Repeated reconstruction in scars
The reasons for the failure of the first operation are ischemia and tension of the anastomosis, infection, radiation changes, and urinary leakage. During a repeat operation, the surgeon excises the scar zone to a known healthy, well-supplied ureter, which causes the defect to become longer - therefore, a psoas hitch or Boari flap is almost always needed, and for a defect larger than 12–15 cm, intestinal ureteroplasty. The anastomosis is covered with an omentum. The stent is left in place for 6–8 weeks, with drainage until the discharge stops. The effectiveness of secondary surgery is 80–90%.
Indications for ureteral reimplantation
- stricture or obliteration of the lower third of the ureter after pelvic surgery, radiation therapy, stones;
- damage to the ureter during gynecological and surgical operations;
- high-grade vesicoureteral reflux with infections and scarring of the kidney;
- ureterocele and ectopic ureter with duplication;
- megaureter with outflow disturbance;
- tumor of the lower third of the ureter after resection.
How the ureter is restored
The essence of the operation is to re-sew a healthy ureter to the bladder so that urine flows freely downwards, but is not thrown back: the ureter is passed through a submucosal tunnel of the bladder wall 2-3 cm long (anti-reflux protection). If, after excision, there is not enough ureteral stricture, the bladder is mobilized and fixed to the psoas muscle (psoas hitch) or a flap-tube is cut out of its wall (Boari operation) - this way the defect is replaced up to 10-12 cm. The anastomosis is formed on a stent, which is removed after 4-6 weeks. Efficiency 90–95%.
