Laparoscopic Ureteroureterostomy for Retrocaval Ureter

Laparoscopic Ureteroureterostomy for Retrocaval Ureter

european urology supplements 5 (2006) 466–469 available at journal homepage: Laparoscopic Ureterourete...

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european urology supplements 5 (2006) 466–469

available at journal homepage:

Laparoscopic Ureteroureterostomy for Retrocaval Ureter Vladimir Mouraviev, Thomas J. Polascik * Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA

Article info


Keywords: Circumcaval Laparoscopy Retrocaval Ureter

Objectives: To debate the different laparoscopic approaches for the surgical management of patients with circumcaval ureter. Methods: Updated literature review and discussion of personal experiences concerning the laparoscopic treatment of the circumcaval ureter. Results: Laparoscopic approaches promote less intraoperative bleeding, a shorter postoperative hospital stay, reduced postoperative pain, earlier return to daily activities and a significant superior aesthetics effect, while preserving therapeutic efficacy in performing reanastomosis of a circumcaval ureter. The main limiting factor for both a transabdominal and a retroperitoneal laparoscopic repair is the intracorporeal anastomosis of the ureter, which significantly increased the surgical time. Interestingly, a laparoscopic pyelopyelostomy for retrocaval ureter without resection of the retrocaval segment has been debated. Conclusions: Comparisons among historical reports regarding open surgery and laparoscopic transposition and reanastomosis of a circumcaval ureter have clearly shown the advantages of minimally invasive approaches. # 2006 Published by Elsevier B.V. * Corresponding author. Duke University Medical Center, Box 2804 ‘‘Yellow Zone’’, Durham, NC 27710, USA. Tel. +1 919 684 4946; Fax: +1 919 684 5220. E-mail address: [email protected] (T.J. Polascik).



Retrocaval ureter, also known as circumcaval ureter, is a rare congenital anomaly with an approximate incidence of one in 1000 live births [1]. It occurs three times more often in males than in females. This anomaly, which results from the posterior cardinal vein persisting as a segment of the infrarenal vena cava during development [2,3], usually entraps a segment of the proximal ureter as it wraps around the vena cava, and often results in obstruction and hydronephrosis [4–6]. However, sometimes (as in our published case) [2,7], it may occur in the middle portion of the ureter. Individuals who become

symptomatic typically present in the third or fourth decade of life with right flank pain, urinary tract infections, haematuria, or urolithiasis [8–10]. When symptoms develop or renal function progressively decreases, surgical correction should be performed [7,11,12]. We found in the literature only anecdotal cases of non-obstructive retrocaval ureter followed expectantly [13]. There are two types of retrocaval ureter according to the classification scheme proposed by Bateson and Atkinson [14]. Type 1 is the more common form, and has the characteristic S or ‘‘fish-hook deformity’’ of the ureter. It is usually associated with moderate to severe hydronephrosis. Type 2 has a ‘‘sickle-shaped’’

1569-9056/$ – see front matter # 2006 Published by Elsevier B.V. doi:10.1016/j.eursup.2006.02.011

european urology supplements 5 (2006) 466–469


Fig. 1 – Scheme of location for insertion of 3 ports for laparoscopic approach.

curve of the ureter and is usually associated with mild hydronephrosis. Spiral CT scan and MRI are the best imaging modalities [15–17]; however, standard IVP also may detect this entity [12,18].

Fig. 3 – Intravenous pyelogram (IVP) preoperatively shows obstruction of mid-portion of ureter.


Fig. 2 – Intraoperative laparoscopic findings: (a) probe pointing to dilated proximal ureter above obstruction; (b) probe pointing to normal distal ureter below obstruction. Arrow is pointing an inferior vena cava respectively.

Surgical treatment for circumcaval ureter

An open ureteroureterostomy has been the gold standard for many years for completely correcting this disease [12]. However, in the last decade, with the intensive growth of minimally invasive surgery, laparoscopic procedures have almost replaced open surgery because of their associated rapid recovery, early discharge from the hospital [19,20], and excellent cosmetic results. Matsuda et al. [21] first performed laparoscopic ureteroureterostomy (LUUS) for a retrocaval ureter in 7.5 hours using five laparoscopic ports. Our group [7] reported the second case that required three hours and 45 minutes using three ports (Fig. 1). Basically our technique was as follows: after exposing the retroperitoneum, the ureter is identified coursing posterior to the inferior vena cava (Fig. 2a and b) corresponding to the preoperative IVU (Fig. 3) and retrograde pyelogram (Fig. 4). The proximal dilated ureter is mobilized, followed by the distal ureter. Using sharp and blunt dissection the ureter is then mobilized behind the vena cava (Fig. 5a and b) and the most distal segment of the


european urology supplements 5 (2006) 466–469

Fig. 4 – Retrograde pyelogram preopreatively reveals retrocaval ureter as a cause of obstruction.

dilated ureter is divided. If not sufficiently dilated, the distal ureteral stump is spatulated for 1.5–2.0 cm. Any segment of redundant ureter can be excised proximally. The ureter is repositioned to lie anterior to the vena cava and a double-J stent is placed. A tensionfree anastomosis is created with several interrupted or running four-zero polyglactin sutures (Fig. 6). A closed suction drain is placed and the operative site is retroperitonealised. The convalescence is usually unremarkable. A contrasted imaging study such as a retrograde pyelogram should be performed approximately three to four months postoperatively (Fig. 7). Few reports document other techniques for laparoscopic repair of a circumcaval ureter. In general, when laparoscopic repair of the circumcaval ureter was first described, only a few case reports appeared in the literature. Most case reports describe prolonged operative times, largely because of the initial difficulties with intracorporeal suture techniques. Baba et al. [22] performed dismembered pyeloplasty through five ports in 9.3 hours, including 2.5 hours for intracorporal suturing. New advances in laparoscopic suturing techniques have improved dramatically in the past few years. Gupta

Fig. 5 – Laparoscopic view of right ureter passing posterior to vena cava shows: (a) mobilized dilated ureter (arrow) above obstruction; (b) stenotic segment (arrow) of retrocaval portion of ureter.

et al. [23] employed a three-port retroperitoneoscopic approach to perform LUUS. They found this approach to be safer, easier, and less time-consuming, and to provide direct access to the ureter and IVC while avoiding spillage into the peritoneal cavity.

Fig. 6 – Laparoscopic view of completed anastomosis (arrow).

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[2] [3]

[4] [5] [6] [7] [8] [9] [10]

[11] Fig. 7 – Retrograde pyelogram postoperatively demonstrates patent anastomosis (arrow). [12]

Ramalingam et al. [24] presented their experience with transperitoneal LUUS of retrocaval ureter in two cases. They believe transperitoneal intracorporeal suturing is less time-consuming and easier than retroperitoneoscopic suturing. The shortest operative time was reported by Gupta (3.5 hours), the other cases took 3.75–9.3 hours. Simforoosh et al. [1] reported the largest series to date of six patients who underwent laparoscopic pyelopyelostomy for retrocaval ureter without resection of the retrocaval segment. This technique allowed them to shorten the operative time to 2.5– 3.5 hours. However, the utility of this technique for an obstruction further distal in the ureter, such as in the middle portion of ureter, is questionable since a ureteroureterostomy can be easily performed. Ultimately, the very limited number of cases reported worldwide does not provide sufficient knowledge about the preferable surgical technique to correct this rare disease. It also depends on the surgeon’s experience and preference. Larger series are needed before a particular surgical technique can be advocated.


[14] [15]


[17] [18] [19]


[21] [22]


References [24] [1] Simforoosh N, Nouri-Mahdavi K, Tabibi A, Nouralizadeh A, Shayaninasab H. Laparoscopic pyelopyelostomy for


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