Introduction: Benign diseases of the lower ureter can be divided into two classes:

 

• Congenital disorders (stenosis of the urinary tract junction ureter, megaureter, vesicoureteral reflux, ureterocele)
• Acquired diseases (iatrogenic ureteral stenosis whether in surgical outcomes or radiotherapy, inflammations, extrinsic compression, retroperitoneal fibrosis)

 

The congenital megaureter is a congenital dilatation (> 7 mm) of the ureter. In some cases, the megaureter does not result in any symptoms. However, in general, it occurs with kidney pains, possibly associated with infection and fever (this is called pyelonephritis ). The megaureter is called refluxing when it favors a return of urine from the bladder to the ureter, while urinating, or independently of it. The ultrasound, intravenous urography and retrograde cystography are available tools to view the expansion.

 

The vesicoureteral reflux is a pathological condition (normally not possible) in which there is the reflux of urine from the bladder to the ureter and, in more serious cases, up to the kidney. Clinically, it manifests by recurrent urinary tract infections and pyelonephritis.

 

The acquired ureteral stenosis can have various causes. In most cases, these are secondary iatrogenic stenosis as a result of surgical and endoscopic procedures or radiation therapy.

 

How are ureter diseases spread?

 

The megaureter represents about 6-10% of all congenital abnormalities of the urinary tract, while the incidence of vesicoureteral reflux is about 1%. Both diseases are principally affecting children.

 

The spread and the increase in endoscopic procedures in charge of the upper urinary tract has led to an increase in the frequency of acquired ureteral stenosis. However, with the use of modern endoscopic instruments, the incidence of iatrogenic ureteral stenosis post-ureterorenoscopy is about 1%. A frequent cause of iatrogenic ureteral stenosis or injury is represented by gynecological surgery (hysterectomy).

 

How is congenital megaureter treated?

 

The megaureter congenital cannot be solved with a drug therapy and requires a corrective surgical intervention when there is pain and/or deterioration of renal function. The procedure, which is called vesicoureteral reimplantation, involves detachment of the ureter from the bladder, the subsequent removal of the excess tissue with possible remodelling of the ureter. Then, the normal calibre of the duct is restored, which is then sewn to the bladder. In the past, this type of intervention was performed with the traditional open technique and now at our center it is performed through a laparoscopic robotic assisted technical note.

What happens during the vesicoureteral replanting intervention?

The surgery is performed with minimally invasive robotic technique thanks to the Da Vinci robotic system. The use of robotics technology (magnified vision, greater possibility of movement of the instruments, elimination of tremor) allows us to obtain greater precision in the wrapping of the suture between the bladder and ureter.

Using 3 operating probes of less than 1cm and a fourth probe of 1.5cm. The procedure initially provides for the detachment of the ureter from the bladder and the subsequent removal of the excess tissue. Later, it restores the normal calibre of the duct, which is then sewn to the bladder. In order to heal properly this suture is necessary to be positioned within the ureter of a small catheter with the top end in the kidney and the lower one in the bladder. This brace is not seen from the outside and it is removed in the clinic a month after surgery. The duration of the procedure is about 2 hours.

 

The steps that lead to the discharge, which occurs on average only 4 days after the intervention are the removal of the bladder catheter 2 days after surgery and the removal of the drainage 3 group after the intervention.

 

How will I feel after vesicoureteral replanting intervention?

 

The aim of the intervention is the resolution of a possible block of the flow of urine from the kidney, resulting in the resolution of symptoms (colic, recurrent infections) and the preservation of kidney function avoiding a vesicoureteral reflux.

How will I be followed after the surgery?

Our protocol provides for a follow-up evaluation at one month after surgery with blood tests, urinalysis and urine cultures, as well as an ultrasound of the abdomen and removal of the ureteral catheter. All further control tests are ultrasound of the abdomen at three months and then six months after surgery.

 

How is iatrogenic ureteral stenosis treated?

 

Iatrogenic (accidental) ureter stenosis, as well as any other ureteral narrowing cannot be solved with a drug therapy and requires corrective surgery. The possible surgical options are delay or an endoscopic incision, that is, without the need for a surgical cut, or the robotic surgery or open surgery on a section of the ureter and suture of the two ureteral stumps. The latter procedure, which is called plastic ureter packaging with uretero-ureteral anastomosis, consists in the section and removal of the diseased and narrow portion of the ureter with the purpose of allowing the correct passage of urine, and in the subsequent sewing of the two ends residual of the duct.

 

 

What happens during surgery of the plastic ureter packaging with uretero-ureteral anastomosis?

The surgery is performed with minimally invasive robotic technique thanks to the Da Vinci robotic system. The use of robotics technology (magnified vision, greater possibility of movement of the instruments, elimination of tremor) allows us to obtain greater precision in the packaging of a suture between the two ureteral stumps.

 

Using 3 operating probes of less than 1cm and a fourth probe of 1.5cm. The procedure consists in the section and removal of the diseased portion of the ureter and in the subsequent sewing of the two remaining ends of the conduit. In order to heal properly, this suture is necessary to be positioned within the ureter of a small catheter with the top end in the kidney and the lower one in the bladder. This brace is not seen from the outside and it is removed in the clinic after a month. The duration of surgery is approximately 2 hours. 

 

The steps that lead to the discharge, which occurs on average only 4 days after surgery are the removal of the bladder catheter 2 days after surgery and the removal of the drainage 3 days after the intervention.

 

 

How will I feel after surgery of plastic ureteral packaging with uretero-ureteral anastomosis?

 

The aim of the intervention is the resolution of the block of the flow of urine from the kidney, resulting in the resolution of symptoms (colic, recurrent infections) and the preservation of kidney function.

 

How will I be followed after the surgery?

 

Our protocol provides for a follow-up evaluation at one month after surgery with blood tests, urinalysis and urine cultures, as well as an ultrasound of the abdomen and removal of the ureteral catheter. All further control tests are ultrasound of the abdomen at three months and then six months and finally renal scintigraphy at six months after the procedure.

Our results

·         http://www.ncbi.nlm.nih.gov/pubmed/21459508