Total ureterectomy consists in the total removal of the ureter.
Can be performed in 3 circumstances:
- As an integral part of a nephroureterectomy for tumor in excreting path of kidney and / or ureter;
- Not associated with nephrectomy, for ureter neoplasm in a single-kindey patient.
In this case the continuity of the kidney excreting pathway with the bladder is guaranteed either:
a. by a direct anastomosis or
b. the interposition of an ileal bight that acts as a substitute for the ureter;
- Not associated with nephrectomy, for severe damage (surgical, traumatic, post-infectious) to the ureter. In this case, solutions a) and b) above apply (more often b).
Nephroureterectomy involves the removal of kidney and ureter including an intravascular distal “pad” of the ureter itself (in practice, the last portion of the ureter, the one entering the bladder and is part of the wall of the bladder). This involves opening the bladder cavity that needs to be sutured later. It may also occur that urethrectomy is performed later, after some timefrom nephrectomy or after a non-total nephroureterectomy, to complete the oncological correctness of the operation.
Interventions can be clinically transperitoneal (with anterior abdominal incision, peritoneal opening, bowel dislocation and access to the kidney and ureter located in the retroperitoneal space; see chapter on transperitoneal nephrectomy) or, in selected cases where transperitoneal access is not appropriate, with combined access (retroperitoneal lumbotomic for kidney and proximal ureter + hypogastric in the lower abdomen for distal ureter). Today it can also be performed with laparoscopic technique, but only in specialized clinics.
Removal of local-regional lymph nodes (retroperitoneal for renal tumors and distal ureter, pelvic for distal ureter) is expected. These interventions involve drainage in the site of the removed organs for a few days and bladder catheterization also for a few days to facilitate the reconstruction of the open bladder cavity by the removal of the distal ureter “pad”.
The total urethrectomy without removing the kidney for multiple ureteral neoplasms becomes necessary only when the kidney is the only functional one and can not be removed. It involves retroperitoneal surgical access and removal of the ureter from the pyelo ureter joint to the bladder with a ureter “pad” and the opening of the bladder cavity (see above).
As mentioned above, the continuity of the kidney excreting cavity to the bladder can be assured by:
- direct anastomosis. In this case the kidney must be moved down and this can be done with the surgical procedure known as autotransplantation. With this procedure the renal artery and kidney vein is removed from its natural site, brought to the outside and refrigerated and perfused with substances that delay the necrosis processes in the absence of blood perfusion; To ensure vascularization, renal artery and renal vein are anastomized to the iliac vessels;
- replacing the ureter with a small intestine segment. In this case, a segment of the intestine must be separated from the rest of the small intestine and, with its own vascularization, anastomized on one side to the kidney pelvis and the other to the bladder. This is as well a complex major surgery with high risk of complications.
As far as the total ureterectomy for widespread ureter lesion, not neoplastic, the above is true for the one practiced in case of neoplastic lesion. The solution chosen for the restoration of ureteral continuity varies depending on the surgeon’s propensity and choice, but iliac bight replacement is much more preferable and less complicated (although it still is a major surgery) because it does not involve c.d. “bench surgery” with its vascular risks. It does not allow direct endoscopic checks of the renal excretory cavity, which, however, in the presence of non-neoplastic disease, are not necessary. Once the continuity of the urinary flow is confirmed a few months after the intervention, the frequent checks needed in the event of neoplastic disease no longer appear necessary.
Preparation for intervention:
A good fiber-free dietary intestinal preparation (two days before surgery) is necessary, purgatives and enemas is required the day before surgery (only for interventions involving the replacement of the ureter with the intestine). Trichotomy, antibiotic and antithrombotic prophylaxis is also required.
Duration of intervention:
Depending on the type of intervention and the need for reconstruction, the intervention may vary from 2 h to 5-6 h.
Type and duration of hospitalization:
Normal inpatient hospitalization. The duration is conditioned by the type of surgery performed: from about 7 to 10 days in the case of nephroureterectomy or ureterectomy without reconstruction, at 2-3 weeks when a ureter is to be replaced with the intestine.
Are strongly dependent on the underlying oncologic disease and therefore related to its degree and stage.
Total ureterectomy compared to the endoscopic treatment techniques of ureter neoplastic disease is almost always resolving in comparison to the high recurrence index and the technical difficulty of obtaining complete clearance in endoscopic treatment.
It is a demolition action that involves the loss of the organ, whose replacement it is not always ideal or possible.
In case the removed ureter has been replaced with ileum, mucus is frequently present in urine especially in the first year.
Possible complications are (especially) bleeding with severe hemorrhage, such as to make it necessary a blood transfusion, infection and lesions of nearby organs (the intestine and the large retroperitoneal vessels).
Possible complication is also lymphorrhea, a consequence of lymphadenectomy. With the loss of a kidney, there is obviously the risk of kidney failure. When intestinal substitution is practiced, electrolytic imbalances are possible (intestinal mucosa absorbs substances contained in urine, unlike the ureteral mucosa) and those with difficulty in recovery of the intestinal function, violated in its continuity (mechanical and paralytic ileum, possible dehiscence and bleeding of the intestinal anastomosis).
Patients should be advised to have a morigerized period of time, especially in cases of ureteral replacement with the intestine. It is also recommended to have plenty of hydration and a long antibiotic prophylaxis.
How to behave in case of complications arising after discharge:
If a ureteral reconstruction with ileum has occurred and fever or lumbar pain appears, it is always better to refer to the nearest urological center
The checks, given the high frequency of recurrences, include periodical TAC studies, cystoscopy and urography for a long time (10 years) with increasing intervals over time. If ureteral replacement with ileum is practiced, periodic checks of serum electrolytes and venous pH (possibly metabolic acidosis) are required.