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Laparoscopic reconstruction for dual extrinsic pathologies compressing the upper ureter: The nutcracker ureteric compression

Surgical Technique

The patient presented with left flank pain of six months’ duration. The blood profile was normal. Ultrasound, intravenous pyelogram, and retrograde pyelogram were suggestive of left pelviureteric junction obstruction. We planned for laparoscopic reconstruction via the transperitoneal approach. Four ports were utilized – one 10 mm camera port and three 5 mm working ports. The colon was reflected medially. The Gerotas’ fascia was entered. The ureter was then dissected and the dissection continued cranially, up to the level of the renal pelvis. We strictly refrained from excessive usage of thermal energy during ureteric handling, and the periureteric adventitia was meticulously preserved. After delineation of the pelvis, we identified a dilated pelvis. The upper ureter, immediately caudal to the pelviureteric junction, was compressed anteriorly by a crossing vessel (lower polar accessory renal artery) and posteriorly by a simple cyst. After dismembering the ureter we could identify the dual compression more clearly. Even after dismemberment, the pelvis revealed persistent fullness without satisfactory urine drainage through the dismembered upper ureteric segment. This dual compression resembled a nutcracker compression. The pelvis and dismembered upper ureter was transposed anterior to the crossing vessel. The cyst was deroofed and the cyst wall was sent for histopathological evaluation. The caudal ureter was then spatulated posterolaterally to ensure a wide anastomosis. The ease of approximation of both ends of the ureter was assessed, to ensure a tension-free anastomosis. Ureteroureterostomy was then carried out employing a 4-0 polyglactin suture in an interrupted fashion. The corner stitch was made first followed by the apical suture. The posterior layer of anastomosis was completed first by everting the ureteroureteric approximation. Mucosa-to-mucosa approximation was carried out. After completion of the posterior layer of anastomosis the suture line was reverted back and a 6F ureteral stent was inserted. This was performed by inserting a percutaneous puncture needle from a preferred site, by passing a guide wire through the needle and dilating the tract with a 6F Teflon dilator, and then gliding the stent along the guide wire into the ureter. After stent insertion the anterior layer of anastomosis was completed in an identical fashion using interrupted sutures of 4-0 polyglactin. A drain was inserted and the ports were closed.

The patient made an uneventful recovery. The drain was removed on the second postoperative day and he was discharged on the third postoperative day. The ureteral stent was removed at six weeks post procedure. Till the one-year follow-up, no further episodes of flank pain were experienced. The follow-up imaging revealed resolution of hydronephrosis with a good drainage pattern