It is a surgical procedure that is used in cases of extensive ureteral damage due to long stenoses or major defects of other nature (traumatic, surgical, floristics, lithiasic, single kidney, urinary deconversion, etc.) or in patients with recurrent lithiasis who need a canal that facilitates the passage of kidney stones.
Nowadays, this is an “extreme” technique, to be practiced when all possible endourologic solutions have failed or no longer tolerable (double J stent, permanent nephrostomy). Renal insufficiency represents an absolute contraindication to this type of intervention because the intestinal reabsorption of acid urine causes further deterioration of renal function. Low urinary obstruction is a relative contraindication because it can and must be corrected at the same time or in advance.
The technique involves a transperitoneal median access that allows a complete visualization of the ureteral tract to be replaced and allows to isolate the intestinal segment that will take the place of the ureter. Usually, the terminal ileum is removed which is detached from the rest of the intestine (while maintaining its vascularisation) and is connected to the ureteral upright ureter (kidney pelvis) and lower to the bladder. Obviously, surgery involves the reconstruction of intestinal continuity. Usually, a catheter is left internally to the intestine used to reconstruct the ureter (double J stent) or a nephrostomic probe escaping from the skin of the hip. Two drains are arranged at the anastomoses (points of connection between kidney pelvis or ureter and intestine, and intestine and bladder) and a drainage into the peritoneal cavity. You must also place a bladder catheter that will be held for 2 weeks or more.
Preparation for intervention:
Preoperative preparation involves the use of high dose cleansers so that the intestine can be used to be completely cleaned from feces. It is also useful to administer “intestinal” antibiotics to have a potentially sterile intestine available. The preliminary positioning of a ureteral catheter is indicated to facilitate the identification of the ureter in cases where intensive peri-ureteral reaction has developed from previous surgical interventions. Preliminary percutaneous nephrostomy allows to restore renal function to optimal levels before proceeding to this surgery.
Duration of the procedure:
The ureteral replacement with an intestinal tract or appendix is a major reconstructive surgery and requires a long operating time (3-6 hours) in relation to the very often complex local conditions (adherence between organs for previous surgery or previous chronic inflammation).
Type and duration of hospitalization:
Ureteral replacement surgery is performed under ordinary hospitalization; Hospitalization lasts from 2 to 3 weeks if there are no complications.
The results reported in the literature are good in 90% of cases (Libertino). For good objective result means:
- Recovery of renal function;
- No major complications.
Usually these results are maintained over time.
The biggest advantage is that of a rescue method that can be performed with a good margin of safety when careful patient selection has been performed and special attention has been paid to surgical details. Compared to endourology techniques, it ensures lasting results over time.
It is a major reconstructive surgery that involves two gastrointestinal and urinary tract infections.
It can be technically complex, not feasible in all patients with long duration of operation and with a long postoperative course and consequently slow return to work activities and potentially affected by life-threatening complications.
Intestinal mucus elimination may last for a few years. The presence of chronic bacteriuria is very common (about 40%) but it does not cause any harm. Hydroelectrolytic disturbances are very rare in patients with a good renal and hepatic function.
Complications can be many and concern the two districts involved in the operation: the intestine and the urinary tracts. All complications of the use of intestinal segments in urological surgery:
- Postoperative intestinal occlusion from adherent bridges that are created in the peritoneum due to the excretion of an intestinal tract;
- Dehiscence of enteric anastomosis (today very rare for the constant use of good intestinal preparation and automatic suturing machines);
- Necrosis of an ileal tract and consequent dehiscence of the pielointestinal or enterovascular anastomosis;
- Obstruction of the intestinal tract for mucus plugs (especially in early stages);
- Possibility of progressive kidney damage by acidosis due to urine reabsorption (Tanagho);
- Possible kidney-bladder reflux even if anti-reflux techniques have been applied;
- Asymptomatic urinary infection in % ranging from 40 to 60%;
At discharge, the patient still has a ureteral stent or percutaneous nephrostomy; Therefore he/she must remain under close medical supervision and lead a very quiet life (reduced physical stress, low activity, moderate diet). It is important to take 1 g of sodium bicarbonate per day in 2 times and practice antibiotic therapy (usually oral way) for a few weeks.
A diet rich in liquids and vitamins is also recommended. Normal work can be resumed after about 1 month after discharge (this period can vary in relation to the type of patient and the type of work performed).
How to behave in case of complications arising after discharge:
In case of bladder irritation symptoms (caused by the presence of the stent) appear, the treating physician may resolve the problem with the prescription of anti-spasm bladder drugs.
In case of high fever associated with lumbar pain, it is advisable to refer to the urologist. So even if the patient, resigned with nephrostomy, complains of malfunction or dislocation of the same.
The first postoperative check is performed after 30-40 days and corresponds to the period when the stent or nephrostomy will be removed.
At the same time, laboratory examinations should be carried out to evaluate both post-operative recovery and possible hydro-electrolyte disturbances. In the absence of clinical problems, subsequent clinical control with ultrasonography should be performed after 2 months.
Subsequently, the patient is usually monitored every 3 months with laboratory and ultrasound examination and after 6 months with urography.