Ureterocalycostomy: A salvage procedure for complex ureteropelvic junction strictures

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RESEARCH ARTICLE

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

Ureterocalycostomy: A salvage procedure for complex ureteropelvic junction strictures

Tejanshu P Shah, Kirtipal Vishana, Rohit N Joshi, Gaurang Kadam, Manish Dhawan
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

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 2013 Jun 19];20:144-7. Available from: http://www.indianjurol.com/text.asp?2004/20/2/144/21531

Introduction

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

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

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

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

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

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.
2.	Hawthorne NJ, Zincke H, Kelalis PP. Ureterocalycostomy: An alternative to nephrectomy. J Urol 1976: 115: 583-6.
3.	Kochakaran W. Viseshsindh V. Muangman V. Ureterocalycostomy for reconstruction of complicated UPJ obstruction. J Med Assoc Thai 2002; 85: 351-5.
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.
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14.	Wesolowski S. Corrective operative procedure after unsuccessful pelviureteric plastic surgery. Br J Urol 1971; 43: 679-86.
15.	Jarowenko MV, Flechner SM. Recipient ureterocalycostomy in a renal allograft: Case report of a transplant salvage. J Urol 1985: 134: 844-5.
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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.
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.