Transureteroureterostomy (Fig. 5.14) A transureteroureterostomy is used where the bladder cannot be mobilised or is of small volume (e.g., post-radiotherapy), such that a psoas hitch or Boari flap cannot be made without tension at the ureterovesical anastomosis. The damaged ureter is swung over to the normal ureter and the two are anastomosed together.
First check that the 'recipient' ureter has not been injured. Perform an on-table retrograde ureterogram. There must be an adequate length of ureter to swing over to the opposite ureter. Remember, just above the pelvic brim the ureters are the closest together of any point throughout their course (6 or 7 cm apart), and therefore at this point the least amount of mobilisation will be required.
Ideally the caecum should be mobilised to avoid having to tunnel the ureter through the retroperitoneum, which runs the risk of angulating or constricting the ureter. The 'donor' ureter (the cut ureter) may be brought over to the opposite ureter below or above the inferior mesenteric artery, but if brought below, be careful that it does not make an acute angle beneath the artery, as it will be obstructed. Make a longitudinal incision in the recipient ureter that is slightly longer than the diameter of the donor ureter. By cutting the end of the donor ureter obliquely (Fig. 5.14), you can increase its length slightly and this may help reduce the chances of postoperative obstruction.
5. TRAUMATIC UROLOGICAL EMERGENCIES 81
Figure 5.13. a: Creating a Boari flap. b: Lengthening the Boari flap. c: Closing the Boari flap.
82 J. REYNARD
Place a 4/0 Vicryl suture from outside to inside at the top end of the recipient ureter and then pass it from inside to outside of the donor ureter. Do the same at the bottom end. Complete the back wall of the anastomosis from inside the ureter, and the front wall from the outside. Before completing the anastomosis, place a JJ stent passing from the donor ureter, across the anastomosis, and down into the recipient ureter, and complete the anastomosis. There is usually not enough space to place a second stent all the way along the recipient ureter. Place a drain down to the site of the anastomosis.