Importance of lower pole nephrectomy during ureterocalicostomy.

Ureterocalicostomy is usually a salvage procedure for recurrent pelvi-ureteric junction (PUJ) stricture or upper ureteric injury. It requires meticulous dissection of the upper ureter, and lower pole nephrectomy is considered an essential step to achieve a wide funneled and dependent ureterocaliceal anastomosis. We, hereby, highlight the importance of guillotine lower pole nephrectomy through a case report of recurrent PUJ stricture managed with ureterocalicostomy that failed due to the omission of lower pole nephrectomy.

INTRODUCTION

Management pelvi-ureteric junction (PUJ) obstruction with intra-renal or PUJ injury and stricture can be challenging to the urological surgeon. Many times these are not amenable to endoscopic management. The technique of lower pole ureterocalicostomy is a useful procedure for the repair of ureteropelvic junction obstruction when access to the renal pelvis is complicated by peripelvic inflammatory adhesions or presence of totally intrarenal pelvis. The procedure has been well described with validated technique. It involves meticulous dissection of perinephric tissue, funnel such as ureterocalicostomy and lower pole nephrectomy. It is a challenging surgery and should be performed meticulously by an experienced surgeon. We report a case of where failed ureterocalicostomy, due to the omission of lower pole nephrectomy led to significant patient morbidity.

CASE REPORT

A 25-year-old man was referred to the Department of Urology, SGPGIMS, India for recurrent right PUJ stricture.

He had undergone open pyelolithotomy for right staghorn calculus [Figure 1]. In the postoperative period, he had persistent nephrostomy output. A nephrostogram was done after 1 month that showed complete cut-off of contrast at PUJ [Figure 2]. He subsequently underwent antegrade endopyelotomy and double-J stent placement. Following double-J stent removal after 3 months he again developed progressively increasing right flank pain and hydronephrosis for which percutaneous nephrostomy was placed. Then the patient underwent right ureterocalicostomy with 6/26 Fr double-J stent placement. Following double-J stent removal after 6 weeks, the patient again developed right flank pain hence double-J stent was replaced.

Figure 1

Plain X-ray showing branched right renal calculus with lower calyceal small stone

Figure 2

Antegrade nephrostogram showing contrast holdup in pelvis suggestive of pelvi-ureteric junction stricture

The computed tomography [Figure 3] shows that though there seems to be a patent anastomosis between the inferior calyx and ureter, the lower pole parenchyma has not been amputated which was most likely the cause of obstructed drainage whenever double-J stent was removed.

Figure 3

Contrast enhanced multi-detector computed tomography of the patient following ureterocalycostomy (stented with JJ) showing intact lower renal pole

We at SGPGIMS did a redo ureterocalicostomy with lower pole nephrectomy. Intraoperatively, there were dense periureteric adhesions. Careful dissection and a double-J stent were helpful in identifying the lower pole and ureterocalicostomy site. A guillotine lower pole nephrectomy followed by ureterocalicostomy was done with vicryl 4–0 [Figure 4]. Postoperative period was uneventful, and a double-J stent was removed after 6 weeks. The patient is doing well now after 6 months follow-up with documented normal drainage on nuclear studies.

Figure 4

Diagram representing the surgical procedure. (a) ureterocalicostomy without lower pole nephrectomy, (b) lower pole nephrectomy, (c) revised ureterocalicostomy

DISCUSSION

Ureterocalicostomy was first described by Neuwirt[1] in 1947 and subsequently technical modifications were suggested by Hawthorne et al.[2] in 1976. It is usually a salvage procedure for recurrent PUJ stricture or upper ureteric injury.[3] The key elements[12] include complete amputation of the lower pole of the kidney, preservation of periureteral tissue and the blood supply, the creation of a widely spatulated, tension-free, mucosa-to-mucosa anastomosis, and adequate internal stenting. Several case series[345] have been published which report usually excellent long-term outcomes. Guillotine amputation of lower pole parenchyma rather than simple wedge resection to avoid anastomotic stricture has recommended by Jameson et al.[6] Our case report highlight the importance of lower pole nephrectomy and also that adherence to key steps of this surgery is essential for a successful outcome and to prevent avoidable patient morbidity.

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Conflicts of interest

There are no conflicts of interest.