral strictures, the narrowed segment is excised after the ureter has been well mobilized both proximally and distally. It is important to remove all damaged tissue and to perform the anastomosis with healthy, well-vascularized ureter. After removal of the strictured area, stay sutures of 4-0 or 5-0 chromic catgut or absorbable synthetic suture, such as Vicryl or Dexon, are placed on each end of the ureter. It is essential that the anastomosis be performed without tension, and additional ureteral length can be obtained by mobilization of the kidney. The ureteral ends should be transected obliquely to allow for a wide-mouthed anastomosis. In addition, spatulation of each end of the ureter 180 degrees apart over a length of 2 to 4 mm may also facilitate the repair. Alternatively, a fishmouth or Z-plasty anastomosis can be performed, although these are used less commonly. In patients with high-velocity missile injuries to the ureter, extensive debridement of the ureteral ends should be performed because the degree of tissue devitalization is often underestimated at the time of surgery.

Once the ends of the ureter have been prepared, two sutures of 4-0 or 5-0 Vicryl or Dexon are placed through the apex of the spatulated area on one end and out the middle of the nonspatulated area on the other end. The knots should lie outside the ureteral lumen. These two initial sutures should be located 180 degrees apart and are held to facilitate the completion of the anastomosis. Running or interrupted sutures are placed approximately 2 mm apart on one side of the anastomosis, and the holding sutures are then rotated to help expose the opposite side. A double-pigtail stent may then be placed by initially passing the guide wire into the bladder and then threading the stent over the wire. The guide wire is then removed. In order to assure proper distal positioning of the stent, have an assistant fill the bladder through the urethral catheter with saline mixed with an ampule of indigo carmine. Visualization of blue-stained solution at the level of the anastomosis assures that the stent is in the bladder, except in unusual cases of preexistent vesicoureteral reflux. The guide wire is then passed proximally into the renal pelvis, and the stent is threaded over the opposite end of the wire, which is brought out through a side hole in the stent.

The stent is then passed proximally until it is straightened in the ureter, and the wire is removed. The anastomosis is completed with interrupted or running sutures. If the repair is tenuous or in patients who have previously received radiation therapy, the ureteral anastomosis may be wrapped with omentum to facilitate healing. This may also be helpful in patients with associated injuries to the bowel or pancreas or those in whom a vascular graft has also been placed. A closed suction drain is placed lateral to the anastomosis and brought out through a separate stab incision before closure of the abdomen. The stent may be left in place for 2 to 4 weeks.

Psoas Hitch Procedure

The psoas hitch procedure is the simplest method for substitution of the lower third of the ureter.5 With this technique, the bladder can be mobilized in a cephalad direction to a level well above the bifurcation of the iliac vessels. In most cases, adequate mobilization of the bladder can be achieved to avoid the need for a technically more difficult and less often successful Boari flap procedure (see below). The choice of incision is based on surgeon preference, and options include a lower midline, Pfannenstiel, or suprapubic V approach. The ureter is initially identified and carefully dissected at or above the crossing of the common iliac vessels. It is generally best to approach the ureter at a level above the site of obstruction and then proceed distally after encircling the uninvolved ureter with a small Penrose drain or vessel loop. Care is taken to avoid damage to the ureteral blood supply. The ureter is sharply divided at or below the pelvic inlet, based on the extent of ureteral pathology, and a stay suture is placed. The distal ureteral stump is ligated with a 2-0 chromic catgut suture.

After the ureter is dissected, the bladder is mobilized to allow it to be hitched to the psoas muscle. The peritoneum is dissected from the dome of the bladder and the space between the rectum and bladder is opened. The superior and middle vesical pedicles are ligated and divided on the contralateral side, leaving the inferior vesical pedicle as the only attachment on the contralateral side of the bladder. The blood supply on the ipsilateral side rarely needs to be divided to provide sufficient upward mobilization of the bladder. The initial incision into the bladder is then made transversely across the middle of the anterior wall at the level of its maximum diameter. The bladder should be opened slightly more than halfway around. A common mistake is to open the bladder over too short a distance, which limits the cephalad displacement that can be achieved. The bladder is then brought to the psoas muscle at a point superior and lateral to the bifurcation of the iliac vessels by placing two fingers into the fundus of the bladder. The ureter can then be gently pulled toward the bladder to determine if an adequate anastomosis without tension can be achieved. If further length is needed, the kidney can be mobilized downward, or the contralateral endopelvic fascia can be opened. Once it is determined that an adequate anastomosis can be performed, the bladder is fixed to the psoas minor tendon or psoas major muscle using three to six 2-0 Vicryl sutures. These sutures should be carefully placed to avoid injury to the genitofemoral nerve. In addition, femoral neuropathy has also been reported after the psoas hitch procedure, and care should be taken not to place the tacking sutures too deeply into the muscle.

Before sutures are tied between the bladder and psoas muscle or tendon, the site of the ureteroneocystostomy should be selected. It is important to anastomose the ureter to an immobile portion of the bladder base so that intermittent obstruction of ureteral drainage does not occur as the bladder fills to varying degrees. The ureter is drawn through the bladder wall by passing a small clamp from inside the bladder and grasping a stay suture that has been placed through the distal ureter. The ureter should not be trimmed until it has been brought into the bladder, and it is clear that there is sufficient length to perform a tension-free anastomosis. If there is adequate ureteral length, a tunneled, nonrefluxing anastomosis may be performed. However, a direct, refluxing ureteroneocystostomy is also acceptable in most adults. The anastomosis is performed using interrupted 4-0 or 5-0 Vicryl sutures after the ureter has been spatulated on its anterior surface. At the distal apex of the anastomosis, one to three sutures are placed deeply into the bladder muscle and then through the tip of the ureter. The remaining sutures are taken through bladder mucosa and the ureter. The ureteral adventitia is loosely attached to the bladder wall where it exits using two or three 4-0 Vicryl sutures placed longitudinally.

An 8-Fr infant feeding tube or double-pigtail stent is then placed into the renal pelvis. The feeding tube is generally preferred because it can be brought out the anterior bladder and body wall through a stab incision. This allows for direct monitoring of drainage; the tube can be irrigated if it becomes obstructed, and the need for stent removal by cystoscopy is avoided. The feeding tube is loosely tied to the bladder mucosa adjacent to the anastomosis using a 5-0 chromic suture to avoid inadvertent displacement during the perioperative period. A suprapubic tube can be placed if desired, although a urethral catheter is generally adequate. The bladder is closed vertically in watertight fashion using two layers of 2-0 and 3-0 chromic catgut. A Penrose or closed suction drain is positioned laterally in the perivesical area. A cystogram and ureterogram are performed through the externally draining stent 7 to 10 days postoperatively to assure adequate healing.

Boari Flap Procedure

A bladder flap operation is rarely needed in patients with distal ureteral strictures and/or fistulas. In most cases, a psoas hitch procedure is adequate to replace the lost or damaged section of ureter. If a Boari flap is necessary, the choice of incision, dissection of the ureter, and initial bladder mobilization are identical to that described above for patients undergoing a psoas hitch ureteral reimplantation. When renal and ureteral mobilization, as well as the psoas hitch, are inadequate to allow a tension-free anastomosis to be performed, a bladder flap may be used. A psoas hitch should accompany the Boari flap to help decrease the length of flap that is needed.

Once the bladder has been mobilized and a psoas hitch performed, the site for the base of the flap should be identified on a fixed portion of the bladder, and the length of flap needed should be measured. A stay suture is placed at each end of the base of the flap, which should be approximately 4 cm wide. In order to assure adequate vascularity of the flap, the base should be wider if a longer flap is necessary. A stay suture is placed at each end of the apex of the flap, which should be 3 cm in width. If needed, a longer flap can be created using a spiral incision in the bladder. The flap should be developed by incising the bladder wall using electrocautery. The flap is then brought up to the ureter, which may be anastomosed to the apex using either a direct or tunneled technique. A 5- to 8-Fr infant feeding tube or double-pigtail stent should be placed. The bladder is closed, and the flap is rolled into a tube over the stent using a running 3-0 chromic catgut suture on the mucosa and interrupted 2-0 chromic catgut suture on the muscularis and adventitia. A perivesical drain is placed, and radiographic evaluation of the bladder and ureter is performed before the ureteral and urethral catheters are removed.

OUTCOMES

Complications

Prolonged urinary drainage is the most common problem in the early postoperative period in patients undergoing ureteroureterostomy, psoas hitch reimplantation, or the Boari flap procedure. In most cases, the leak will seal as long as adequate drainage of the upper urinary tract and bladder is assured. If there is concern regarding the site of leakage, a cystogram and/or ureterogram may be obtained. If an externally draining ureteral catheter is not present, an intravenous pyelogram may be helpful. Rarely, injury to the contralateral ureter may occur, and this possibility should be considered in patients with unusual or complicated problems. In patients with unexplained fever and/or sepsis, the presence of an undrained urine collection (urinoma) should be considered. Ultrasonography or CT scans may be useful in such cases both in establishing the presence of a fluid collection and guiding percutaneous placement of a drainage catheter.

The most significant long-term risk associated with the surgical repair of ureteral strictures is recurrent obstruction. Although some patients may present with flank pain and/or infection, others will remain asymptomatic, presumably because of the slow development of a recurrent stricture. For this reason, all patients should undergo radiographic evaluation of the upper urinary tract 6 to 12 weeks following stent removal and again 6 to 12 months after surgery. Risk factors that increase the likelihood of recurrent obstruction include previous ureteral and bladder surgery, a history of pelvic or lower abdominal irradiation, devascularization of the ureter at the time of surgery, and an anastomosis performed under tension. If detected early, recurrent strictures may respond favorably to balloon dilation and/or endoureterotomy, and these procedures should be considered before resorting to open surgical revision.

Results

Surgical repair of ureteral strictures is associated with excellent long-term success rates. The most important factors responsible for these results include selection of the most appropriate surgical technique, based on the site and length of stricture. In addition, consideration of preoperative issues, such as a history of irradiation or prior bladder and ureteral surgery, is also essential to avoiding recurrent obstruction. In general, as long as a tension-free anastomosis can be performed using well-vascularized ureteral tissue, the long-term success of open surgical repair of ureteral strictures should be assured in the vast majority of patients.

Ureteral Reconstruction

Partial or complete ureteral replacement remains a challenge for the urologist. The maintenance of kidney function is the primary goal of this procedure. The crucial problem with ureteral replacement is that in most cases several surgical procedures and frequently radiotherapy have been performed beforehand, and kidney function is usually already impaired at the time of intervention. Therefore, standardized recommendations may not be applicable, and the approach must be tailored according to the individual situation.

Several ureteral substitutes have been proposed, including blood vessels, fallopian tubes, and the appendix. Nevertheless, all these tissues or organs and the corresponding procedures are correlated with a significant morbidity, including recurrent infection, stone, or stricture formation, with a worsening of kidney function in many patients. Because larger series have rarely been reported, the results and morbidity of the various procedures differ significantly.

DIAGNOSIS

Because partial or complete ureteral replacement with small bowel is always a secondary treatment, every attempt should be made to preserve as much ureteral length as possible. Antegrade and retrograde pyelography will usually provide sufficient information regarding the length and degree of the stricture, but in selected cases ureteroscopy may provide valuable information. In patients treated for malignant disease, tumor recurrence must be excluded by CAT scan or MRI. Kidney function needs to be examined by preoperative isotope scintigraphy to ensure it is appropriate because with severely decreased function, the results of ureteral reconstruction are poor. Furthermore, preoperative isotope scintigraphy provides a baseline for follow-up examinations after surgery.

INDICATIONS FOR SURGERY

Partial or complete ureteral replacement with small bowel is indicated as a second-line treatment after failure of ureter-sparing surgery.

ALTERNATIVE THERAPY

Every attempt should be made to maintain the ureter. Depending on the length and location of the stricture, the preoperative evaluation should demonstrate whether ureter-sparing approaches are viable alternatives to ureteral replacement. Because of their relatively low morbidity, endoscopic procedures should be considered first. A success rate of only 50% to 70% with endoscopy necessitates further measures in a number of patients.

Autotransplantation carries several disadvantages and risks, especially after previous surgery and/or radiotherapy and impaired renal function. Although no prospective study addressing this question has been conducted, ureteral replacement with small bowel seems preferable in this patient population.

SURGICAL TECHNIQUE

Preparation

Bladder outlet obstruction is a contraindication for ureteral replacement with small bowel and, therefore, must be excluded. If necessary, urodynamic examination of the lower urinary tract should be performed. In patients with obstructive prostatic hyperplasia, prostatectomy should be performed before ureteral replacement. Preoperative bowel preparation should be performed as in patients undergoing bowel surgery for other urologic procedures . A nephrostomy tube is already in place in most patients or should be inserted during surgery.

Position and Incision

If both sides are affected, a midline incision or a right paramedian incision is recommended. If only one ureter is to be replaced, a lateral flank position (twist position) with the table flexed and the chest positioned at about a 60-degree angle to the table is preferable. Allow the pelvis to fall back. The incision starts between the 11th and 12th ribs, continues semiobliquely nearly to the midline, and ends as a paramedian incision to the os pubis. The peritoneum is opened, and the small bowel packed away.

For a right ureteral replacement, mobilize the cecum and divide the lateral attachments of the ascending colon . Mobilize the ascending colon as for an extensive retroperitoneal lymph node dissection. Mobilize the peritoneum from the bladder dome and the lateral aspect of the bladder. Carefully determine the length of intestine required for ureteral replacement.

Select an appropriate segment from the preterminal ileum. Consider adequate vascularization of the chosen segment . It is mandatory to select the sites of transection to permit a dissection deep enough for the proximal end to reach the renal pelvis and the laborial or distal end to reach the bladder. The bowel is divided, and the continuity restored, as described for the ileal conduit. The mesenteric defect is then closed with 3-0 vicryl to prevent internal herniation. The excised bowel segment is irrigated with saline solution until the effluent is clear.

The mesentery of the ascending colon is incised depending on the location of the mesentery of the ileal segment, and the ileum is passed into the retroperitoneal space. The ileal segment is then rotated to place the distal end near the bladder and the proximal end close to the renal pelvis or the ureter. The defect in the colonic mesentery is closed using 3-0 vicryl sutures. In this closure, it is important to avoid compression of the ileal mesenteric vessels.

Pyeloileal Anastomosis or Ileoureteral Anastomosis

In cases of partial ureteral replacement, the proximal opening of the ileal segment is closed with a running 3-0 chromic catgut suture. Before the anastomosis, the ureter is stented with a 6- to 9-Fr catheter held in place with a 4-0 catgut suture. The ileoureteral anastomosis of the spatulated ureter is performed end to side with a single-layer technique with either a running suture or interrupted sutures of 4-0 or 5-0 vicryl sutures.

For complete ureteral replacement, the proximal opening of the ileal segment is brought to the renal pelvis. The renal pelvis is opened widely to permit end-to-end anastomosis to the ileum. In case of a small renal pelvis, it may become necessary to taper the ileum by closing the proximal opening of the ileum partially on the antimesenteric side. The pyeloileal anastomosis is performed in a single layer with either a running suture or interrupted sutures of 3-0 or 4-0 chromic catgut. Because a nephrostomy tube is already in place, it is not necessary to stent the ileal ureter.

Ileocystostomy

We prefer to perform ileocystostomy on the posterior bladder wall about 1 to 2 cm craniolaterally to the native ureteral orifice to avoid extensive angulation and possible obstruction of the ileum during bladder filling. The anastomosis is performed in a double-layered technique with a running mucosa-to-mucosa suture (4-0 vicryl) and interrupted seromuscular–detrusor muscle sutures of 3-0 vicryl . Except for the fixation of the mutual stent, vicryl may be replaced by chromic catgut.

OUTCOMES

Most reports on ureteral replacement with ileum are case reports including only a few patients. Because no larger contemporary series are available for review, the assessment of the outcome of this procedure is difficult.

Complications

No data are available regarding perioperative complications of ureteral replacement with ileum. It is assumed that the complications are similar to those observed after surgery for an ileal neobladder. In patients with partial replacement of the ureter, strictures at the ureteroileal anastomosis presumably occur at a similar frequency as in patients after an ileal conduit. Ileoureteral reflux is observed in 50% to 85% of the patients depending on whether the bladder is filling or emptying. The significance of this reflux is unknown.

Hyperchloremic metabolic acidosis requiring treatment should be anticipated in approximately 50% of patients. Careful follow-up examination including routine measurements of base excess, serum bicarbonate, and pH are mandatory.

This group of patients is certainly prone to urinary tract infections (UTI). In 30% to 100% of the patients, UTI will occur. Regular urinalysis and appropriate antibiotic treatment in cases of proven UTI are required.

Results

The results of ureteral replacement with ileum are difficult to assess because this form of surgery is not standardized, and patient selection varies considerably between the different series. Furthermore, the objective goals of the procedure are not clearly defined. The values of BUN or serum creatinine that have been reported in some series are probably not sufficient to define the outcome in patients with bilateral kidneys. Dilation of the upper urinary tract is another parameter used in the literature. However, it is difficult to discriminate between persistent dilation despite reduction of ureteral obstruction and those cases in which dilation persists as a result of obstruction and/or reflux after surgery. To date, no reports including diuretic isotope scintigraphy have been published.

In the few studies with long-term results, a favorable outcome has been reported in up to 85% of the cases. This does not include patients with impaired renal function with serum creatinine levels greater than 2.0mg/dl. In this population, fewer than 50% will benefit from ureteral replacement.

In general, to avoid metabolic problems, the length of the ileal segment should be as short as possible. Hinman and Oppenheimer, however, have shown in the dog that an ileal segment greater than 18 cm will block the transmission of 20 to 30 cm H2O pressure. These experiments also form the basis for the introduction of a nontubularized ileal segment in modifications of the neobladder. Clinical reports on ureteral replacement with ileum apparently do not support this experimental observation, however, because cystoileal reflux and/or ileal–ureteral reflux can be observed in some patients at an intravesical pressure of only 3 to 8 cm H2O. It is questionable whether a pressure of less than 20 cm H2O can lead to damage to the upper urinary tract. So far, no clinical data including simultaneous measurement of intravesical and intrapelvic pressures are available. In addition, long-term results seen after ureteral replacement with ileum and experiences with the intestinal neobladder suggest that some protection of the upper urinary tract may be afforded by the ileal segment. We therefore prefer to use a bowel segment at least 15 cm in length.

In summary, ureteral replacement with ileum is a feasible technique that carries considerable perioperative and long-term morbidity and should therefore be considered only as a second-line treatment in selected patients.

Ureterolithotomy

For centuries, “cutting for stone” was synonymous with urology, and just over a decade ago it still made up at least one-fourth of the surgical activity in the field. The development of extracorporeal shockwave lithotripsy (SWL) and endoscopic stone surgery shattered this tradition, and the change becomes most obvious in the indications for ureterolithotomy. Once one of the most common procedures in urology, it all but vanished in the last years in spite of the fact that almost 50% of all patients with upper tract urolithiasis coming to treatment today have stones impacted in the ureter.8 Specifically, the development of ultrathin semirigid and flexible ureteroscopes with effective laser, electrohydraulic, or ballistic lithotripsy laparoscopic ureterolithotomy, and third-generation lithotriptors with ultrasonic and fluoroscopic stone localization and small focal zones, which can be pinpointed onto ureteric stones even in infants, have closed the last gaps in the spectrum of minimally invasive therapy of ureteric calculi.

DIAGNOSIS

With less invasive methods of stone removal, a sudden change of the position of the calculus can be met without major problems, even when noticed only during the intervention. In open stone surgery, this could result in a catastrophe, with failure to remove the stone and the need for further procedures. The time-honored rule of precise delineation of the size, number, and shape of all calculi and their topography within the collecting system before an incisional procedure remains as valid as ever.

In general, ureteric stones can be located precisely with a good intravenous pyelogram with appropriate oblique, delayed, and postvoiding films. To differentiate radiolucent stones from tumors, clots, or papillae, a nonenhanced abdominal computed tomography may be helpful, but significant stones may be missed with this technique, even when 5-mm cuts are obtained at the level of interest. Retrograde ureterography and, if needed, diagnostic ureteroscopy immediately before surgery will clarify the situation. Urinary infection should always be treated with appropriate antibiotics before surgery. With severe obstruction and any evidence of infection, it is prudent to first drain the kidney by percutaneous nephrostomy for about 48 hours until any pathogen is cultured and adequately treated.

A plain abdominal roentgenogram is always obtained immediately before surgery, before anesthesia is initiated. Even the largest calculus seemingly incapable of changing its position may do so, and this may necessitate a completely different surgical strategy.

INDICATIONS FOR SURGERY

In general, ureterolithotomy today becomes necessary only where ESWL or endoscopic techniques fail. Usually, these failures are concomitant with a complication of previous therapeutic interventions, in particular endoscopic manipulation. Urinary extravasation, an impacted ureteral basket, ureteral avulsion, and an obstructing stone are the typical scenarios. At the author’s institution, incisional surgery was required in only six of 3,123 patients subjected to a therapeutic intervention to remove ureteric stones in a 7-year period. Two patients had suffered ureteric avulsion, one patient had a basket trapped around a stone, in two patients stones could not be reached endoscopically, and one patient, pregnant in the fourth week of gestation, required rapid removal of a very large stone impacted in the lumbar ureter. Stones can of course also be trapped above congenital or acquired ureteric strictures. Where these require surgical correction, the stone is removed at the time of reconstructive surgery, but the underlying pathology dictates the surgical strategy and technique.

ALTERNATIVE THERAPY

Alternatives to open ureterolithotomy are observation, which is indicated in small (<5 mm) stones with no signs of sepsis or extravasation, or one of many forms of minimally invasive surgeries including SWL, endoscopic extraction (via cystoscope, nephroscope, or ureteroscope), percutaneous stone surgery including laparoscopic removal, endoscopic destruction of the stone, or, in certain stones such as struvite or uric acid, chemolysis.

SURGICAL TECHNIQUE

In the difficult situations in which ureterolithotomy is still indicated today, ample exposure is usually needed. Many of the minimally muscle-splitting incisions designed for specific stone situations in the past, such as the Foley incision through the lumbar triangle for high ureteral stones, the gridiron incision for midureteral stones, and the transvesical or transvaginal approach for intramural stones, have become obsolete. They provide only limited access to a small segment of the ureter and should be avoided in difficult situations, especially if the surgeon has limited experience with them.

The entire proximal half of the ureter is best approached by a modified 12th-rib supracostal incision, which is carried anterior to the tip of the rib (anterior supracostal incision). Large, firmly embedded stones in the area of the ureteropelvic junction can be removed with minimal morbidity through a posterior lumbotomy. The distal half of the ureter is best reached by a suprainguinal extraperitoneal access.

Anterior Supracostal Approach

The patient is placed in a lateral jackknife position. The skin incision runs parallel to the upper margin of the 12th rib and distally in the line of the rib. Its length depends on the precise nature of the procedure. For a standard ureterolithotomy in the lumbar ureter, an incision along the distal half of the rib extending 5 to 7 cm into the abdominal muscles suffices. It can be extended anteriorly as required to reach lower stones and posteriorly so that the entire kidney can be mobilized if necessary.

After the subcutaneous fat has been divided, the fibers of the abdominal musculature are incised with cutting diathermy immediately beyond the tip of the 12th rib . The transversus abdominis muscle blends here with the deep leaf of the thoracolumbar fascia and should be divided along the same line. The second and third fingers of each hand are now used to sweep the peritoneum off the underside of the abdominal wall muscles before the muscle incision is extended medially as required. The incision should be kept strictly in line with the extension of the 12th rib so as to keep well clear of subcostal vessels and nerves. Once it has been carried as far medially as needed, dissection can proceed in the opposite direction along the 12th rib. The latissimus dorsi and intercostal muscles are divided by diathermy moving backward along the upper margin of the rib. As the rib is progressively mobilized, the insertion of the diaphragm and the pleural reflection come into view. The subcostal nerve is carefully preserved as the diaphragm is divided flush with its insertion to the abdominal wall. The pleura is pushed away by blunt finger dissection. Depending on the degree of exposure needed, dissection of the 12th rib may proceed up to the vertebral column. After division of the costovertebral ligament, the 12th rib can be swung outward like a door. A rib retractor or modified Wickham ring retractor permits excellent exposure. The peritoneum is retracted medially, and the ureter is exposed in the retroperitoneal space below the lower pole of the kidney, where it already lies outside of Gerota’s fascia. If the stone lies higher, Gerota’s fascia is incised, and the ureter is followed upward to the stone, tilting the kidney anteriorly.

Posterior Lumbotomy

The proximal third of the ureter (and renal pelvis) can be reached with minimal muscle trauma through the thoracolumbar fascia lateral to the sacrospinalis and quadratus lumborum muscles. In terms of postoperative pain and morbidity, this incision is superior to all other lumbotomies. The 12th rib above and the iliac crest below limit exposure of the kidney and midureter. Therefore, the ideal stone for this approach should be one that is firmly embedded in the upper third of the ureter or at the ureteropelvic junction.

The patient is placed in the lateral recumbent position, with approximately 15-degree anterior rotation, and the table is flexed at the tip of the 12th rib. Simultaneous bilateral surgery may be performed with the patient prone.10 The most commonly used access6 utilizes an oblique skin incision parallel and 3 cm lateral to the erector trunci, from the 12th rib down to the iliac crest . Fat and subcutaneous tissue are divided until the lateral fibers of the latissimus dorsi are exposed. The muscle is split to expose the subjacent 12th rib. The posterior leaf of the lumbodorsal fascia is divided in the line of the skin incision, and the lateral margin of the sacrospinalis muscle so exposed is retracted medially. The middle layer of the thoracolumbar fascia is then seen and incised somewhat lateral to the fleshy belly of the sacrospinalis muscle. The lateral border of the quadratus lumborum now comes into view and may be retracted with a hook toward the vertebral column. The deep layer of the thoracolumbar fascia is exposed and opened, care being exercised to spare the twelfth subcostal nerve and the iliohypogastric nerve coursing obliquely and laterally on its deep aspect. Gerota’s fascia is incised, and the perirenal fat is divided by blunt dissection to expose the renal pelvis. In a modification,4 the incision runs from a point three fingerbreadths lateral to the dorsal spines to the junction of the middle and anterior third of the iliac crest. The lower parts of the latissimus dorsi and the serratus posterior inferior and the costovertebral ligament are divided, and the middle and deep leaves of the thoracolumbar fascia are split. A Finochiettio rib retractor is inserted to expose the field.

Suprainguinal Approach

The distal half of the ureter is best approached by a suprainguinal extraperitoneal incision. The patient is in a prone position with the ipsilateral flank supported by a cushion. Depending on the exposure needed, the skin is incised in an oblique direction along a line from the pubic tubercle upward to a point about two fingerbreadths anterior to the superior iliac crest. The external oblique abdominal muscles and the transversalis fascia are divided with cutting diathermy in the same direction. After ligation and transection of the epigastric vessels, the peritoneal fold is reflected medially to expose the ureter. It can be identified without problems either where it crosses the common iliac artery or where it runs immediately below the obliterated umbilical artery. The latter structure is routinely divided and ligated.

With stones in the distal third of the ureter, a urethral catheter should routinely be placed to keep the bladder empty during the procedure.

Ureterolithotomy

Once the ureter is identified, the stone is located by palpation, carefully avoiding any milking movements that could dislocate it. Without mobilizing the ureter, it is snared with vessel loops just above and below the stone. The ureteral wall is incised with a scalpel directly onto the stone in a longitudinal direction. As soon as the mucosa is opened, the incision is enlarged with angulated scissors so that the stone can be extracted with nerve hooks. The ureter is then probed in both directions with a soft ureteral catheter to ascertain complete stone removal and is irrigated copiously.

With the slightest possibility of obstruction, extravasation, or difficult closure, a self-retaining stent is inserted, taking care to position the two ends properly in the bladder and renal pelvis. A standard double-J stent can usually be inserted from the ureterotomy. Because the distal segment of the ureter is, in general, more difficult to negotiate, especially after previous endoscopic maneuvers, it is intubated first. By reversing the stent, i.e., advancing the blunted, closed tip of the stent, which is otherwise advanced up to the kidney, down to the bladder, the ureterovesical junction can usually be passed. The guide wire is then removed, and the stent is advanced further down the ureter until it almost disappears in the ureterotomy. Its upper end can now be straightened and advanced up into the renal pelvis. If the proximal corner of the ureteric incision is elevated with a nerve hook during this procedure, this rarely causes problems. It is important to note the markings on the stent for correct placement. To ascertain that the distal end of the stent is in the bladder, indigo carmine can be administered through the urethral catheter; it should reflux freely into ureter and stent. Intraoperative fluoroscopy offers a more elegant alternative.

If any problems are encountered in intubating the ureter, the ureter should be inspected with a thin flexible ureteroscope inserted through the ureterotomy to avoid missing an additional ureteric stone. Any additional stone is either removed through a second ureterotomy or, preferably, by endoscopic lithotripsy. A guide wire is then advanced under endoscopic control down into the bladder, and the stent is inserted over it. Problems in the ureter proximal to the incision are handled in a similar manner, but this segment of the ureter is usually dilated and therefore easier to engage.

Whenever self-retaining stents are used, the patient should routinely be subjected to a flexible cystoscopy at the end of the procedure to be certain the vesical end of the stent is indeed in the bladder.

The ureterotomy is closed with one to three interrupted sutures of 5-0 chromic catgut. The sutures should grasp only the superficial seromuscular layers to approximate the ureteric wall rather than achieving watertight closure. If placed too tight or too deep, they may compromise ureteric blood supply and promote leakage. Obstructing sutures have a similar effect. Whenever closure is difficult because of scarring, it is safer not to close the ureterotomy at all and to stent the ureter. The site of the ureterotomy should be covered with retroperitoneal fat or an omental flap.

Every ureterotomy has to be drained precisely. We routinely use a No. 21 tube drain of silicone rubber with one or two side holes, which is brought out through all layers of the abdominal wall via a separate stab incision lateral to the lower end of the incision. The tip of the drain must be in a dependent position to the ureter-otomy, but not in the immediate vicinity or in contact with the ureter. If the ureter was approached transperitoneally, it should be drained through the retroperitoneum. The wound is closed in layers with absorbable suture material.

Postoperatively, patients are mobilized within 24 hours, with analgesics administered generously as needed. Antibiotics are given only with proven infection and according to appropriate sensitivity testing. The patients are well hydrated, with intravenous fluid replacement in the first two postoperative days. Especially after lumbar ureterolithotomy, bowel function may take 2 to 3 days to normalize, and an enema and even cholinergic agents may be needed.

OUTCOMES

Complications

The wound drain should not be removed before the fourth or fifth postoperative day. Prolonged discharge of urine from the drain is usually caused by impaired drainage caused by a missed calculus, clot, or ureteral obstruction. Occasionally leakage results from incorrect positioning of the tip of the drain immediately adjacent to the ureterotomy. Careful retraction of the drain by 1 to 2 cm then rapidly dries up the wound. If urine leaks from the drain longer than 5 days, an indwelling ureteric stent should be inserted. Permanent urinary fistulas are extremely rare and, when present, almost always result from obstruction below the level of surgery.

Urinary extravasation may cause severe problems if the wound is improperly drained because the drain either was not placed in a dependent position or was removed too early. Urinoma formation is usually heralded by fever and flank pain but may occur inconspicuously. A high degree of suspicion should therefore be directed toward this potential complication. Any unexplained fever, flank pain, or delayed healing should be investigated immediately by ultrasonography, an antegrade pyelogram (if the nephrostomy is still in place), or excretory urography with delayed films. The situation can usually be corrected by draining the kidney with an indwelling stent or a nephrostomy and by draining the urinoma percutaneously.

In the pre-SWL era, the most frustrating complication of any stone operation was the retained calculus. Although the availability of SWL should still not be an excuse for a less careful attempt at complete stone removal once open surgery is decided on, retained stones can be treated in this manner highly successfully some days after the operation. Likewise, if a calculus below the level of surgery was overseen and resulted in obstruction and/or extravasation, it can be treated endoscopically or by SWL, just as any other ureteral stone in the immediate postoperative period.

Pyelolithotomy

Pyelolithotomy is an operation that is now uncommonly performed. The advent of percutaneous nephrolithotomy with contact lithotripsy (PCN) and extracorporeal shockwave lithotripsy (ESWL) has reduced the indications for pyelolithotomy, which is a considerably more invasive procedure.

It is interesting to note that when surgeons were first performing pyelolithotomy, there was considerable disagreement as to which was the preferred approach to stone removal. Clearly, people liked to argue even then, when one had to do so mainly by letter or book rather than by published article, conference, phone call, telefax, or Internet. Vincenz Czerny probably performed the first pyelotomy, with Sir Henry Morris performing a similar operation to remove a stone in the same year, 1880.

Further developments took place over the years, with many incisions through the thorax and abdomen being introduced, and then many incisions through the renal pelvis and renal parenchyma following. The introduction of radiologic visualization of the kidney completed the picture. It is clear, however, that the landmark contributions to open surgical removal of stones from the kidney were made in recent years by Gil Vernet, Marshall, Boyce, and Wickham.

DIAGNOSIS

The usual presenting symptom for renal calculi is radiating colicky flank pain, usually associated with hematuria. Larger stones, however, may be relatively asymptomatic or present with persistent infection and/or hematuria. The diagnosis of renal calculi is generally made radiographically. Currently, the most common radiologic method of diagnosis is via a KUB and intravenous pyelography, though some centers are investigating the use of ultrasound and computed tomography.

INDICATIONS FOR SURGERY

Although its use is limited because of this relative invasiveness, it sometimes has a role to play, particularly when the stone burden is large or when problems with body shape or habitus prevent percutaneous access to renal calculi or focusing on the stone by ESWL.

ALTERNATIVE PROCEDURES

Alternatives to pyelolithotomy include ESWL, percutaneous stone extraction/destruction, ureteroscopic stone destruction, chemolysis (uric acid or struvite stones), or anatrophic nephrolithotomy.

SURGICAL TECHNIQUE

Surgical Access to the Kidney

The urologist may consider five possible approaches to the kidney for open stone removal:

1.Flank approach

a. Subcostal

b.Costal (11th or 12th rib)

c.Intercostal (above the 11th or 12th rib)

2.Transabdominal

3.Posterior lumbotomy

The advantages of the flank approach are described after I explain why, in my opinion, the transabdominal and posterior lumbotomy incisions are rarely required in what is, after all, a relatively uncommon procedure. Transabdominal and transperitoneal access may be required if the patient has spinal deformities and very occasionally after several previous surgical procedures. It is the most invasive of all the approaches, and recovery is delayed postoperatively. It should not be used as the standard approach for pyelolithotomy.

The posterior lumbotomy incision has its advocates, particularly because postoperative pain is minimal, and recovery is quick with shortened hospital stay. The patient is placed either in the lateral decubitus position or prone, with pillows under the upper abdomen. The incision is made about 2.5 cm lateral to the erector spinae muscle from the 12th rib down to the superior border of the iliac crest. The incision is extended through fat and fascia and then through the aponeurotic fibers of the latissimus dorsi. If further access is required, a small part of the 12th rib can be removed, or the lower end of the incision can be curved inferolaterally along the iliac crest. The advantages of this approach have been listed above, but a major disadvantage is that access to the upper pole is difficult, as is access to the ureter below its upper portion. I feel that when an open operation is being performed today for stone removal, it is unlikely to be a simple procedure but rather a more complex one for which greater exposure may be required than is afforded by this incision.

Of the flank incisions, I prefer the costal route of access. The subcostal approach is usually too low for renal surgery of any complexity. In considering the incision, it is worth remembering that although it is possible to be too low, preventing complete visualization of each step of the subsequent dissection, it is never possible to be too high. For this reason, the skin incision should be made on top of or superior to one of the ribs. In this way, damage to the subcostal or infracostal nerves is prevented, and the likelihood of a wound hernia is minimized. The intercostal approach requires division of the posterior costotransverse ligament in order to allow the rib to “bucket-handle.” Otherwise, access between the ribs may be suboptimal, and, indeed, the ribs may break when spread apart by a self-retaining retractor.

When an incision is based on a rib (the costal approach), removal of the end of the rib is required. A careful review of the preoperative x-ray films and examination of the patient with the table broken will clarify whether the 12th, 11th, or even, on some occasions, the tenth rib should be the line of the skin incision. The patient should be placed on the table in the lateral decubitus position with the side to be operated on facing directly upward. The patient can be stabilized by inserting three T-pieces along the sides of the table or by fastening tape to the upper thorax and over the hip, thereby fixing the patient on the table. The table is broken, thus opening up the space between the ribs and the iliac crest, and then tilted 20 degrees laterally toward the surgeon. The surgeon and assistant are both positioned behind the patient, and the surgeon can sit down throughout the procedure.

The incision is made in the skin over the distal 6 cm of the rib, extending medially for another 10 to 12 cm. It should be deepened down to the rib before any muscles are cut. Once the rib can be clearly seen, the skin, fat, and fascial layers are retracted on both sides to give a better view. The intercostal muscles are divided above the rib with a knife until the diaphragm can be seen; this is then divided with a scissors until the distal 6 cm of rib is cleared. Then the same approach is made below the rib, with the intercostal muscles being divided if the 11th rib is being used, or the latissimus dorsi if it is the 12th. The diaphragm will not be divided inferior to the rib, but it is advisable to identify the nerve bundle and sweep it inferiorly. Once the rib has been dissected free of the surrounding muscles, the distal 6 cm is removed with a rib shears. I do not approach the rib subperiosteally, as leaving the periosteum does not confer any advantage.

Once the rib has been removed, Gerota’s fascia can be visualized, and through it the kidney can be palpated. Two fingers should be introduced under the abdominal muscles through this incision, and the peritoneum swept away from their under surface. The incision is then deepened through the external oblique, internal oblique, and transversus abdominus muscles using the knife or cutting diathermy. The incision should not extend as far medially as the rectus sheath.

At this stage, a body wall retractor should be inserted, preferably the Wickham retractor, which is self-retaining and shaped to the body wall. Gerota’s fascia is then opened, and this incision is extended upward toward the diaphragm and inferiorly toward the pelvic brim. The peritoneum can then be mobilized medially away from the ureter, which is visualized exiting from the perirenal fat, and the ureter is encircled with a loop or tape. The perirenal fat is then grasped over the lateral border of the kidney, elevated by two Babcock forceps, and incised, revealing the capsule of the kidney. The degree of mobilization of the kidney required depends on how large the stone is. If full mobilization is required, it can be performed easily but should always be carried out by sharp dissection with a Metzenbaum scissors under direct vision. Remember that the main renal vein is always best accessed from anterior to the kidney (although there may be tributaries lying posteriorly). The main renal artery is best approached from above and posterior to the kidney, although there may be other branches, particularly an upper pole or lower pole branch directly from the aorta. The artery need not be isolated in the unusual situation that small stones are being removed, unless a parenchymal incision is being contemplated. When it is isolated, a loop or tape should be put around it.

In the case of surgical access after previous surgery and after many previous surgical procedures, great care must be taken. After incision of the muscles, the fascial and perirenal areas are likely to be greatly thickened and indurated. It is very helpful to isolate the ureter first (prestented if required) and to trace the ureter upward to the ureteropelvic junction. The kidney can then be dissected free from the surrounding tissues with the scissors. Care must be taken not to incise the renal capsule because considerable hemorrhage can occur under these circumstances. Because the kidney is likely to be encased in dense fibrous tissue, the perirenal anatomy will be difficult to define accurately, and upper and lower pole arteries can be damaged. In addition, identification of the renal artery can be somewhat more difficult; palpation of the tissues medial to the kidney will reveal its position.

Access to the Renal Pelvis

In general terms, it is preferable to open the renal pelvis posteriorly rather than anteriorly. This approach will avoid the renal vein, which often runs along the upper part of the anterior surface of the pelvis. Damage to the renal parenchyma can be avoided if only the renal pelvis is incised. The degree of dissection around the renal pelvis will not affect renal function.2 The subparenchymal and intrasinusal pyelotomy5 has made easier the removal of even the most complex calculi.

Simple Pyelolithotomy

This method of opening the renal pelvis would only be considered if the stone to be removed is only 1 to 2 cm in diameter in the renal pelvis or in a calyx, or if there were a number of such sized calculi in several calyces.

After opening Gerota’s fascia and the perirenal fat and putting a tape around the upper ureter, as described above, the amount of dissection in the region of the renal pelvis that is required is not extensive. The ureteropelvic junction and the pelvis itself should be clearly defined, but a subparenchymal dissection is not required unless the pelvis is intrarenal . After placing two stay sutures of 4-0 polyglycolic acid or chromic catgut, make a longitudinal incision in the renal pelvis using a scalpel. The incision must not extend through or into the ureteropelvic junction because of the risk of subsequent scarring.

When the urologist is certain that all stones have been removed, the pelvis should be closed with continuous 4-0 polyglycolic acid or chromic catgut suture. The attempt is to make the closure watertight, but even making the suture continuous does not guarantee this, so the peripelvic tissues should be drained.

Extended Pyelolithotomy

In most cases, the reason for performing open pyelolithotomy will be the complexity of the stone in the renal pelvis and its multiple extensions into the calyces. In many cases it will be possible to remove the stone completely by extending the dissection under the parenchyma and exposing the renal pelvis and calyceal infundibula in the manner described by Gil Vernet. In this way, incisions into the renal parenchyma can be avoided, thus reducing the potential for renal injury.

The anatomy of the renal hilum allows for extensive exposure of the renal pelvis, but care must be taken that the correct planes of dissection are adhered to. There is a thin layer of connective tissue extending from the renal capsule into the fat in the renal hilum and then onto the renal pelvis. This closes off the renal hilum, and it is this layer that must be incised in order to gain access to the infundibula in carrying out an extended pyelolithotomy. Once this layer of connective tissue has been incised, the dissection is continued by inserting specially designed retractors under the parenchyma. The dissection is carried out by inserting and spreading a fine scissors or by the use of a Küttner dissector. This dissection is carried out between the fatty layer in the hilum and the pelvis itself. If, mistakenly, the surgeon enters the layer between the fat and the parenchyma, considerable hemorrhage can be encountered because of many venous channels in this area.

Even if there is perihilar inflammation, or if there has been previous surgery, it is possible to develop this plane. Sharp dissection is required, but early insertion of Gil Vernet retractors moves the vessels in the hilum out of the way so that damage to important structures is avoided. Even if veins in this area are opened, they can be compressed by the insertion of small sponges between the retractors and the hilum, and bleeding kept to a minimum.

The subparenchymal dissection can be extended to the infundibula without damaging the superior or inferior apical branches of the renal artery. An incision is then made with a scalpel into the renal pelvis, directly down onto the main bulk of the stone. It is extended in a curved fashion with angled scissors into the necks of the superior and inferior calyces. Alternatively, a straight incision is made in the parenchyma from side to side, and perpendicular extensions are made into the necks of the individual calyces.

In general, the large central bulk of the stone is removed first. The best way to do this is to pass a stone dissector around the stone and lever it out of the pelvis. This is preferable to grasping the stone with a forceps, as the stone may break. Once the main fragment is out, fine Turner–Warwick stone forceps, either straight or curved, can be inserted into the calyces, and individual fragments can be removed.

After the surgeon feels that all of the stone has been removed, it is advisable to irrigate the renal pelvis and flush smaller fragments out of the calyces. This is done by inserting a wide-bore tube into the calyces, through which a high pressure jet of saline can be passed; the high flow of the saline is essential for effectiveness, and this is best induced by a pressure cuff around a bag of saline attached to an infusion cannula.

Contact radiography should then be performed by putting a kidney film behind the kidney. It is helpful to put the kidney into an elastic net sling and then tie the sling to the retractor or to a gantry on the retractor. Ligaclips can then be clipped onto the sling, thereby facilitating the location of even small residual fragments on the x-ray film.

The renal pelvis is then closed by using a continuous 4-0 polyglycolic acid or chromic catgut suture. Sometimes it may be easier to put one or two interrupted sutures in the apical parts of the necks of the infundibula, and this will facilitate closure. Again, the closure may not be watertight, and drainage of the area is thus required. Unless there is noticeable intrarenal hemorrhage, no nephrostomy tube is necessary.

Additional Nephrotomies

On some occasions, it may not be possible to remove the entire stone through a pyelotomy, and additional transparenchymal access is required; the anatrophic nephrolithotomy1 would be excessive if the renal pelvis has been opened in the manner described above, and multiple radial paravascular nephrotomies are a relatively atraumatic method of access. The method of doing this is to make a small (1 cm) radial incision over the stone, which can be localized either by palpation with a needle through the parenchyma or by intraoperative ultrasonography. The parenchyma is then separated by spreading with two MacDonald’s stone dissectors until the calyx is opened and the stone removed. This can be done in a number of positions with a minimal effect on renal function. The nephrotomies are closed with a continuous 4-0 polyglycolic acid or chromic catgut suture, which is placed superficially, incorporating only capsule and a thin layer of parenchyma. A nephrostomy tube should be placed into the most dependent calyx opened; a 12-Fr whistle-tip catheter is satisfactory. This should be brought out through a separate stab incision in the skin.

If a radial paravascular incision is to be made, the renal artery must be located and either a silastic loop or a cotton tape passed around it in order to gain control. A single nephrotomy may not require vascular occlusion, and occlusion can be avoided altogether by the use of the Doppler ultrasound, which is especially valuable in kidneys with decreased function and thinned parenchyma.4 If the renal artery must be occluded, renal function should be preserved during the period of ischemia. Renal hypothermia is achieved by surface cooling with sterile crushed ice6 or by external cooling coils.

A less complex method of protecting against renal ischemic damage is the use of intravenous inosine. This can be injected into a peripheral vein and is valuable in protecting renal function, particularly if the ischemic period is less than 60 minutes and overall preoperative renal function is good.

Wound Closure

After complete stone removal and adequate hemostasis are ensured, the wound is closed. A Robinson drain is brought out through a separate stab incision. A gravity drainage system such as this is preferable to a suction drain, which may cause a urinary fistula to develop.

The wound is closed using a series of interrupted #1 polyglycolic acid sutures. These are passed through all muscular layers at 2-mm intervals and are left untied until all are placed. The table is then unbroken, which brings the wound edges closer together and allows the sutures to be tied without tension. A continuous layer of #1 polyglycolic acid suture is then passed through the outer layer of the external oblique muscle and the fascial layers. The skin can be closed with 3-0 monofilament nylon or with skin clips.

OUTCOMES

Complications

Complications from open renal stone surgery are significant and include hemorrhage, urinary fistula, recurrent stones, and actual or functional loss of the renal unit. The risk of these complications is dependent on the associated findings of chronic infection, prior surgery, and surgeon’s expertise.

There is a small chance that the pleura may be opened when a costal or intercostal incision is made, and the probability of this increases the higher the incision is made. A pleurotomy is readily identified by hearing the sound of air being sucked into the thorax and by seeing the lung on inspiration. The diaphragm should be dissected free from the ribs and used to strengthen the closure of the pleura, which is itself too thin and fragile to hold a suture. The 3-0 chromic catgut suture should include the diaphragm, pleura, and intercostal muscles, and the anesthesiologist should inflate the lung before the last suture is put in. This usually prevents a pneumothorax. A postoperative chest x-ray must be performed, and, in the relatively uncommon event of a persistent pneumothorax, a chest tube should be inserted.

Results

Stone-free rates in patients undergoing pyelolithotomy are variable, depending on the number of stones, the composition of the stone, and the presence of calyceal stones or obstruction. Solitary stones have virtually a 100% stone-free rate, whereas staghorn stones (stru-vite) or patients with multiple stones scattered among the calyces may have an incidence of retained stones of 10% or more.

Nephroureterectomy

Malignant tumors of the upper urinary tract are uncommon and account for only 5% to 10% of all urothelial malignancies. The peak incidence is in the sixth and seventh decade of life with a male predominance of 2:1.3 Most upper tract tumors are transitional-cell carcinoma (TCC, 85% to 90%), with 10% to 15% squamous cell carcinoma or mixed TCC and squamous. Adenocarcinoma of the renal pelvis is extremely rare, accounting for only 1% of upper tract tumors.

Cigarette smoking is the major risk factor for development of TCC of the renal pelvis. It has been reported that there is a three- to sevenfold increased risk of carcinoma associated with cigarette smoking and that cessation of smoking is associated with a decreased risk.

Phenacetin abuse is also associated with an increased risk of TCC of the renal pelvis. Although the specific mechanism of tumorigenesis is unknown, the phenacetin metabolite 4-acetoaminoprophenol is thought to cause chronic inflammation and papillary necrosis. The combination of papillary necrosis and chronic inflammation has been associated with a 20-fold increased risk of cancer development.

Balkan nephropathy, also known as Danuvian endemic familial nephropathy, is a condition strictly associated with TCC of the upper tracts. This endemic disease is confined to the Balkan states that lie on the Danube river. Cancer of the renal pelvis in these states accounts for 42% of renal tumors. The specific cause is unknown, although the drinking water has been suggested. The tumors are typically low grade, multifocal, and slow growing. Bilateral tumors occur 10% of the time. Occupational risk factors have also been correlated with TCC of the renal pelvis, including exposure to chemicals in the rubber, petroleum, plastics, and aniline dye industries. Forty to eighty percent of patients with upper tract tumors will have urothelial carcinomas at some time elsewhere in the urinary tract, usually in the bladder. About 3% of patients with transitional cell cancer of the bladder develop upper tract tumors; however, patients with urothelial tract tumors of the prostate or urethra have approximately a 30% risk of developing upper tract tumors.

DIAGNOSIS

Approximately 80% of patients present with hematuria. Some patients present with flank pain or constitutional symptoms. Intravenous pyelography (IVP) is the initial study of choice in the evaluation of a patient suspected of having a renal pelvic or ureteral tumor. Assessment of the entire urinary tract is important in evaluating patients diagnosed with a renal pelvic or ureteral tumor because the upper urinary tract has a high potential of developing multiple tumors as described by the field-change theory. Grabstald reported that approximately 50% of patients with renal tumors have coexisting tumors in the ipsilateral ureter and bladder, and 3% to 4% of those patients have tumors in the contralateral upper urinary system. A retrograde pyelogram is usually indicated if the collecting system of the affected kidney is not completely visualized or in the case of renal insufficiency or contrast allergy. Additional urothelial assessment may include renal pelvic and/or ureteral washing for cytology, brush biopsies, cystoscopy, and bladder washing for urinary cytology. The role of ureteroscopy in the diagnosis of upper tract tumors is complementary and may confirm the findings of the IVP, retrograde pyelography, and cytology. Ureteroscopy may aid in visual identification and biopsy of tumors for grading and staging. Additional staging evaluation for the detection of metastatic disease should include a chest radiograph and/or computed tomography (CT) of the chest, abdomen, and pelvis. A bone scan may be obtained in patients with an elevated serum calcium, alkaline phosphatase, or bony abnormalities seen on CT scan.

INDICATIONS FOR SURGERY

Nephroureterectomy with excision of a cuff of bladder is the classic surgical procedure for carcinoma of the renal pelvis or ureter. However, conservative surgery may be indicated in those patients diagnosed with a small, solitary, well-differentiated papillary tumor. Current staging techniques, however, may make accurate preoperative staging and grading of tumors difficult. In addition, half of all cases of ureteral tumors involve at least the musculature. Furthermore, there is a high incidence of multiple ipsilateral tumors. Last, recurrent tumors in the remaining ureteral stump have been reported in more than 30% of patients treated by nephrectomy and partial ureterectomy. Although patients with solitary distal ureteral tumors may be successfully treated with distal ureterectomy and ureteroneocystostomy, in general, a conservative surgical approach should be reserved for the highly selected patient pop-ulation in whom nephron sparing is essential, i.e., pa-tients diagnosed with bilateral tumors, Balkan nephropathy, patients with a solitary kidney, renal insufficiency, and patients with comorbid health problems. Patients treated with a conservative approach are at increased risk of local recurrence and require frequent and careful follow-up including IVPs, retrograde pyelograms, and endoscopies.

ALTERNATIVE THERAPY

Alternatives to nephroureterectomy include (a) endoscopic resection and/or fulguration, in either a retrograde or antegrade fashion, (b) topical chemo- or immunotherapy via either a nephrostomy tube or ureteral stent, (c) external beam radiotherapy, or (d) laparoscopic nephroureterectomy.

Lesions in the ureter may be treated with resection of the ureteral tumor and ureteroureterostomy, replacement with ileal interposition, and ureteral reimplantation. These operations require a careful assessment of the entire urothelium and careful follow-up. Because of the “field change” effect of the urothelium and multiplicity of tumors, these operations may not be appropriate in patients with high-grade or -stage tumors.

SURGICAL TECHNIQUE

In performing a nephroureterectomy, technical considerations include the choice of incision, whether it is appropriate and to what extent the surgeon should perform a lymph node dissection, and excision of bladder cuff and distal ureter via an intravesical versus extravesical approach.

Two-Incision Approach

An intrathoracic, extrapleural, extraperitoneal approach, removing the kidney within Gerota’s fascia without removing the adrenal gland, is our preferred procedure. In order to gain proper exposure, the incision can never be too high, and thus, a tenth interspace or supra-11th-rib incision is generally utilized. The patient is placed in a modified flank position (approximately 60 degrees rotated) with the table flexed and the kidney rest elevated. The patient is taped into position with wide adhesive tape, and an arm rest is utilized. The patient is adequately padded with an axillary roll, pillows, and sheets and is prepped and draped from nipples to the symphysis pubis in the usual sterile fashion.

The 11th rib and the tenth intercostal space are identified, and a supra-11th-rib incision is made in the tenth intercostal space. The incision extends from the edge of the erector spinae muscle and courses obliquely and medially to the lateral border of the rectus fascia to incise the external and internal oblique muscles, exposing the transversalis fascia, and the latissimus dorsi and serratus muscles, exposing the intercostal muscles. The lumbodorsal fascia is then incised at the level of the tip of the 11th rib to avoid inadvertent division of the peritoneum or pleura.

The peritoneum is mobilized off the posterior aspect of the transversalis muscle, moving the peritoneum medially and inferiorly. Primarily by use of blunt dissection with minimal sharp dissection, Gerota’s fascia is mobilized superiorly from the diaphragm and posteriorly and inferiorly from the psoas and quadratus musculature. The intercostal muscles are then incised, carefully avoiding the pleural membrane. The plane between the pleura and chest wall is identified with careful blunt dissection along the tenth rib using a Kitner dissector. The diaphragmatic attachments to the 11th and 12th rib are transected sharply down to their insertion between the quadratus and psoas muscles, avoiding the intercostal nerve and vessels. Sharp dissection is continued posteriorly until the intercostal ligament is divided, allowing the rib to hinge posteriorly.

A self-retaining retractor is placed into the wound for optimal exposure. A Balfour or Finochietto retractor may be used, but a multibladed ring retractor that is secured to the operating table such as a Buckwalter retractor is preferable. The renal mass within Gerota’s fascia is rotated medially, and the dissection is carried posteriorly off the psoas and quadratus musculature. The iliohypogastric and ilioinguinal nerves and 12th thoracic neurovascular bundle can usually be identified .

The colon is then held medially and superiorly, an avascular plane between the colonic mesocolon and Gerota’s fascia is developed, and the renal mass is sharply separated from the peritoneum. By use of sharp and blunt dissection, the superior and inferior aspects of the kidney are dissected free of the adrenal gland and surrounding tissues, respectively. There may be several vessels between the adrenal gland and the kidney that should be ligated with ligaclips. The kidney is dissected posteriorly to the level of the renal hilum. Attention is directed to the main renal vessels. The pulsating renal artery is identified by palpation, double ligated as it exits the aorta with 0 silk sutures and then divided.

On the right side, especially with a large tumor mass, the artery may be approached anteriorly or in the interaortocaval region, though the preferred approach to the right renal artery is posteriorly. On the left side, the gonadal and adrenal veins are identified anteriorly, as is the renal vein. The gonadal and any lumbar veins are ligated before double ligating the renal vein with 2-0 silk suture. On the right side, the inferior vena cava is identified as well as the renal vein. Careful palpation for a second renal artery is important before ligation of the renal vein. The remaining soft tissue attachments to the kidney should be divided so that the only remaining attachment is to the ureter.

Attention is then directed to the inferior aspect of the kidney. The ureter is identified and dissected free to a level distal to the bifurcation of the iliac vessels. The ureter is ligated distally with a 0 silk suture, making sure not to include any surrounding tissue in the ligature. A large straight clip is placed proximally to prevent urine spillage, and the ureter is divided. The specimen is then removed.

Transitional-cell carcinoma may spread by direct extension or metastasis by hematogenous or lymphatic routes. Therefore, a regional lymphadenectomy should be performed as part of the surgical procedure. A lymph node dissection is performed by identifying the midline of the aorta for a left-sided tumor, and the vena cava for a right-sided tumor. Starting from just cephalad to the renal hilum to the level of the inferior mesenteric artery, the lymphatic tissue is dissected using a “split and roll technique” with ligaclips placed on the lymphatics to avoid a lymphocele.

Hemostasis is obtained using electrocautery. The diaphragm is not repaired if only the lateral attachments have been taken down. If a pleurotomy has been made, a red rubber catheter with additional side holes cut out is placed into the pleural space, and the pleurotomy is closed with a running 3-0 chromic suture. The kidney rest is lowered, the table is taken out of flexion, and the wound is closed in two layers using a continuous suture of #1 PDS. The skin is closed using staples. The pleural cavity is then bubbled out with the red rubber catheter in a basin of saline. When fluid and bubbles cease to emerge from the catheter, it is removed, and additional skin staples are applied. Auscultation of the chest at the apex of the lung as well as a chest x-ray should be performed postoperatively to diagnose a pneumothorax. If there are any concerns, a temporary chest tube may be placed.

The patient is taken out of flank position, placed in supine position over the break of the operating room table with the table flexed, and prepped and draped in the usual sterile fashion. A 20-Fr Foley catheter is passed into the bladder, and the bladder is then filled with 200 to 300 cc of normal saline. A lower midline abdominal incision is made and carried down through the rectus and transversalis fascia. A Balfour retractor is placed. The bladder is identified and opened longitudinally between two laterally placed 2-0 Vicryl stay sutures. Additional stay sutures are placed at the apex of the incision in the bladder. The ureteral orifices are identified, the bladder is packed with several sponges, and the bladder blade is placed in the dome of the bladder. A 5-Fr feeding tube is placed in the ipsilateral ureteral orifice and sewn in place with a 4-0 chromic suture. The ureteral orifice is circumscribed sharply, including a 1-cm cuff of bladder. The ureter is dissected from its orifice using a pinpoint electrocautery and sharp dissecting scissors .

The entire distal ureter is dissected free to the level of the 0 silk tie, removed with a cuff of bladder, and passed off the table as a specimen. In most cases the remaining stump of distal ureter may be removed entirely with an intravesical approach; however, in some cases additional extravesical dissection is required in which the superior and middle vesicle pedicles are divided. A two-layer closure of the posterior bladder wall is performed using 2-0 Vicryl suture to close the muscle and serosa and 5-0 chromic to close the bladder mucosa. A 3-0 Vicryl continuous suture and subsequently 2-0 Vicryl figure-of-eight Lembert sutures are used to close the bladder incision in two layers. A Davol drain is placed in the pelvis and secured with a 3-0 nylon suture. The abdomen is closed with a continuous #1 PDS suture. The skin is closed with staples.

OUTCOMES


Complications

Early complications include hemorrhage, wound infection, pneumothorax, atelectasis, and pneumonia. Meticulous dissection around the renal vessels, aorta, and vena cava will aid in decreasing intraoperative blood loss. The supra-11th-rib incision provides excellent exposure to the great vessels and kidney, thus reducing the chance of inadvertent injury to the vasculature. Later complications include “flank sag,” which may be related to division of more than one intercostal nerve.

Results

The survival rate after nephroureterectomy is dependent on the stage and grade of the tumor. Superficial low-grade tumors rarely metastasize and when adequately treated rarely decrease life expectancy. Invasive lesions have a higher metastatic rate and are associated with a poorer prognosis. Patients with low-grade and high-grade tumors have approximately 80% and 20% survival at 5 years, respectively.4 Patients with pT2–3a renal pelvic and ureteral tumors have a 75% and 15% survival at 5 years, respectively, and patients with pT3b–4, N+ tumors have approximately a 5% survival at 5 years. Interestingly, in patients with ureteral tumors, survival may be more dependent on the stage and grade of tumor than the surgical approach.

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