Ureteric reimplantation

The ureters are muscular pipes that connect the kidney to the bladder, one on each side of the body. Blockages to the pipe can be congenital (anatomical variations present from birth) or acquired by injury, most commonly from kidney stones or surgery, although there are other potential causes.

The job of the kidneys is to remove toxins and excess fluid from the body by a filter mechanism. The free flow of urine down the ureter to the bladder is important to allow the kidney to work properly. If the kidney remains obstructed for a long period of time this can lead to a permanent loss of its function.

Repairing strictured (scarred and blocked) ureters can be a delicate, technical and difficult procedure. Traditionally this has been done as an open procedure with an incision in the abdomen to allow access to the ureter but with the refinement of laparoscopic and robotic techniques and technology a minimally invasive approach is increasingly an option, especially for the top (see pyeloplasty) and bottom ends of the ureter.

The abdominal space is accessed via small ports, inflated with CO2 gas and robotic instruments are inserted to perform the operation. The advanced da Vinci Surgical system is used for the procedure allowing the robotic instruments to be directed under the command of the surgeon who sits at a console.

Robotic surgery is commonly known as "keyhole surgery”, however, although the incisions are small the view is not. Modern equipment produces a wide, bright, clear, three-dimensional and magnified view of the operation, often superior to the traditional open approach. In addition, the gas used to distend the abdomen during laparoscopy also reduces bleeding during surgery.

The ureter is identified and dissected free of surrounding structures. It is then traced down to the bladder and the obstructed portion is removed. The bladder is opened and the ureter is sutured onto it. The sophisticated robotic “endowrist” allows a wide range of movement and precise control of the suturing to reconstruct the urinary drainage system.

A “JJ stent” (a temporary plastic tube) is placed inside the ureter to support the join. It helps the urine to drain to the bladder while the join heals. If the gap left by removing the scarred ureter is large, a portion of the bladder may have to be reconstructed to bridge the defect.

A temporary drain is routinely placed to remove any fluid from the area after the surgery and a urinary catheter is inserted to measure urine production during and after the operation. The entire operation is performed without the surgeon’s hands entering the body.

After the operation

Minimally invasive procedures are less traumatic than open procedures however this does not mean that they are pain-free. Medication will be given to keep pain at a manageable level to allow you to mobilise. It is important to get out of bed early in the recovery period. The benefits of this include avoiding blood clots and chest infections as well as promoting the return of normal bowel function. The nursing staff are very helpful with this process. Blood tests will be done after surgery and medical staff will review your progress on a regular basis as well. The drain will be removed as your recovery progresses. The sutures are dissolvable and do not need to be removed.

Most patients are able to leave the hospital by day 2 following their operation. The catheter needs to remain in initially to allow the join of the bladder to the ureter to heal, however, this is straightforward to manage and the nursing staff will show you how to do this before you leave the hospital. Follow-up will be discussed before your discharge, typically being arranged around 7-10 days postoperatively for catheter removal in the clinic. At around 4 weeks postoperatively removal of the JJ stent in the clinic will be arranged by a short procedure.

You can usually resume normal activities 4 weeks after surgery, however, it is best to build into this gradually. You are safe to drive as soon as you are comfortable enough to brake hard and swerve, this point is normally reached within 2 to 3 weeks. Urinary symptoms are expected once the catheter has been removed due to inflammation and healing in the bladder. They generally improve progressively over 4-6 weeks.