There are a number of different surgical approaches to ureter repair and management. These can vary from simple outpatient procedures that require camera approaches with minimal recovery to major abdominal repairs which necessitate long hospitalizations and longer months-long recoveries. Each repair is based on a number of factors, which include location of the injury, length of the injury, mechanism of the injury and complicating factors and other medical conditions which affect the situation. Potential complications of surgery include recurrence of urinary tract blockage or obstruction, bleeding, infections, kidney stones, kidney deterioration, blood clots or urine leak (urinoma).
Cystoscopy with Ureteral Dilation and Stent Placement
This endoscopic approach is generally used for patients who are not deemed good surgical candidates for definitive repair. These approaches will require exchanges of the stents due to encrustation and occlusion (blockage).
This surgical approach takes advantage of natural redundancy in the lower distal ureter. In a reimplantation procedure, the ureteral is rerouted above the level of obstruction and repositioned into the bladder in a new location, avoiding the need for complex bladder and bowel reconstruction. This common repair technique is utilized for lower ureter problems and cannot be used for upper obstructions.
Psoas Hitch/Boari Flap Repair
For injuries above the bladder but higher in the pelvis, the amount of ureter injury can be longer and require and more complex repair where the bladder is used to bridge the distant. The loss of length is accomplished by mobilizing the upper ureter and stretching it down along with freeing the bladder and moving it towards the injured side. The bladder mobilization will require the bladder being fixed into position by “hitching” or tacking into position along the psoas muscle in the pelvis. This can be combined with a bladder flap where part of the bladder is tubularized to cover the distance. With these repairs, a potential complication is bladder frequency and urgency due to the bladder involvement in the repair. This is usually short-lived and can be managed with medications.
End to End Repair (Uretero-ureterostomy)
A uretero-ureterostomy (UU) is an end to end reconnection of the ureter tube. This surgery entails removal of the diseased portion of the tube, opening up the cut ends along with freeing up the length of the tube to gain mobility, and sewing them together. Only short sections of the tube can be removed, therefore longer strictures and blockages cannot be repaired with this technique. Advantages of this approach include: avoiding more complex procedures, maintaining normal anatomy, and good long-term success and patency.
Ureter Cross Over (Trans Uretero-ureterostomy)
The Trans UU is a reconstruction technique used to bypass the distal ureter by crossing the disease ureter over the body’s midline and connecting it to the normal contralateral side. This procedure is very useful in patients who have had previous complicated pelvic surgery that would make other techniques difficult.
Ileal Ureter (Bowel Interposition)
This complex reconstructive technique utilizes a section of small bowel to replace longer segments of diseased/injured ureter. This technique is reserved for longer ureteral problems and have failed more conservative approaches. Since bowel is being used to replace a section of the urinary tract, the individual’s urine after surgery may look cloudy or have mucus in it. This is normal and expected.