Uretero-ureterostomy and uretero-neocystostomy with psoas hitch performed in a cadaveric model. The authors have the following disclosures. Ureteral obstruction or injury occurs in 0.3 to 11% of all female pelvic reconstructive surgeries. Ideally, repair should be performed at the time of the initial injury. Ureteral repair procedures require advanced techniques and detailed knowledge of the anatomy. The type of ureteral repair procedure depends on the location and mechanism of injury. For injuries to the proximal two-thirds of the ureter, a uretero-ureterostomy or end-to-end anastomosis is most commonly performed. For injuries to the distal one-third of the ureter, a uretero-neocystostomy, psoas hitch, or bioriflap may be performed. The bioriflap is used for large ureteral defects which require additional length for repair, typically giving an additional six centimeters in length. This will not be performed in the video. The objectives of this video are to review pertinent anatomy to ureteral repair procedures and to demonstrate uretero-ureterostomy and uretero-neocystostomy with psoas hitch in a cadaveric model. The ureter is roughly 25 centimeters long in adults and courses down the retroperitoneum in an S-shaped curve. The blood supply to the ureters is medial in the abdomen, originating from the renal artery as well as branches from the gonadal vessels and aorta. The pelvic ureter receives its blood supply from lateral branches of the uterine artery and the superior vesicle artery. The most common location of injury during gynecologic surgery is at the distal three to four centimeters where the ureter crosses the uterine artery in the cardinal ligament and then across the lateral fornix of the vagina as it enters the trigone of the bladder. In this cadaveric model, you can see the ureter as it passes underneath the uterine artery and enters into the trigone of the bladder. The uterus has been retracted laterally away from the ipsilateral psoas minor tendon. Injuries to the upper two-thirds of the ureter are best managed with uretero-ureterostomy. For this procedure, you will need fine-tipped scissors, 3-0 or 4-0 delayed absorbable suture, a 5 French double-J stent, a closed suction drain, and a Foley catheter. First, the injured portion of the ureter is removed. A guide wire is introduced into the ureter. The ureteral stent is inserted over the guide wire and then the guide wire is removed. The cut ends of the ureter are then spatulated approximately 5-6 mm as demonstrated by this illustration. The apex of the distal spatulated ureter is then sutured to the opposite edge of the proximal ureter. We use a syringe to provide additional lubrication to the cadaveric model. The stent is introduced into the proximal ureter ensuring that the end of the stent is situated in the renal pelvis. The cut ends of the ureter are gently brought together and the suture is secured. This is next repeated with the opposite apex and closely spaced interrupted sutures are used to complete the reanastomosis. A closed suction drain is then placed in the location of the reanastomosis. The ureteral stent remains in place for approximately 6 weeks. Ureteroneostostomy is a common procedure for injuries to the distal one-third of the ureter. A psoas hitch can also be performed if additional length is required to obtain a tension-free repair. We use similar instrumentation for this procedure as we did in the previously demonstrated ureteroureterostomy. First, the space of retzius is dissected to obtain adequate mobility of the bladder. The bladder should be able to reach the psoas minor tendon without stretch or tension. The ureter is transected at the level of injury and the distal end is ligated with a permanent suture. The bladder is then sutured to the psoas minor tendon, taking care to avoid injury to the genitofemoral nerve. We use a 2-0 delayed absorbable suture and place several sutures to secure the bladder to the tendon. The anterior cystotomy is made in the trajectory of the reanastomosis with a medial location in the dome of the bladder. The ureter is spatulated 5-6 mm and the apex of the spatulated end of the ureter is sutured to the most cephalad portion of the cystotomy. A 5 French double J ureteral stent is placed with one end advanced into the ureter and the other end resting in the bladder. Interrupted sutures are placed a few mm apart circumferentially to complete the reanastomosis. Once this is complete, the bladder is backfilled to confirm a watertight seal. A closed suction drain is placed in the pelvis and the ureteral stent is left in place for 6 weeks. A Foley catheter is placed and will remain in the bladder for approximately 2 weeks.

uretero-ureterostomy

uretero-neocystostomy

psoas hitch

ureteral repair procedures

ureteral obstruction