Upper Tract Reconstruction

In this episode of BackTable Urology, Dr. Aditya Bagrodia talks with Dr. Lee Zhao, director of the Male Reconstructive Surgery program at NYU Urology, about indications, surgical techniques, and post-operative management for patients requiring upper tract ureteral reconstruction.

First, Dr. Zhao outlines his indications for upper tract reconstruction in patients with ureteral strictures. Most of his patients come from subspecialized urologists, while the other half come from self-referral. Before surgery, Dr. Zhao assesses three areas: kidney function via a renal scan, the anatomy and location of the stricture via antegrade and retrograde pyelograms, and assessment of bladder function via a cystogram. Additionally, he takes pre-existing stents out to allow the ureter to rest.

If a patient has a stricture less than 2 cm long, endoscopic management may be possible. However, if the stricture is longer than 2 cm, Dr. Zhao utilizes robotic surgery. Although he and Dr. Bagrodia discuss both single port and multiport approaches, he prefers the single port approach. He usually tries to avoid interfering with adhesions from previous surgeries and performs a concurrent ureteroscopy while gaining access. Only in cases involving obliterative strictures does he consider nephropexy.

For simple cases involving virginal abdomens, Dr. Zhao usually performs a primary ureteroureterostomy (UU). For longer strictures, he will choose to place a graft. He uses two types of grafts depending on which ureter is affected. For left sided strictures, he will perform a buccal mucosa ureteroplasty. For right sided strictures, he will use an appendiceal graft. Both grafts are able to fix strictures up to 10 cm in length. For longer strictures, he will create an ileal ureter, in which he makes an anastomosis between the ureter and the bowel. A trans UU is unusual to perform because complications are possible that will cause both tracts to fail. Dr. Zhao treats mid and proximal ureteral strictures the same but adds that Boari flaps may also be an option in mid-ureteral strictures. For distal ureteral strictures, boari flaps, psoas hitch, and other procedures can be considered instead. For distal ureteral strictures, Dr. Zhao prefers to do a non-transecting reimplant, which consists of making a longitudinal incision of ureter at stricture and dropping the bladder down to the level of stricture. This technique is best to preserve inferior blood vessels, which can be useful in patients who have fragile vascular supply from radiation therapy.

Finally, the doctors discuss post-operative management of reconstruction patients. Dr. Zhao does not routinely place a stent in all his patients and instead saves them for his buccal mucosal graft patients. Similarly, because he assesses the integrity of his anastomoses in the OR through retrograde filling or with the ureteroscope, he rarely places a drain after surgery. Finally, he prescribes post-operative antibiotics conservatively depending on the surgical technique chosen.