LAPAROSCOPIC RESECTION OF STENOSIS OF URETER – VIDEO

Summary

Introduction:
The development of endoscopic methods and their widespread use in the treatment of urolithiasis increases the risk of ureteric trauma and subsequent ureteral stenosis, which leads to resection or other performance on the ureter. Open surgery with different types of reconstruction (most often resections or re-implantations) are standardized with relatively satisfactory results. Similar techniques are also used for other pathologies, especially for low risk urothelial carcinoma or utereral endometriosis. The disadvantage of open surgery is a relatively extensive intervention in the integrity of the abdominal wall. This disadvantage can be eliminated by miniinvasive laparoscopic / robotic approach. The video presents one case of using laparoscopy for resection of the ureter.

Material:
3107 laparoscopic procedures were performed between 1/2003 and 7/2017. Primary ureteral operations were 46 (1.5% of all laparoscopies) – 22x ureterolithotomy, 9x ureterocutaneostomy, 7x reimplantation, 7x deliberation, 1x resection). Of course, many other procedures also involve extensive work with ureters, especially nephroureterectomy (140 cases) and radical cystectomy (33 cases).

Indication and surgical procedure of laparoscopic resection of the ureter:
Female, 34 years old, after repeated treatment of left-sided urolithiasis by ureteroscopy and percutaneous nephroscopy (PCNL). Now, megaureter of the left due to a duplex stenosis of the middle ureter measuring 2 cm in length, endoscopic dilatation with stent without effect. Proven by non-contrast CT, ascending ureterography and nephrostomogram. According to scintigraphy, the left renal function was 17%. Surgery was performed in a flank position on the right side with the left lower limb elevated, allowing simultaneous laparoscopic and endoscopic access (flexible cystoscopy with ureteric probe). First, a ureteral catheter was inserted endoscopically to the site of stenosis. Capnoperitoneum was established at 12 mm Hg pressure, operated from 3 ports (10 mm in the umbilicus for the camera), 2 ports 5 mm for tool. The dorsal peritoneum was incised laterally to colon with the harmonic scalpel, and the Gerota’s fascia was incised. The ovarian vessels were released and then the ureter is liberated with hook from fibrotic changes to surrounding tissue. The stenotic section of the ureter was resected. An ureteral stent (double loop) was introduced into the renal pelvis. The caudal non-dilated ureter was briefly spatulated (incised) and ureterorrhaphy was performed with single 3-0 polyglactin stitches.

Results:
The postoperative course was complicated by long-term insertion of nephrostomy and ureteral stent for repeated mild leakage of the contrast agent from anastomosis at nephrostomogram. Therefore nephrostomy and stent were removed at 12 weeks post procedure. Seven months after surgery, the kidney is withoud dilatation on ultrasound and the renal function at scintigraphy increased to 34%.

Conclusion:
In carefully selected cases, laparoscopy can replace open access to ureteral operations including resection with subsequent ureterorrhaphy.

KEY WORDS:
Ureteral stricture, resection of ureter, ureterorrhaphy, laparoscopy.