End-to-end anastomosis

Ureterouretrostomy or End-to-end anastomosis of ureter, is a simple operation for the treatment of short segment strictures (< 3 cm) of the proximal and mid ureter. The operation is performed to remove obstruction in ureter by excising defective segment of ureter. This is as safe as any other traditional surgeries and blood transfusion may not be necessary.

Length of Surgery:

3- 4 hours.

Diagnosis:

Procedure of End-to-end anastomosis–is preceded by following diagnosis tests:

  • Physical exam and complete Medical history.
  • KUB ( abdominal X-ray)
  • EKG (electrocardiogram)
  • CBC (complete blood count)
  • PT / PTT (blood coagulation profile)
  • Comprehensive Metabolic Panel (blood chemistry profile)
  • Urinalysis
  • Renal ultrasound: grade of hydronephrosis?
  • Intravenous urography or abdominal CT
  • Endoscopy: Retrograde pyelography and ureterorenoscopy

Treatment:

Ureteroureterostomy (UU) is an end-to-end anastomosis of the segments of the same ureter, with excision of the intervening affected or scarred ureter.

Transperitoneal ureteroureterostomy (TUU) –in this operation, the injured ureter is brought from one side across the peritoneal cavity under the mesentery of the intestine to the other healthy ureter on the opposite side and is connected ( joined) to anastomose it.

Preparation:

Certain medications to be specifically avoided pre surgery:

  • Aspirin.
  • Ibuprofen Motrin.
  • Voltaren, Plavix, Lovenox, Vioxx, Celebrex.
  • Advil, Ticlid, Alka Seltzer, Coumadin, Vitamin E.
  • Arthritis medications: avoided since before a week of the surgery otherwise it can cause bleeding during the surgery.
  • In case of UTI Urinary Tract Infection, it should be treated before the surgery.
  • In case of severe lung/ heart conditions, it is advisable to exercise extra caution before and during the procedure
  • Insertion of a DJ ureter stent and insuring the diagnosis with retrograde pyelography, if possible.
  • Perioperative antibiotic prophylaxis
  • Insertion of a transurethral catheter

Procedure:

The surgical approach to the proximal ureter is via a flank incision. The mid-ureter and distal ureter is reached with retroperitoneal or transperitoneal lower abdomen incisions: e.g.paramedian laparotomy or Gibson incision. After identification of the ureter with stricture or injury, the ureter is carefully exposed. Atraumatic treatment and protection of the vascular supply is important..

  • Surgery is performed under general anaesthesia
  • Patient is sufficinelty prepared and supine position is given
  • Flank incision is taken to rea
  • After identification of the stricture or injury, the diseased part of the ureter is removed. Both ends of the ureter must be free of scarred tissue, with good vascular supply and should be brought together without tension.
  • The proximal and distal end are spatulated about 7–10 mm at 180 degrees apart.
  • Placement of a ureteral stent, if you have not done preoperatively.
  • Corner sutures (e.g. PDS 5-0) are placed. Afterwards, the ureter anastomosis is completed by using the corner sutures (running suture) or in a interrupted fashion.
  • Insert a wound drainage
  • Wound closure

Risks:

  • Bleeding after the operation
  • Poor wound healing ( following open surgery)
  • Fever.
  • Fatigue.
  • Urinary abnormalities.
  • Infection.
  • prolonged urinary leakage at the anastomotic site, which can present as urinoma,
  • Abscess, or peritonitis
  • Hydronephrosis, abscess, fistula formation, and infection.
  • Long-term complications, usually ureteral stenosis

Follow- up:

  • 24 hour surveillance.
  • Visit doctor: for removal of cathedral after surgery.
  • Emergency Follow up:
  • Chest pain/ breathing difficulty.
  • Vomiting/ nausea
  • Worsening pain .
  • Large amounts of blood clots in the urine.
  • Difficult/ painful voiding and fully emptying the bladder.
  • Hospital stay for one to three days after radical prostatectomy.
  • During the operation, urinary catheter is inserted and few patients may be required to wear the catheter for some more days to a few weeks even after discharge from hospital.
  • Retaining catheter kept in skin after surgery should be there for some more days after discharge from hospital.
  • The ureteral stent is removed approximately one month after the procedure.
  • Renal ultrasonography is performed approximately 2 months postoperatively and periodically thereafter.
  • If significant dilatation of the collecting system is found after stent removal, a BUN and creatinine study should be obtained. If dilatation persists or increases, consider further studies to rule out obstruction

All above, treatments are finalized taking into consideration the overall health, severity, age and other ailments of the patient. Only a well experienced urologist should perform the above treatment.