What are the types of ureter (urinary tube) repair?

Types of Ureter Repair

The choice of ureteral repair technique is determined primarily by the location of injury and the length of ureteral defect, with ureteroureterostomy for upper/middle third injuries, ureteroneocystostomy for distal injuries, and bladder augmentation techniques (psoas hitch or Boari flap) when additional length is needed. 1

Conservative/Minimally Invasive Approaches

For partial ureteral injuries or ligations without complete transection, minimally invasive techniques should be attempted first 1:

• Balloon dilation of ligated segments can avoid surgery in select cases 1
• Percutaneous nephrostomy with ureteral stenting is preferred for partial transections 1
• Retrograde or anterograde stent placement alone may suffice for incomplete injuries 1
• Important caveat: Conservative management carries risk of subsequent stricture formation requiring strict follow-up 1

Surgical Repair by Location

Upper and Middle Third Injuries

Ureteroureterostomy is the first-line surgical repair for complete injuries of the upper and middle ureter 1:

• Debride ureteral ends back to viable tissue
• Perform spatulated end-to-end anastomosis (running or interrupted) 1
• Minimize ureteral devascularization 1
• Always place internal stent 1
• Cover anastomosis with peritoneum or other tissue when possible 1
• Consider kidney-psoas hitch for tension-free anastomosis 1

Lower Third Injuries

Ureteroneocystostomy (direct reimplantation into bladder) is required for distal ureteral injuries 1:

• Use tunnel technique for reimplantation to prevent reflux 1
• If remaining ureter cannot reach bladder, employ bladder mobilization techniques 1

Psoas hitch technique (preferred method for bridging gaps) 1:

• Mobilize bladder and hitch to psoas minor tendon
• Covers 6-10 cm defects 2
• Requires normal bladder capacity 1

Boari flap technique (for longer defects) 1:

• Create full-thickness anterior bladder flap
• Swing cranially and tubularize for anastomosis
• Covers 12-15 cm defects 2
• More technically demanding; refer to experienced urological center 1

Second-Line Techniques

Transureteroureterostomy is reserved for when primary reconstruction fails 1:

• Mobilize "donor ureter" and transpose below sigmoid colon through mesentery
• Perform end-to-side anastomosis to "recipient ureter" 1
• Minimize mobilization of recipient ureter to preserve blood supply 1
• Stent donor ureter and retroperitonealize anastomosis 1
• Major concern: Risk of injury to contralateral healthy ureter 1
• Restricted to patients with poor prognosis 1

Salvage Procedures

For extensive or multifocal injuries when standard techniques are not feasible 1:

Renal auto-transplantation 1:

• Nephrectomy with kidney reimplantation in pelvis
• Anastomose renal vessels to iliac vessels
• Anastomose ureter to bladder
• Caution: Risk of renal perfusion injury and limited quality evidence 1

Ureteral substitution with bowel 1:

• Ileal substitution most common (can replace >15 cm or entire ureter) 2
• Alternative: appendix or colon segments
• Contraindications: azotemia, inflammatory bowel disease, hepatic dysfunction, short gut syndrome, high bladder pressure 1

Nephrectomy: Last resort only when all other options exhausted 1

Technical Considerations

Surgical Approach

• Open surgery remains traditional approach 1
• Laparoscopic or robotic-assisted techniques increasingly employed with encouraging results 1, 2
• Robotic platforms may facilitate anastomosis construction 1

Essential Principles for All Repairs 1

• Ensure good vascular supply
• Provide adequate drainage
• Create wide spatulated tension-free mucosa-to-mucosa anastomosis
• Always place ureteral stent to reduce failures and strictures 1
• Drain adequately to prevent urinoma and abscess formation 1

Damage Control Strategy

When immediate definitive repair is not feasible due to patient instability 1:

• Ligate damaged ureter
• Place temporary nephrostomy for urinary diversion
• Perform delayed elective reconstruction 1

Critical Pitfall

Urologist involvement is paramount for ureteral repairs given technical complexity and evolution of techniques over past 30 years 1. The paradigm has shifted from primary surgeon management to mandatory urological consultation for optimal outcomes 1.