Surgery of the Ureter. Questo articolo non è disponibile.Surgery of the Ureter

There has been great progress in ureteral surgery in the last twenty years. The predominant indication is still calculous obstruction but reparative and plastic surgery of the ureter for congenital and acquired lesions are among the most interesting advances in modern urology. The essential goal of this surgery is to ensure free flow of the urine from the kidney to the bladder and so to preserve or improve kidney function which is always affected or threatened by any defect in the excretory pathway. The ideal is to re-establish a closed circuit flow from kidney to bladder by repair or substitution of the ureteral conduit so as to avoid as far as possible the dis­ abilities that result from diversion of the urine to the skin surface or to the intestine. This objective can now be achieved in the treatment of most of the diseases of the ureter when the relevant kidney is sufficiently healthy to merit conserva­ tion. The techniques used are not necessarily new but the advent of antibiotics has made it possible to avoid or reduce the risks of infection, pyelonephritis, or pyonephrosis that so often complicated such surgery in earlier times. Progress in the investigation of renal function and of the excretory tract has brought a better understanding of the physio-pathology of the urinary apparatus and more accurate judgement of the results of reparative surgery.

General Considerations.- I. The Surgical Approach to the Ureter.- 1. Exposure of the Lumbar Ureter.- A. Lumbar, Extraperitoneal Approach.- B. “Limited”, Muscle-Splitting Approach to the Lumbar Ureter.- C. Posterior Approach.- 2. Exposure of the Iliac Ureter.- a) Extraperitoneal Iliac Approach.- b) Modifications.- 3. Exposure of the Pelvic Ureter.- A. Lateral Extraperitoneal Approach.- B. Midline Extraperitoneal Approach.- 4. Exposure of the Terminal Ureter.- A. Lateral, Paravesical Approach.- B. Transvesical Approach.- C. Combined Approach (Intra- and Extra-Vesical).- D. Vaginal Approach.- 5. Transperitoneal Exposure of the Ureter.- A. Segmental Exposure.- a) The Lumbar Ureter.- b) The Iliac Ureter.- c) The Pelvic Ureter.- B. Exposure of Entire Ureter.- II. Ureterolysis.- A. Simple Ureterolysis.- B. Ureterolysis with Intraperitoneal Transposition of the Ureters.- a) Indications.- b) Technique.- c) Modifications.- d) Results and Limitations of the Operation.- III. Ureterotomy.- 1. Ureterolithotomy.- A. Iliac Ureterolithotomy.- a) Finding and Controlling the Stone.- b) Ureteral Incision and Removal of the Stone.- c) Suture of the Ureter.- d) Drainage.- B. Modifications.- a) The Position of the Stone.- b) Ureteral Lesions.- c) Repeated Ureterotomy.- C. Post-Operative Course ― Complications ― Results.- 2. Ureterotomy for Stenosis.- 3. Extramucosal Ureterotomy.- IV. Ureteral Anastomosis.- 1. Uretero-Ureteral Anastomosis.- A. End-to-End Anastomosis.- a) Operative Technique.- B. End-to-Side Anastomosis.- 2. Uretero-Pelvic and Uretero-Calyceal Anastomosis.- A. Uretero-Pelvic Anastomosis.- a) Uretero-Pelvic Anastomosis after Resection of Pelvi-Ureteral Junction.- b) Uretero-Pelvic Anastomosis without Resection (Side-to-Side).- B. Uretero-Calyceal Anastomosis.- a) Operative Technique.- b) Indications ― Results.- 3. Uretero-Vesical Anastomosis: Ureteroneocystostomy.- A. Direct Uretero-Vesical Implantation.- a) Uretero-Vesical Implantation by Combined Transvesical and Extra-vesical Approach.- b) Modifications.- c) Indications and Results.- B. Side-to-Side Uretero-Vesical Anastomosis.- a) Operative Technique.- b) Indications and Results.- V. Ureterectomy.- 1. Segmental Ureterectomy.- A. Segmental Resection of the Lumbar Ureter.- a) Mobilization of the Kidney.- b) Renal Autotransplantation.- B. Segmental Resection of Iliac and Pelvic Ureter.- C. Resection of the Terminal Ureter.- a) Resection of the Terminal Ureter above the Ureteral Orifice.- b) Transvesical Resection of Terminal Ureter (Including the Ureteral Orifice).- D. Multiple Resections of the Ureter.- 2. Total Ureterectomy.- a) Total Ureterectomy with Preservation of the Kidney.- b) Total Nephro-Ureterectomy.- c) Ureterectomy of Residual Ureter (after Previous Nephrectomy).- VI. Replacement Ureteroplasty.- a) Inert Ureteral Prostheses.- b) Regeneration of the Ureter.- c) Preserved Human Tissues.- d) Pedicled Grafts.- 1. Ureteroplasty with a Tubed Bladder Flap.- A. The Boari-Küss Operation.- a) Surgical Approach.- b) Size of the Bladder Flap.- c) Tubing the Flap and End-to-End Anastomosis of the Tube to the Ureter.- d) Closure.- B. Alternative Techniques.- a) Anastomosis by Intubation.- b) Bilateral Ureterocystoplasty.- C. Postoperative Course and Complications.- D. Indications and Long Term Results.- a) Long Term Results.- 2. Pyelo-Ureteroplasty with a Tubed Flap from Renal Pelvis.- a) Operative Technique.- b) Results.- 3. Uretero-Ureterostomy.- a) Homolateral Uretero-Ureterostomy.- b) Crossed Uretero-Ureterostomy.- Technique.- c) Discussion and Results.- 4. Entero-Ureteroplasty.- A. Surgical Technique.- a) Total Left Ileo-Ureteroplasty.- b) Total Right Ileo-Ureteroplasty.- c) Partial Ileo-Ureteroplasty.- d) Left Colo-Ureteroplasty.- e) Bilateral Entero-Ureteroplasty.- f) Ureteroplasty Utilising the Ileo-Caeco-Colic Segment.- g) Entero-Ureterocystoplasty.- B. Postoperative Course ― Complications ― Results.- a) Early Complications.- b) Operative Mortality.- c) The Long Term Results.- C. Indications.- D. Replacement of the Ureter by the Appendix.- a) Operative Technique.- b) Indications and Results.- VII. Urinary Diversion Utilising the Ureter.- 1. Cutaneous Ureterostomy.- A. Operative Technique.- a) Terminal Iliac Cutaneous Ureterostomy.- b) Lateral, or Loop Cutaneous Ureterostomy.- c) Ureterostomy “in situ”.- d) Technical Modifications of Bilateral Cutaneous Ureterostomy.- B. Critical Analysis of Cutaneous Ureterostomy.- a) Advantages.- b) Complications.- c) Collecting Apparatus.- d) Long Term Results.- C. Indications.- 2. Ureterosigmoidostomy.- A. The Various Techniques of Uretero-Colic Anastomosis.- a) Tubular Implantation with Submucosal Tunnel: the Coffey Procedure.- b) Uretero-Colic Implantation by Direct End-to-Side Anastomosis.- c) Direct End-to-Side Implantation with a Tunnel.- d) Mathisen Technique.- B. Critical Analysis of Uretero-Colic Implantation Techniques.- C. Surgical Tactics.- D. Postoperative Course ― Complications.- E. Technical Modifications.- F. Indications.- G. Results.- a) Continence.- b) Electrolyte Disorders.- c) Long Term Effects on the Kidney.- 3. Implanting the Ureters into an Excluded Intestinal Segment.- A. Trans-Ileal Cutaneous Ureterostomy (“Ileal Conduit”, “Bricker Operation”).- a) Operative Technique.- b) Modifications.- c) Complications.- d) Results.- B. Trans-Sigmoid Cutaneous Ureterostomy (“Colonic Conduit”).- a) Operative Technique.- b) Complications ― Results.- C. The Substitute Caecal Bladder.- a) Operative Technique.- b) Complications ― Results.- D. Rectal Bladders.- E. General Indications for Urinary Diversion into an Excluded Intestinal Segment, Ileal, Left Colic or Ileo-Caecal.- VIII. Surgery of Vesico-Uretero-Renal Reflux.- 1. Techniques.- A. Techniques Preserving the Ureteral Meatus.- a) Hutch I Technique.- b) Gregoir Technique.- c) Mucosal Plasties.- B. Techniques that Do not Preserve the Ureteral Meatus.- a) Techniques of Detachment and Advancement of the Ureteral Meatus.- b) Techniques Including Removal of the Meatus and Terminal Ureter.- 2. General Therapeutic Indications?.- A. When is Surgery Indicated.- a) In Children.- b) In Adults.- B. If Surgery is Necessary, which Technique Should be Chosen?.- 3. Results.- IX. Surgery of Megaureter.- 1. Classification.- a) Malformation of the Uretero-Vesical Junction.- b) Megaureter Secondary to Lower Tract Obstruction.- c) Primary Megaureter.- 2. Surgical Technique.- a) Total Nephroureterectomy.- b) Cutaneous Ureterostomy.- 3. Conservative and Corrective Operations.- A. Operations Correcting the Malformation of the Uretero-Vesical Junction.- a) Endoscopic Dilatation.- b) Ureteral Meatotomy.- B. Resection and Tailoring.- a) Tailoring the Pelvic Ureter.- b) Tailoring the Lumbar Ureter.- C. Ureteral Replacement.- 4. Indications for Surgery.- A. In Children.- a) Is Surgery Indicated for All Megaureters.- b) Surgical Tactics and Technique.- B. In Adults.- a) Isolated Pelvic Megaureter.- 5. Results.- X. Surgery of Ureterocele.- 1. Simple Ureterocele (“Adult Type”).- a) Endoscopic Incision.- b) Open Surgical Excision.- c) The Technique of Hutch and Chisholm.- 2. Ectopic Ureterocele (“Infantile Type”).- A. Excision of the Ureterocele.- a) Transvesical Approach.- b) Combined Approach.- B. Treatment of the Upper Urinary Tract.- a) Upper Heminephro-Ureterectomy.- b) Consideration of the Upper Pyelon.- C. General Principles of Treatment.- XI. Surgery of Retrocaval Ureter.- 1. General Therapeutic Indications.- 2. Operative Technique.- a) Surgical Approach.- b) Ureterolysis.- c) Resection of the Pathologic Ureteral Segment.- d) Reestablishment of Ureteral Continuity.- e) The Retroperitoneal Space.- 3. Results.- XII. Surgery of the Ureter in Kidney Transplantation.- 1. General Considerations.- 2. Surgical Technique.- A. Uretero-Ureteral Anastomosis.- B. Uretero-Pelvic and Pelvi-Pelvic Anastomosis.- C. Uretero-Vesical Implantation.- 3. Results and Complications.- General Conclusions.- References.