Ureteral Stricture, Laparoscopic Ileal Ureterectomy and Laparoscopic Ureteroureterotomy
Ureteral narrowing varies in location and length, and thus in their various treatment options. The patient and his/her surgeon must determine the best treatment option for the diseased ureter. Once the decision is made to perform reconstruction of the ureter, the University of Chicago offers the laparoscopic approach to reconstruction of the ureter. For mid-ureteral and long strictures, we can perform the ureteroureterostomy and the ileal ureter.
The patient is placed to sleep. He/she is then turned onto the side. 4-5 key-hole size incisions are placed on the same side of the body as the diseased ureter. The surgeon’s hands are never inside the patient’s body during surgery. Long instruments are inserted through these keyhole incisions. The surgeon watches a television monitor which gives him a view of the abdominal cavity. The colon which covers the kidney is first taken down, exposing the ureter. The area of the stricture is dissected and exposed clearly from all attachments. Then, the area of the narrowing is cut and removed. For shorter strictures, the cut ends of the ureter are connected back together with sutures. A plastic tube, or a stent, is placed in the ureter to protect the sutured connection as it heals. For longer strictures, the diseased part of the ureter is cut and removed. Then, a 3” incision is extended from one of the keyhole incisions previously made. Part of the small intestine, the ileum, is brought out of this incision, and a length of ileum equal to the length of the stricture is detached from the rest of the small intestine. This is then placed back into the abdomen. The 3” incision is sutured closed. The isolated portion of the ileum is connected to the kidney on one end, and to healthy ureter on the other end with sutures. A stent is placed, extending from the kidney to the bladder to protect the ileal ureter as it heals.
The laparoscopic approach has numerous advantages over the conventional open approach. First, the patient will feel less pain postoperatively compared to the open approach. This is in part due to the small keyhole incisions made as compared to an open ureteral reconstruction surgery, which could result in a much larger scar, depending on the location of the stricture and the type of open surgery performed. Another reason for less pain is that less trauma is caused in a laparoscopic case since the surgeon’s hands are never inside the patient’s abdomen, and large metal retractors for keeping the incision open are not needed. Less pain also means faster postoperative recovery. The patients are typically given regular diet and are ambulating by the first day after surgery. The patients usually stay in the hospital for 2-3 days, and are back to their normal activities by approximately 4 weeks following surgery. In addition to these advantages, the laparoscopic approach also offers a better cosmetic result due to the small and almost negligible incisional scars over time.