Create a hole or a tunnel through which the ureter will be anastomosed to the bladder. Draw the ureter through the tunnel in the bladder. The ureter may be either anastomosed to the bladder in a refluxing fashion or tunnelled through the muscle of the bladder to produce a nonrefluxing anastomosis. In the former situation, place a right-angled forceps on the outside of the bladder at the site of intended reimplantation, cut onto the tip of the forceps, and simply draw the end of the ureter (by the stay suture) into the bladder. Spatulate the end of the ureter on its anterior surface using a Potts scissors. Perform the anastomosis over a JJ stent. Place the first suture through all layers of the posterior wall of the ureter and take a deep bite of the bladder. The remaining sutures may be mucosa to mucosa only.
For a nonrefluxing anastomosis, create a submucosal tunnel in the wall of the bladder. It is easier to do this by starting inside the bladder with a pair of McIndoe or Addson's scissors. Make a small cut in the mucosa of the bladder, and then tunnel under the mucosa with the tips of the scissors, rapidly opening and closing the tips to create the tunnel. After 2 cm or so (allowing a tunnel length to ureteric diameter ratio of approximately 3:1), turn the scissors over, and cut onto their ends with diathermy so that the scissors may exit the bladder. Exchange them for a Robert's forceps, which is used to grasp the suture in the end of the ureter. Anastomose the ureter to the bladder in the same way as for the refluxing anastomosis.
80 J. REYNARD
The defect in the bladder is then closed, in the same axis as the ureter. Place a drain down to the site of bladder closure and leave the catheter in the bladder for 2 weeks.
Place stay sutures in the inflated bladder, around the edges of the flap (Fig. 5.13a). The flap will receive all its blood supply from its base and therefore it should be at least 4 cm wide and with a length-to-width ratio of no more than 3:1. Fold the flap backward. If more length is required, small transverse incisions can be made in the side of the flap; by pulling lengthways, these can lengthen the flap (Fig. 5.13b). Remember, if you prefer to reimplant the ureter in a nonrefluxing fashion, you will need an extra 3 cm or so of length. Perform the reimplantation as described above and then close the bladder. We find this easier to do by starting at the ureter end, folding the sides of the flap toward each other in the form of a tube. Complete the bladder closure, place a drain down to the site of bladder closure, and leave the catheter in the bladder for 2 weeks.