Laparoscopic ureteral reimplantation with extracorporeal tailoring for primary
obstructive right megaureter
Savoca Gianfranco, Curto Francesco
ARNAS Civico-Di Cristina-Benfratelli Hospital, Urology Department, Palermo, Italy
Introduction and objectives:
Primary obstructive megaureter is an uncommon presentation in adult patients, it is often
symptomatic and warrants aggressive surgical management. We present our technique of
laparoscopic ureteral reimplantation with extracorporeal tailoring of the distal ureter after
transportal exteriorization of the ureter.
Materials and methods:
A 24-year-old female patient presented with recurrent right flank pain and urinary tract infection.
CT scan demonstrated a marked ureterohydronephrosis with reduced thickness of the renal
parenchyma, voiding cystourethrogram revealed no vesico-ureteral reflux. The laparoscopic
technique was carried on. The patient was positioned in a 20° left lateral decubitus and 30°
Trendelemburg position. Four port were used. The right colon was reflected medially to expose the
retroperitoneal course of the dilated ureter. The ureter was dissected circumferentially down to the
bladder and ligated with an hem-o-lock clip close to the bladder and divided proximal to it. The free
ureteral end was delivered out through the ipsilateral 12 mm port. The lower end was tailored over
an 10Fr feeding tube according to the ureteral plication technique of Kalicinski. The excess ureter
was isolated along its least vascular portion, a running 4-0 mattress suture was passed parallel to the
course of the ureter separating it from the redundant segment that was then wrapped around the
intubated ureter and secured with a second suture layer. A 6Fr double-J stent was placed in
substitution of the 10Fr tube. The whole assembly was replaced in the abdominal cavity through the
same port. The reimplantation of the ureter was carried out laparoscopically in nonrefluxing fashion
using the technique of Lich-Gregoir. The bladder detrusor muscle was longitudinally incised for 2
cm down to the epithelium in the right lateral aspect. A little operculum in the mucosa was created
and a mucosa-to-mucosa ureterovesical anastomosis was completed with 4-0 running suture. The
detrusor layer was sutured over the ureter with interrupted 4-0 sutures. A tubular vacuum drain was
left in the pelvis for 48 hours.
Results:
The total operating time was 100 minutes, the blood loss was 20 ml. No intraoperative and
postoperative complications were observed. The foley catheter was removed on the fourth
postoperative day and the patient was discharged from the hospital. The double J stent was removed
four weeks after surgery. CT showed improvement in hydroureteronephrosis 3 months after
surgery. The patient was asymptomatic during the follow-up period of 12 months.
Discussion:
The advantage of plication technique relates to preservation of ureteral blood supply, decreased
incidence of devascularisation, and minimal risk of urinary leak and obstruction.
Conclusion:
Although open surgery remains the gold standard the described technique without a formal incision
achieves all the advantages of pure laparoscopic surgery but is less demanding, simpler, quicker and
cost-effective to perform and may be considered an alternative to open surgery.