Full Bilateral Laparoscopic Intraperitonealization of Ureters: Surgical Technique

Abstract

Ureterolysis with intraperitonealization of ureters is traditionally performed by an open approach.However, it carries the risks associated with laparotomy, including prolonged ileus, lengthy hospital stay and higher complication rate. More recently, the laparoscopic approach has been employed as a minimally invasive option with advantages in terms of invasiveness and complications. In this video, we describe the surgical technique of full bilateral laparoscopic intraperitonealization of ureters in a case of retroperitoneal fibrosis after radiation therapy. The patient was a 52-year-old male who underwent radiation therapy for right testicular cancer 15 years before. A left nephrostomy tube and a right double-J stent were placed before surgery for obstructive renal failure. The patient was placed in a supine position with moderate Trendelenburg and a urethral catheter and a nasogastric tube were placed. The first infra-umbilical 11 mm port was introduced under direct visualization. Thereafter, two 5 mm ports were placed on each side of the abdomen. Firstly, the cecum was identified and the right colon and small intestine were mobilized. The retroperitoneum was then exposed, with visualization of severe fibrosis which distorted the normal anatomy. Firstly, the duodenum was identified as adherent to the retroperitoneum. After smooth mobilization, the right ureter was identified and isolated. The dissection then proceeded to the left side, which was more severely affected by the fibrosis. A fibrous cord was isolated and the inferior mesenteric artery and left gonadal vein were identified. The fibrous cord and the inferior mesenteric artery were then ligated. Thereafter, the left ureter was observed and dissected. The left colon was mobilized and the distal left ureter was isolated in the pelvis. Lastly, the ureter was transposed intraperitoneally by reapproximating the edges of the posterior peritoneum behind it with hem-o-loks and suture. The left nephrostomy tube was removed on postoperative day 2 and the patient was discharged on postoperative day 3. The right double-J stent was removed 4 weeks after surgery. Computed tomography (CT) urography 4 months after surgery showed minimal residual bilateral hydronephrosis. After 6 months of follow-up, the patient was well, with no infection or pain and normal renal function. Laparoscopy is an effective approach for full bilateral laparoscopic intraperitonealization of ureters, with similar outcomes and inferior patient burden compared to the open approach.