Principles of ureteric reconstruction.

The principles of ureteric reconstruction are not different from those of reconstructive urology in the rest of the urinary system. The importance of ensuring good vascular supply, complete excision of pathological lesions, good drainage and a wide spatulated and tension-free anastomosis of mucosa to mucosa remain paramount. Although time of diagnosis is the most single most adverse factor affecting outcome, the majority of ureteric injuries still present postoperatively, and delays in diagnosis are the rule rather than the exception. Successful management requires early and definitive intervention using endoscopic means or percutaneous drainage and stenting where possible. Failing this, a number of open surgical options to foreshorten the course of the ureter should be implemented. Most ureteric injuries below the pelvic brim can be treated easily with a ureteroneocystostomy using a bladder elongation procedure or a Boari flap. Mid and upper ureteric injuries above the pelvic brim, however, can be repaired with a spatulated ureteroureterostomy if the defect is small. In those with extensive ureteral loss, measures such as mobilizing the kidney, transureteroureterostomy, renal autotransplantation and ureteral substitution using small bowel may be required. Artificial ureteral substitutes may be an alternative in selected cases.