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RESEARCH ARTICLE
Year : 2004  |  Volume : 20  |  Issue : 2  |  Page : 144-147
 

Ureterocalycostomy: A salvage procedure for complex ureteropelvic junction strictures


Department of Urology and Kidney Transplantation, Institute of Kidney Diseases and Transplantation Sciences, BJ Medical College and Civil Hospital Campus, Ahmedabad, India

Correspondence Address:
Tejanshu P Shah
65-B, Swastik Society, Navrangpura, Ahmedabad - 380 009
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Objectives: To report our experience with Ureterocaly­costomy for treating complex ureteropelvic junction stric­tures, to salvage a renal unit.
Methods: Twenty-five patients were subjected to ure­terocalycostomy between year 1992 and 2002. Nineteen patients had UPJ obstruction; 7 had primary UPJ obstruc­tion with 3 having horseshoe anomaly and 4 having intrarenal pelvis, while 12 had secondary UPJ obstruc­tion following pyeloplasty (5), endopyelotomy (2) and pyelolithotomy (5). Six patients had long proximal ureteric strictures; 5 tuberculous and 1 following blunt abdominal trauma. Five patients had solitary units. Preliminary nephrostomy drainage was provided in all secondary cases and in solitary units. A wide spatulated anastomosis was performed after amputating lower pole parenchyma and further length was achieved by renal descensus in indi­cated cases.
Results: Follow-up evaluation included ultrasonogra­phy, intravenous urography and renal scan. Twenty two patients improved and are still doing well. Two patients failed to show radiographic improvement although being asymptomatic. One patient presented with restricture and pyonephrosis and warranted nephrectomy.
Conclusions: Ureterocalycostomy is a viable alterna­tive for salvaging a renal unit jeopardized by complex UPJ strictures. This procedure is a versatile one which can be done without any extra preparation even in unexpected situations.


Keywords: Ureterocalycostomy, ureteropelvic junction, salvage.


How to cite this article:
Shah TP, Vishana K, Joshi RN, Kadam G, Dhawan M. Ureterocalycostomy: A salvage procedure for complex ureteropelvic junction strictures. Indian J Urol 2004;20:144-7

How to cite this URL:
Shah TP, Vishana K, Joshi RN, Kadam G, Dhawan M. Ureterocalycostomy: A salvage procedure for complex ureteropelvic junction strictures. Indian J Urol [serial online] 2004 [cited 2019 Jun 27];20:144-7. Available from: http://www.indianjurol.com/text.asp?2004/20/2/144/21531



   Introduction Top


Ureterocalycostomy entails an end to end anastomosis between ureter and lower pole calyx to bypass severe peripelvic fibrosis with ureteropelvic junction obstruction or a long upper ureteral stricture. It was first described by Neuwirt [1] in 1947 and subsequently technical modifica­tions were suggested by Hawthorne [2] in 1976. Since then ureterocalycostomy has progressively gained widespread acceptance not only as a salvage procedure but also as a primary procedure in selected cases of ureteropelvic junc­tion obstruction and/or upper ureteral strictures with excel­lent long-term results as recently reported by Kochakaran et al. [3] We, hereby, review our indications and long-term results of this procedure in 25 patients.


   Patients and Methods Top


We have treated 25 patients with ureterocalycostomy between 1992 and 2002. Age ranged from 6 to 63 years with mean being 30 years. Seventeen patients were male and 8 were female. Nineteen patients had ureteropelvic junction obstruction. Seven patients had primary uretero­pelvic junction obstruction, out of which 4 had complete intrarenal pelvis while 3 had horse-shoe anomaly. Twelve patients had secondary ureteropelvic junction obstruction, 5 following pyeloplasty, 2 following endopyelotomy and 5 following pyelolithotomy. Remaining 6 patients had long upper ureteral strictures, 5 secondary to genitourinary tu­berculosis and 1 following blunt abdominal trauma [Figure - 1]. Five patients had solitary unit and 4 out of these had renal insufficiency on presentation. Twelve patients requir­ed preliminary diversion due either to infection or compro­mised function of the concerned renal unit. Preoperative anatomical assessment was done by intravenous urogra­phy, nephrostomogram and retrograde pyelography, while functional evaluation of the concerned renal unit was assessed by calculating creatinine clearance or by isotope renal scan.

Operative technique:

An anterolateral extraperitoneal flank approach through 11 th rib bed was utilized in all cases, after preliminary cys­toscopy and retrograde ureteropyelographic assessment of the disease. Certain technical points taken into consid­eration were:

  • Access through a virgin area as advocated by Rohrman et al. [4]
  • Dissection of the ureter proximally taking care to pre­serve a good amount of adventitial tissue so as to pre­serve ureteral blood supply with lateral spatulation.
  • Guillotine amputation of lower pole parenchyma rather than simple wedge resection to avoid anasto­motic stricture as recommended by Jameson et al. [5]
  • Freeing 2 to 3 mm of calyceal wall from the overly­ing cortex for precise mucosa to mucosa anastomosis as described by Mollard and Brawn. [6]
  • Wrapping the anastomosis with an omental pedicle graft as suggested by Turner Warwick et al [Figure - 2]. [7]
  • Stenting of anastomosis and proximal diversion in the form of nephrostomy.
  • Achieving additional length by renal descensus as de­scribed by Popescu which helped in achieving a ten­sion free anastomosis. [8]



   Results Top


Drain was removed on an average 6 th postoperative day. JJ stent was removed after 6 weeks in all the patients. All the patients were followed up stringently. Follow-up evalu­ation included ultrasonography, intravenous urography and isotope renal scan. Follow-up ranged from 1 to 10 years, mean being 5.5 years. The outcome of the various patients is shown in the following table.

Twenty-two (88%) out of 25 patients did extremely well in having excellent outcome both symptomatically as well as radiologically evident by significant reduction in hy­dronephrosis on ultrasonography and improvement in function on intravenous urography or renal scan. Two (8%) patients although had no symptoms on follow-up, failed to show radiographic improvement. One (4%) patient had a poor outcome and on follow-up had restricture and py­onephrosis and ultimately warranted nephrectomy.


   Discussion Top


Complex ureteropelvic junction strictures are very dif­ficult to deal with by routine reconstructive procedures because of inadequate length of ureter, peripelvic or per­iureteral scarring or intrarenal pelvis. Options available in such situations include renal capsular flap, Davis' intu­bated ureterotomy, auto-transplantation and ileal replace­ment of ureter which all are technically demanding and are of considerable surgical magnitude with associated morbidity. [9],[10] Ureterocalycostomy, in such circumstances provides relatively safer, simpler and effective alternative in salvaging the concerned renal unit. The advantages of ureterocalycostomy are extra length which leads to a ten­sion free anastomosis and the anastomosis between sup­ple tissue with good blood supply away from the diseased part with good dependent drainage.

Primary ureteropelvic junction obstruction is best treated by various forms of pyeloplasty amongst which Anderson Hynes type dismembered reduction pyeloplasty is still the gold standard. But there are some conditions wherein re­sults are not as good as we expect. Complete intrarenal pelvis [Figure - 3] is one such entity that is not suited for Anderson Hynes pyeloplasty. Ureterocalycostomy as a primary procedure has potential to replace it in such cases [Figure - 4]. [5],[10] Horse-shoe anomaly presents another such complex condition wherein pyeloplasty without isthmec­tomy, even when completely dependent, results in the up­per ureter traversing the medially displaced dilated lower pole calyx, which at times acts as a ball valve obstruction when the patient is in an upright position. Ureterocalyco­stomy in such circumstances provides gravity dependent drainage and obviates the need to divide the isthmus which may result in significant parenchymal loss. [6],[11],[12],[13] .

Secondary ureteropelvic junction strictures following conventional pyeloplasty, open stone surgery and endo­pyelotomy are complicated by severe peripelvic inflam­mation and dense fibrosis caused by urinary extravasation, which makes them relatively unsuitable for ureteropelvic reconstruction. A repeat pyeloplasty, still is the procedure of choice if the renal pelvis and the ureter can be mobilized adequately, the strictured area excised and reanastomosed without tension. [10] But when dense scarring and fibrosis precludes a repeat pyeloplasty, ureterocalycostomy proves to be a very good alternative [4],[9],[14],[15],[16],[17] In our series, we have treated 12 such patients, out of which 11 improved both symptomatically and radiologically.

Long upper ureteral strictures are caused by genito­urinary tuberculosis. Couvelaire et al reported ureterocaly­costomy for long upper ureteral tuberculous strictures with good results. [18] We had 5 such patients. All were initially treated with anti-tuberculous chemotherapy with JJ stenting or percutaneous nephrostomy and definitive re­construction was deferred till 6 weeks. The stricture length was reassessed and calyceal neck stenosis was ruled out by means of intravenous urography and retrograde pyelog­raphy. Out of 5 patients, 1 patient did not improve radiologically and 1 patient subsequently underwent ne­phrectorny for restricture and pyonephrosis. One of our patients had 7 cm long upper ureteral stricture [Figure l] fol­lowing blunt abdominal trauma in a solitary unit presenting late with azotemia. After preliminary diversion in form of nephrostomy, ureterocalycostomy with renal descen­sus was done, following which patient fared well and re­nal parameters were normalized. Hawthorne et al, [2] Kochakaran et al [3] and de la Taille et al [19] reported primary ureterocalycostomy for traumatic ureteral stricture with moderate success.


   Conclusions Top


Ureterocalycostomy with or without renal descensus is a viable alternative for salvaging a renal unit jeopardized by complex ureteropelvic junction strictures. The most likely clinical situations in which ureterocalycostomy may prove to be extremely useful are:

  • Secondary ureteropelvic junction obstruction with se­vere peripelvic fibrosis.
  • Long upper ureteral strictures (tuberculous and/or trau­matic).
  • Selected cases of ureteropelvic junction obstruction in horse-shoe anomaly.
  • Primary ureteropelvic junction obstruction with com­pletely intrarenal pelvis.


 
   References Top

1.Neuwirt K. Implantation of ureter into lower calyx of renal pelvis. In VII Congress de la Societe Internationale d'Urologie. part 2. 1947. Pp 253-255.  Back to cited text no. 1    
2.Hawthorne NJ, Zincke H, Kelalis PP. Ureterocalycostomy: An al­ternative to nephrectomy. J Urol 1976: 115: 583-6.  Back to cited text no. 2    
3.Kochakaran W. Viseshsindh V. Muangman V. Ureterocalycostomy for reconstruction of complicated UPJ obstruction. J Med Assoc Thai 2002; 85: 351-5.  Back to cited text no. 3    
4.Rohrmann D. Snyder III HM. Duckett Jr JW, Canning DA. Zderic SA. Operative management of recurrent UPJ obstruction. J Urol 1987: 158: 1257-9.  Back to cited text no. 4    
5.Jameson SG, McKinney JS, Rushton JF. Ureterocalycostomy a new surgical procedure for correction of ureteropelvic stricture associ­ated with intrarenal pelvis. J Urol 1957: 77: 135-43.  Back to cited text no. 5    
6.Mollard P. Braun P. Primary ureterocalycostomy for severe hydrone­phrosis in children. J Pediatr Surg 1980: 15: 87-91.  Back to cited text no. 6    
7.Turner Warwick R. Wynne EJ. Handley M. The use of omental pedicle graft in the repair and reconstruction of urinary tract. Br J Urol 1967: 54: 849.  Back to cited text no. 7    
8.Popescu C. The surgical management of postoperative ureteral fis­tulae. Surg Gynec Obstet 1964; 119: 107.  Back to cited text no. 8    
9.Levitt SB. Nalizadeh I, Javaid M. Ban - M, Kegan S. Hanna M, Milsten D. Weiss R. Primary calycoureterostomy for pelviureteral junction obstruction: Indications and results. J Urol 1981: 126: 382-­6.  Back to cited text no. 9    
10.Duckett JW. Pfister R. Ureterocalycostomy for renal salvage. J Urol 1982: 128: 98-101.  Back to cited text no. 10    
11.Mesrobian HG. Kelalis PP. Ureterocalycostomy: Indications and results in 21 patients. J Urol 1989: 142: 1285-7.  Back to cited text no. 11    
12.Mollard P. Mouriquard P. Joubert P. Pouyau A. Ureterocalycostomy for hydronephrosis caused by junction disease in children and ado­lescents. apropos of 35 cases. Chir Paediatr 1990; 31: 87-91.  Back to cited text no. 12    
13.Ross JH, Streem SB, Novick AC. Kay R. Montie J. Ureterocalyco­stomy for reconstruction of complicated UPJ obstruction. Br J Urol 1990: 65: 322-5.  Back to cited text no. 13    
14.Wesolowski S. Corrective operative procedure after unsuccessful pelviureteric plastic surgery. Br J Urol 1971; 43: 679-86.  Back to cited text no. 14    
15.Jarowenko MV, Flechner SM. Recipient ureterocalycostomy in a renal allograft: Case report of a transplant salvage. J Urol 1985: 134: 844-5.  Back to cited text no. 15    
16.Dewan PA. Clark S, Condron S. Henning P. Point of technique: ureterocalycostomy in the management of pelviureteral junction obstruction in horse-shoe kidney. Br J Urol 1999; 84: 366-8.  Back to cited text no. 16    
17.Selli C. Rizzo M, Movani F, Dedola G, Amorosi A. Ureterocalyco­stomy in treatment of pyeloplasty failures. Urol Int 1992: 48: 274-7.  Back to cited text no. 17    
18.Couvelaire R. Auvert J, Moulonguet A. Cukier J, Leger P. Implan­tations et anastomoses uretero-calicielles: techniques et indications. J Urol Neph 1964; 70: 437.  Back to cited text no. 18    
19.De la Taille A. Houdelatte P, Houlgatte A, Saporta F, Berlizot P, Foux R. Late diagnosis of avulsion of UPJ treated by ureterocalyco­stomy. Ann Urol (Paris) 1997; 31: 288-90.  Back to cited text no. 19    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
 
 
    Tables

  [Table - 1]



 

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    Abstract
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    Patients and Methods
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