Ureteric Reimplantation

Mainly a procedure for paediatric urology to correct grade 4-5 vesicoureteric reflux

Why is it done?

• Grade 4-5 Vesico-Ureteric Reflux where conservative management has failed with a progressive deterioration in renal function.
• Distal ureterectomy due to stricture disease.
• Iatrogenic injury to lower ureter during surgical procedure: hysterectomy, colectomy, sacro-colpo-pexy etc.
• Ureteric involvement in pelvic oncological (cancer) conditions, ie: colon cancer, rectal cancer, ovarian cancer, etc.
• Ureteric involvement in pelvic inflammatory conditions: Diverticular abcesses, Pelvic Inflammatory disease etc.

How is it done?

• Patients will receive a general anaesthesia.
• Prophylactic antibiotics is given.
• The correct kidney is identified and marked while you are awake.
• This will be an combined open surgical and endoscopic procedure.
• A Cystoscopy will be done with placement of ureteric catheter or stent, if not already done.
• Patients with complete closure of the ureter may have a nephrostomy tube into their kidney via the back.
• An indwelling catheter is placed.
• A midline lower abdominal incision is made, and the pelvic cavity is entered.
• The ureter is identified and the affected area of the lower ureter is identified and cut off above the injury / diseased area.
• The bladder is opened, Bi-valved and the the ureter is re-implanted either as refluxing or non refluxing.
• A Psoas-hitch procedure will be performed where the bladder is fixed onto the affected side’s Psoas muscle as to take off tension from the anastomosis / reimplantation.
• A Boari-flap may be considered with considerable length of defect.
• In the case of VUR, the ureter is not cut, rather loosened in the bladder and retunnelled in a non refluxing technique under the mucosa of the bladder. Several techniques have been described.
• An ureteric stent is placed for 6 weeks and an indwelling catheter for 10 days.
• A drain is also placed for post-operative drainage for a couple of days.

VUR grades

What next?

• You may be in hospital for at least 3-5 days.
• You may have continuous intravenous antibiotics on board.
• You will have a drain and an indwelling catheter.
• The drain will be removed on D2-3 as soon as the drainage is less than 20-30cc per 24 hours.
• The indwelling catheter will remain for 10 days until a cystogram reveals no leaks.
• Your stent will be removed on a separate occasion in 6 weeks after all the fibrosis has settled.
• A ward prescription may be issued on your discharge, for your own collection at any pharmacy.
• A follow-up appointment will be scheduled for 6 weeks to remove the stent.
• A further follow-up is arranged with a CT IVP to check on the end result of the ureter.
• Don’t hesitate to ask Jo if you have any queries.
• DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

Possible complications:

• Vesico – Ureteric Reflux.
• Stricturing / Narrowing of the implanted ureter.
• Persistent Reflux.
• Re-implantation.
• VUR.
• Stenosis and narrowing with persistent hydronephrosis.

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Ureteric Reimplantation VUR