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Major Ureter Reconstruction

What is a ureter?

A ureter is a thin tube that allows urine to travel from the kidney to the bladder. Each ureter is a muscular tube about 8 to 10 inches long. The muscles tighten and relax to force urine down into the bladder, away from the kidneys.

During what types of surgeries can the ureter be injured?

The ureter can be injured during any type of pelvic surgery. It is most commonly injured during gynecological surgery. Colorectal surgery also can lead to ureter injury.

In patients who have a large uterus due to benign fibroids or cancer, a large sized rectal or sigmoid colon cancer, or have received prior pelvic radiation, the normal ureter anatomy may be very distorted. This distorted anatomy can place the ureter in an abnormal place or very close to a tumor. Sometimes, the tumor involves the ureter and thus a segment of the ureter has to be removed in order to remove all the cancer.

The ureter can also be injured during endoscopic surgery for kidney stones. Here, a telescope is placed up into the ureter and the stones are fragmented with a laser. The ureter can be injured particularly if the stone is large or stuck to the wall. The injured ureter can become badly scarred and prevent urine draining from the kidney. Such scar tissue of the ureter requires surgical reconstruction.

Can the ureter be injured during uterus removal (hysterectomy)?

The ureter can be injured during a hysterectomy. The drawing below shows that the part of the ureter that lies in the pelvis, close to the uterus and vagina, is the most common site of surgical misadventure and injury of the ureter.

Diagram of ureter in a hysterectomy

Does risk of ureter injury differ depending on the type of hysterectomy performed?

Yes, ureter injuries occur most often during open surgical removal of the uterus. Radical hysterectomy for removal of a cancerous uterus is by far the most risky for ureter injury. Here, the injury risk is more likely because the tumor can distort the anatomy and push the ureter into an abnormal position. Ureter injury can also occur during laparoscopic assisted vaginal hysterectomy. With pure vaginal hysterectomy, ureter injuries are extremely uncommon.

What surgical methods are used to reconstruct the injured ureter?

  • Ureter reimplant
  • Psoas hitch surgery
  • Boari flap surgery
  • Ureter patch or interposition with the appendix
  • Ileal ureter
  • End-to-end repair

What is psoas hitch surgery?

When the ureter is injured relatively high above the bladder (close to the junction where the pelvis meets the abdomen), the amount of ureter loss can be great. In order to bridge the gap of the injured segment of ureter, two surgical methods are used:

  • Freeing up the ureter and stretching it, and pulling it down to reach the bladder
  • Freeing up the bladder and stretching it toward the kidney.

A ‘psoas hitch’ entails stretching the bladder toward the kidney and tacking it in position, by sewing it (“hitching”) to the psoas muscle. See illustrations below: “B” shows the bladder being stretched toward the kidney with two fingers. “C” shows the bladder sewn to the psoas muscle, “D” shows the opening in the bladder sewn closed.

Diagram of Psoas Hitch

What are the potential side effects or complications from psoas hitch surgery?

By freeing up and stretching the bladder, it sometimes becomes a little unstable, causing frequent urination. This is a temporary side effect, but It will often take months for the bladder to stretch up till normal. If the frequent urination is annoying, there is medicine to calm the bladder down (Ditropan).

Another possible side effect of psoas hitch surgery is injury of the genito-femoral nerve. This occurs very rarely and usually only when the ureter is stuck to the nerve. The consequence of this nerve injury is numbness of the anterior thigh skin. Numbness typically resolves or gets much better with time.

What is the follow-up after psoas hitch surgery?

After psoas hitch surgery, patients require a Foley catheter in the bladder for 10-14 days. They will get an X-ray of the bladder (cystogram) to confirm the bladder has healed before the catheter is removed.

A stent in the ureter that was placed at the time of the surgery will need to be removed 3 to 6 weeks after surgery. Stent removal is a quick in office procedure, done under local anesthesia.

Are there are any activity restrictions after psoas hitch surgery?

  • No driving for 2 weeks or until the Foley catheter is removed
  • No heavy lifting or strenuous activity for 4 to 6 weeks

What is Boari (bladder) flap surgery?

Boari flaps are used when the ureter injury is high in the abdomen and too far up for the psoas bladder hitch to reach.

Boari flap surgery involves a tongue of bladder wall that is cut from bladder top side and then rolled in and sewn into a tube. The tube is pulled toward the kidney in order to bridge the missing segment of injured ureter.

Diagram of Boari Flap surgery

What are the potential side effects or complications from Boari flap surgery?

By freeing up and stretching the bladder and rolling a segment of it into a tube, the bladder sometimes becomes a little unstable, causing frequent urination. It will often take months for the bladder to stretch up till normal. If the urinary side effects are annoying, there is good medicine to calm the bladder down (Ditropan).

What is the follow-up after Boari flap surgery?

After Boari flap surgery, patients require a Foley catheter in the bladder for 10-14 days. They will get an X-ray of the bladder (cystogram) to confirm the bladder has healed before the catheter is removed.A stent in the ureter that was placed at the time of the surgery will need to be removed 3 to 6 weeks after surgery. Stent removal is a quick in office procedure, done under local anesthesia.

Are there are any activity restrictions after Borai flap surgery?

  • No driving for 2 weeks or until the Foley catheter is removed
  • No heavy lifting or strenuous activity for 4 to 6 weeks

When is the method of “end to end” repair used to repair the injured ureter?

When the mid-portion of the ureter is surgically injured, the ureter can be repaired by sewing the two cut ends together as long as the gap between them is less than 3 cm. At the time the ureter is sewn together a stent (plastic tube) is also placed in the ureter. The stent helps the ureter to heal. The stent is typically removed 3 to 4 weeks after repair. See the drawing below illustrating this surgical method.

Diagram of "end to end" ureter repair