Ileal ureter: total replacement of a long ureteric loss

Operative visualisation

UrOops3D · UroRef · © Nity G

How to use this module. Play through the nine steps, or use Back and Next. Watch the arcades light up against the mesentery, the segment turn to lie with its oral end at the kidney, both joins made, and the saline test. The triggers show a dusky segment, a bowel leak, an upper join leak and the metabolic price.

Operative steps

1. Open and expose An adult with good renal function and a long right ureteric loss, from below the pelviureteric junction to the brim, after radiation or an iatrogenic stricture: too long for a psoas hitch or a Boari flap, too long to join end to end. Midline transperitoneal laparotomy, the bowel examined for inflammatory disease or radiation enteritis. The white line of Toldt is incised with diathermy and the caecum and ascending colon are reflected medially, which opens the right retroperitoneum from the kidney to the brim. The scarred ureter is identified and inspected: pale, narrow, without peristalsis. The cava lies medial to it and the duodenum above the field.
   where it bites: the cava is medial to the ureter and the duodenum sits at the top of the reflection; both are named before anything is divided.
2. Choose the segment The small bowel is delivered and the terminal ileum followed back from the caecum. A loop is held up against the light so the vascular arcades show through the mesentery, and a segment of distal ileum is chosen, long enough for the gap and a comfortable distance from the ileocaecal valve, where a good arcade runs to it. Marking stitches go in at both ends. The segment is measured against the gap from the renal pelvis to the bladder and not guessed.
   where it bites: the arcade is chosen by transillumination before any bowel is cut; the ileocolic arcade and the last of the ileum are kept.
3. Isolate on its pedicle An avascular mesenteric window is opened at each end of the chosen segment with a vessel-sealing device, incising and sealing the mesentery between the arcades without touching the main vessels. The bowel is divided at each end with a linear cutting stapler, so both ends of the segment and both ends of the remaining ileum are stapled shut. The segment now sits free on its mesenteric pedicle and is placed caudal to the mesenteric defect.
   where it bites: a window cut too deep toward the root takes the pedicle with it and the segment dies; the windows stay between the arcades.
4. Restore continuity The antimesenteric corners of the two remaining ileal ends are trimmed off the staple lines. One limb of the linear cutting stapler goes into each end, the bowel is turned so the antimesenteric walls face each other, and the stapler is fired: a side-to-side, functional end-to-end anastomosis. Four clamps hold the ends; the common opening is closed across with a TA stapler and the staple line checked and reinforced. The mesenteric window is closed with a running stitch so nothing can herniate through it. The anastomosis lies above the segment, which is kept caudal to it.
   where it bites: mesentery caught in the stapler bleeds or devascularises the join; the window is closed against an internal hernia.
5. Open, wash and orient The staple lines are resected off both ends of the segment and the lumen is irrigated with saline until it is clear of mucus and enteric content. The segment is then oriented isoperistaltically, its oral end toward the kidney and its aboral end toward the bladder, and positioned high in the right retroperitoneum with its mesentery untwisted and without tension. The mesenteric vessels are checked again once it lies in place.
   where it bites: isoperistaltic means the oral end goes to the kidney; a twist or tension on the pedicle is found now, not after the joins are made.
6. Ileopyelostomy Gerota's fascia is opened over the renal pelvis by sharp dissection and the pelvis is dissected and mobilised with its vessels preserved. Stay sutures go in above and below and the pelvis is incised obliquely, for a length equal to the opening of the bowel. The native ureter is divided below the junction and its stump tied (the book is silent on the native ureter; this is drawn as the default). The ileopyelostomy is completed with interrupted absorbable sutures in one layer, mucosa to mucosa, with the mesentery lying easy.
   where it bites: the renal hilar vessels run behind the pelvis; the pelvis is mobilised with its own vessels kept, and the ileal mesentery must not pull on the join.
7. Bladder window Two stay sutures go into the mid-anterior bladder wall and a full-thickness stab incision is made between them with diathermy, then extended cranially and caudally into a midline cystotomy. The catheter comes out to improve the view and the bladder is inspected: both orifices in their normal position, no tumour, stone, foreign body or diverticulum. A full-thickness segment of the posterolateral right bladder wall is excised to make the window. A Babcock clamp is passed through it from inside, the distal ileal end is grasped and drawn into the bladder.
   where it bites: the right ureteric orifice and the trigone are seen and kept clear of the window and of every bite that follows.
8. Ileovesical join and test The ileovesical anastomosis is sewn in two layers of interrupted absorbable sutures: an outer seromuscular row and an inner mucosal row. It is a refluxing, direct join by design. With the interposition complete, the ileal ureter is irrigated with saline from above to confirm a watertight repair at both ends; only then is the midline cystotomy closed in two layers, a new urethral catheter passed, and the bladder irrigated to confirm a patent, watertight closure.
   where it bites: watertight at both joins before the bladder is closed; a leak found afterwards is a return to theatre.
9. Drain and close The abdomen and pelvis are examined for bleeding and haemostasis is secured. A closed suction drain is placed in the retroperitoneum beside the joins, not on them, and brought out through a separate stab incision. The colon is returned over the segment without kinking it, the small bowel laid back, the field irrigated with warm saline and inspected, and the midline closed in layers. One continuous lumen now runs from the renal pelvis to the bladder.
   where it bites: the colon and small bowel are returned without kinking or compressing the segment or its pedicle.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance

Curriculum. Supports learning relevant to the ISCP Urology Curriculum syllabus topics Ureteric reconstruction and Urinary diversion. Not a workplace-based assessment and not evidence of competence.